Understanding SIBO: A Closer Look at Small Intestinal Bacterial Overgrowth

In the realm of gastrointestinal health, one term that has garnered attention in recent years is SIBO - Small Intestinal Bacterial Overgrowth. This condition, while not widely known, can significantly impact one's digestive system and overall well-being. Let's delve into what SIBO is, its symptoms, causes, diagnosis, and treatment options.

What is SIBO?

Small Intestinal Bacterial Overgrowth refers to an excessive growth of bacteria in the small intestine. Normally, the small intestine contains relatively few bacteria compared to the large intestine. However, when the bacterial population in the small intestine becomes imbalanced or overgrown, it can lead to various symptoms and complications.

Symptoms of SIBO

The symptoms of SIBO can vary widely and may overlap with other gastrointestinal disorders, which can make diagnosis challenging. Common symptoms include:

• Abdominal pain or discomfort: Often felt in the lower abdomen.

• Bloating: Feeling excessively full or swollen after eating, especially after consuming carbohydrates.

• Diarrhea or constipation: SIBO can disrupt normal bowel movements.

• Gas and belching: Excessive gas production is a hallmark of SIBO.

• Nutritional deficiencies: Malabsorption of nutrients due to bacterial interference with normal digestion and absorption processes.

These symptoms can significantly impact quality of life and may vary in severity from person to person.

Although these are typical symptoms, you can have unexplained symptoms elsewhere that may directly relate to SIBO. In other words, you could have anxiety or depression that is from gut inflammation. The underlying cause could be SIBO and you may not even have any gut symptoms. This makes it a tricky diagnosis but luckily, you can test for it. We’ll dive into that later. 

Causes of SIBO

Several factors can contribute to the development of SIBO:

• Impaired motility: Conditions such as irritable bowel syndrome (IBS) or scleroderma can slow down the movement of food and bacteria through the intestines. Decreased motility from GLP-1 agonists such as semaglutide may contribute and there is some emerging anecdotal evidence to suggest this correlation. 

• Structural abnormalities: Surgery or conditions that alter the anatomy of the gastrointestinal tract can predispose individuals to SIBO.

• Certain medications: Proton pump inhibitors (PPIs) and antibiotics can disrupt the balance of bacteria in the gut, potentially leading to SIBO.

• Underlying conditions: Disorders such as diabetes or immune deficiencies can create an environment where bacterial overgrowth is more likely.

• Hypochlorhydria: Low stomach acid can cause food to be undigested, feeding the bacteria in the small intestine. See below:

Diagnosis of SIBO

Diagnosing SIBO typically involves a combination of clinical evaluation and specific tests. Breath tests are commonly used to detect the presence of certain gases produced by bacteria in the small intestine. These tests involve drinking a solution of lactulose or glucose and then measuring breath samples over a period of time to detect elevated levels of hydrogen and methane gases.

Treatment Options

Treatment for SIBO aims to reduce bacterial overgrowth, alleviate symptoms, and prevent recurrence. Common treatment approaches include:

• Antibiotics: Specific antibiotics targeting the overgrown bacteria are often prescribed for a period of time to reduce bacterial load.

• Probiotics: In some cases, probiotics may be recommended to help restore a healthy balance of bacteria in the gut.

• Dietary changes: Following a low FODMAP diet or reducing intake of fermentable carbohydrates can help alleviate symptoms.

• Managing underlying conditions: Addressing any underlying causes or conditions that contribute to SIBO is crucial for long-term management.

Small Intestinal Bacterial Overgrowth (SIBO) is a complex condition that requires careful diagnosis and management. If you suspect you may have SIBO based on symptoms like bloating, abdominal pain, or irregular bowel movements, let’s get on a call and see if we can help you out. 

Understanding Collagen Deficiency

Collagen, often touted as the body's scaffolding, is a crucial protein that provides structure and support to various tissues, including skin, bones, muscles, and tendons. Its importance extends beyond structural integrity, influencing skin elasticity, joint flexibility, and overall vitality. However, when the body fails to produce sufficient collagen, it can lead to a condition known as collagen deficiency. This deficiency can manifest in several ways, impacting both health and appearance.

Signs and Symptoms of Collagen Deficiency

Identifying collagen deficiency can be challenging since its symptoms vary widely and may mimic other health issues. However, some common signs include:

1. **Joint Pain and Stiffness**: Reduced collagen levels can affect joint flexibility and lead to discomfort or stiffness, particularly noticeable in activities requiring movement.

2. **Skin Changes**: Collagen depletion often results in dryness, increased wrinkles, and sagging skin due to diminished elasticity and moisture retention.

3. **Digestive Issues**: Collagen supports the intestinal lining, and its deficiency can contribute to digestive problems like leaky gut syndrome or irritable bowel syndrome (IBS).

4. **Muscle Weakness**: Since collagen is vital for muscle structure, low levels may lead to weakness or decreased muscle tone.

5. **Bone Health**: Reduced collagen can impact bone density and increase the risk of conditions like osteoporosis.

Causes of Collagen Deficiency

Several factors can contribute to collagen deficiency, including:

- **Aging**: Natural collagen production declines with age, leading to gradual depletion.

- **Poor Diet**: Inadequate intake of collagen-rich foods (like bone broth, fish, and leafy greens) or essential nutrients (vitamin C, zinc) necessary for collagen synthesis.

- **Lifestyle Choices**: Smoking, excessive sun exposure, and high sugar consumption can accelerate collagen breakdown.

- **Genetics**: Some individuals may have genetic predispositions that affect collagen production or structure.

Addressing Collagen Deficiency

While collagen deficiency can pose challenges, several approaches can help mitigate its effects:

1. **Dietary Adjustments**: Incorporating collagen-rich foods and supplements can support natural production. Foods like bone broth, chicken, fish, and leafy greens provide essential amino acids needed for collagen synthesis.

2. **Supplements**: Collagen supplements, available in various forms (e.g., hydrolyzed collagen peptides), can boost collagen levels when diet alone is insufficient.

3. **Lifestyle Changes**: Avoiding smoking, minimizing sun exposure, and adopting a balanced diet rich in antioxidants and nutrients support collagen health.

4. **Skincare**: Using topical products containing collagen-boosting ingredients like retinol, vitamin C, and peptides can improve skin elasticity and reduce signs of aging.

5. **Medical Consultation**: For severe symptoms or conditions like osteoporosis, consulting a healthcare professional is crucial to explore tailored treatment options.

Collagen deficiency is a multifaceted issue that impacts various aspects of health and appearance. While aging is a natural contributor, lifestyle choices and diet play significant roles in mitigating its effects. By understanding the signs, addressing potential causes, and adopting proactive measures like dietary adjustments and supplements, individuals can support collagen production and maintain overall wellness. Ultimately, taking proactive steps towards collagen health can contribute to a vibrant, resilient body that ages gracefully.

Incorporating these strategies not only addresses current symptoms but also promotes long-term vitality and well-being, ensuring that collagen deficiency doesn't overshadow one's quality of life.

If you want to see the collagen we like, fill out this form:

Understanding the Connection Between Arthritis and Gut Dysbiosis: Exploring the Gut-Joint Axis

Arthritis, a condition characterized by inflammation and stiffness in the joints, affects millions of people worldwide, causing pain and reduced mobility. While it's traditionally been viewed as a joint-specific issue, emerging research is shedding light on the intricate connection between arthritis and gut health. In particular, the concept of gut dysbiosis, an imbalance in the gut microbiota, is gaining attention for its potential role in exacerbating arthritis symptoms and even contributing to its development.

The Gut Microbiota: A Key Player in Health

The gut microbiota, consisting of trillions of microorganisms residing in our gastrointestinal tract, plays a crucial role in various aspects of our health, from digestion and nutrient absorption to immune system regulation and beyond. A diverse and balanced gut microbiome is essential for maintaining overall well-being. 

Arthritis encompasses a range of conditions, including osteoarthritis, rheumatoid arthritis, and psoriatic arthritis, each with its unique characteristics and underlying causes. While joint inflammation is the hallmark feature of arthritis, it's increasingly recognized as a systemic condition that can affect multiple organs and systems in the body.

The Gut-Joint Axis: Unraveling the Link

There appears to be a bidirectional relationship between the gut and joints, known as the gut-joint axis. This means that gut dysbiosis can influence the development and progression of arthritis, while arthritis can, in turn, impact gut integrity and microbial balance. It was long thought that being obese causes too much wear and tear on the joints. Well we now know that fat cells secrete inflammatory cytokines. So fat cells are in a sense, an endocrine organ. 

Gut dysbiosis refers to an imbalance in the composition and function of the gut microbiota, often characterized by a reduction in beneficial bacteria and an overgrowth of harmful microbes. Diet, medications, stress, and environmental toxins can disrupt the delicate balance of the gut microbiome, leading to dysbiosis. Joints that are arthritic have the same pathologic bacteria in them that the gut does. It’s thought that these bacteria inhibit the action of the progenitor cells, the ones that replace cartilage. 

Several mechanisms have been proposed to explain how gut dysbiosis may contribute to arthritis. These include:

1. Immune Dysregulation: The gut microbiota plays a crucial role in educating the immune system and maintaining immune homeostasis. Dysbiosis can trigger an inappropriate immune response, leading to systemic inflammation that exacerbates joint inflammation in arthritis.

2. Intestinal Permeability: Dysbiosis-induced damage to the intestinal lining, known as increased intestinal permeability or "leaky gut," allows harmful substances such as bacterial toxins and undigested food particles to enter the bloodstream, triggering immune reactions and promoting inflammation throughout the body, including the joints.

3. Metabolic Dysfunction: Dysbiosis can alter the metabolism of dietary components and produce metabolites that influence inflammation and oxidative stress, both of which are implicated in the pathogenesis of arthritis.

4. Molecular Mimicry: Dysbiosis may promote the production of microbial antigens that resemble host tissues, leading to cross-reactive immune responses that mistakenly target joint tissues, contributing to autoimmune forms of arthritis such as rheumatoid arthritis.

Managing Arthritis Through Gut Health

Optimizing gut health may offer a promising approach for managing arthritis symptoms and slowing disease progression. Strategies to support gut health include:

1. Probiotics and Prebiotics: Consuming probiotic-rich foods (such as yogurt, kefir, and fermented vegetables) and prebiotic fibers (found in fruits, vegetables, and whole grains) can help restore microbial balance and promote a healthy gut environment.

2. Dietary Modifications: Adopting an anti-inflammatory diet rich in fruits, vegetables, healthy fats, and animal proteins while minimizing processed foods, sugar, and polyunsaturated fats can reduce inflammation and support gut health.

3. Stress Management: Exercise has a well established role in reducing stress. Practicing stress-reduction techniques such as meditation, yoga, and deep breathing exercises can help modulate the gut-brain axis and improve gut function. Cold plunges are another quick way to reduce stress. 

4. Supplements: Certain supplements, such as omega-3 fatty acids, vitamin D, and butyrate, may have beneficial effects on gut health and inflammation in arthritis.

To read some research articles on this topic, see below:

If you want help restoring your gut microbiome, let’s get on a free consult call:

Nourishing the Hidden Guardians: Exploring the Connection Between Lymphatics and Nutrition

In the intricate symphony of human health, nutrition acts as the conductor, orchestrating the harmonious functioning of various systems within the body. While we often associate nutrition with fueling our muscles and organs, its impact on the lymphatic system remains a lesser-known but equally crucial aspect. In this blog, we'll delve into the fascinating relationship between lymphatics and nutrition, exploring how what we eat can influence the health and function of this vital system.

The Role of Lymphatics in Nutrient Absorption: Before we can appreciate the connection between lymphatics and nutrition, it's essential to understand the role of the lymphatic system in nutrient absorption. In the digestive tract, specialized lymphatic vessels called lacteals line the walls of the small intestine. These lacteals play a key role in absorbing dietary fats and fat-soluble vitamins, such as A, D, E, and K.

When we consume foods rich in fats, such as oils, nuts, and avocados, these fats are broken down into fatty acids and glycerol in the digestive tract. The resulting fatty acids are then absorbed by the lacteals and transported via the lymphatic system to the bloodstream, where they can be utilized for energy or stored for future use.

In addition to fats, the lymphatic system also aids in the absorption of fat-soluble vitamins, which are essential for various physiological functions. For example, vitamin D is crucial for bone health and immune function, while vitamin E acts as a powerful antioxidant, protecting cells from damage caused by free radicals.

Nutrition and Lymphatic Health: Just as the lymphatic system facilitates the absorption of nutrients, the quality of our diet can influence the health and function of lymphatic vessels and nodes. A diet rich in whole foods, including fruits, vegetables, lean proteins, and healthy fats, provides the essential nutrients and antioxidants needed to support lymphatic health.

For instance, antioxidants found in colorful fruits and vegetables, such as vitamin C, vitamin E, and beta-carotene, help combat oxidative stress and inflammation, which can damage lymphatic vessels and impair their function. Including sources of omega-3 fatty acids, such as fatty fish, flaxseeds, and walnuts, may also help reduce inflammation and support lymphatic health.

Conversely, a diet high in processed foods, refined sugars, and unhealthy fats may have the opposite effect, contributing to inflammation, oxidative stress, and lymphatic dysfunction. Excessive consumption of polyunsaturated and trans fats, for example, has been linked to impaired lymphatic drainage and an increased risk of conditions like obesity and metabolic syndrome.

Practical Tips for Supporting Lymphatic Health Through Nutrition:

1. Prioritize whole, nutrient-dense foods: Choose a variety of colorful fruits and vegetables, lean proteins, whole grains, and healthy fats to provide essential nutrients and antioxidants.

2. Stay hydrated: Adequate hydration is essential for maintaining lymphatic flow and preventing fluid retention. Aim to drink plenty of water throughout the day.

3. Limit processed foods and added sugars: Minimize your intake of processed foods, sugary beverages, and unhealthy fats, which can contribute to inflammation and lymphatic dysfunction.

4. Include lymphatic-supportive foods: Incorporate foods known to support lymphatic health, such as citrus fruits, berries, leafy greens, garlic, ginger, turmeric, and green tea.

5. Practice mindful eating: Pay attention to your body's hunger and fullness cues, and aim to eat slowly and mindfully to support digestion and nutrient absorption.

The relationship between lymphatics and nutrition underscores the profound impact that our dietary choices can have on our overall health and well-being. By nourishing our bodies with nutrient-dense foods and adopting healthy eating habits, we can support the function of the lymphatic system and promote optimal health. So, let's raise a toast to the hidden guardians within us—the lymphatics—and fuel them with the nourishment they need to thrive.

-Amanda Salazar, OTD, OTR/L, CLT

Anemia of Chronic Disease

Understanding Anemia of Chronic Disease: Causes, Symptoms, and Management

Anemia of chronic disease (ACD), also known as anemia of inflammation, is a common type of anemia that often accompanies chronic infections, inflammatory diseases, and other long-term medical conditions. Unlike other forms of anemia, ACD is not primarily caused by nutritional deficiencies or blood loss. Instead, it is a result of the body's response to chronic disease.

What is Anemia of Chronic Disease?

Anemia of chronic disease is a condition where the body has adequate iron stores, but the iron is not properly utilized for the production of hemoglobin, the protein in red blood cells that carries oxygen. This dysfunction is typically due to an underlying chronic condition, such as an infection, autoimmune disorder, cancer, or chronic kidney disease.

Causes and Mechanisms

The pathophysiology of ACD is complex and involves multiple factors:

1. Inflammation: Chronic inflammation plays a central role in ACD. Inflammatory cytokines like interleukin-6 (IL-6) increase the production of hepcidin, a hormone that regulates iron metabolism. Elevated hepcidin levels lead to reduced iron absorption from the gut and sequestration of iron in macrophages, making it less available for erythropoiesis (red blood cell production).

2. Iron Homeostasis: In ACD, despite normal or increased total body iron stores, the availability of iron for red blood cell production is diminished. This is due to the aforementioned effects of hepcidin and the body's response to inflammation.

3. Erythropoietin Production and Response: Erythropoietin (EPO) is a hormone produced by the kidneys that stimulates the production of red blood cells. In ACD, the response to EPO is often blunted, and chronic diseases can also directly affect EPO production.

4. Red Blood Cell Lifespan: Chronic diseases can also reduce the lifespan of red blood cells, contributing to anemia.

Common Conditions Associated with ACD

• Chronic infections: Tuberculosis, HIV, and chronic bacterial infections.

• Autoimmune diseases: Rheumatoid arthritis, lupus, and inflammatory bowel disease.

• Chronic kidney disease: Impaired kidney function affects EPO production.

• Cancers: Particularly hematologic malignancies like lymphoma and multiple myeloma.

Symptoms of ACD

The symptoms of anemia of chronic disease are often subtle and can overlap with those of the underlying chronic condition. Common symptoms include:

• Fatigue and weakness

• Pale skin

• Shortness of breath

• Dizziness or lightheadedness

• Reduced exercise tolerance

Diagnosis

Diagnosis of ACD involves a combination of clinical evaluation and laboratory tests:

• Complete Blood Count (CBC): Typically shows normocytic or microcytic anemia with normal or increased ferritin levels, indicating adequate iron stores.

• Serum Iron and Total Iron-Binding Capacity (TIBC): Low serum iron and low TIBC.

• Inflammatory Markers: Elevated levels of C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) indicating inflammation.

Differentiating ACD from other types of anemia, especially iron-deficiency anemia, is crucial for appropriate management.

Treatment and Management

The primary approach to managing ACD is to treat the underlying chronic condition. Additional treatments may include:

• Iron Therapy: Oral or intravenous iron supplements may be considered if there is concurrent iron deficiency.

• Erythropoiesis-Stimulating Agents (ESAs): In cases where anemia is severe and significantly impacts quality of life, ESAs can stimulate red blood cell production.

• Anti-inflammatory Medications: Reducing inflammation can help improve anemia.

• Nutritional Support: Ensuring adequate intake of essential nutrients like iron, vitamin B12, and folate.

Anemia of chronic disease is a multifaceted condition that requires a comprehensive approach for diagnosis and management. Understanding the interplay between chronic disease and anemia is crucial for effective treatment. By addressing the underlying chronic condition and optimizing anemia management strategies, patients can achieve better overall health outcomes and improved quality of life.

If you suspect this may be an issue for you, let’s hop on a free consult call:

The Link Between Excess Iron and Diabetes

Iron deficiency anemia affects more than 3 million people per year in the U.S. However, a lesser known problem is too much iron, or iron overload. Iron overload affects 200,000 people per year in the U.S. This can be much more devastating, and even deadly if it goes untreated because it “rusts” the organs. It affects men more than women because men accumulate iron over a lifetime, whereas women lose iron from menstruation. After menopause, iron overload can become a problem for women as well. Many women are anemic through their menstruating years and are told to take iron, but are rarely told to come off it after menopause which can induce iron overload. There is a line of evidence building that shows a correlation between the development of diabetes due to excess iron. 

We know there is a strong association between diabetes and cardiovascular disease. Iron overload may explain the uptick in heart attack of post menopausal women. The original theory was that estrogen had a protective effect on heart disease and replacement therapy was suggested. Researchers began to question the role of excess iron in heart disease. In 2002, a study was conducted that aimed to determine if phlebotomy (bloodletting) affected risk for heart disease. Iron depletion at near-deficiency levels were associated with a reduction of risk, and improvements in lipids were observed. Blood pressure reduced, triglycerides reduced, and there was also an increase in response to glucose and insulin. These are all metabolic markers, and these were completely revered with iron repletion. 

Iron can easily become oxidized, so it acts as an oxidant. That means it takes poorly reactive free radicals and converts them into highly reactive ones. As iron accumulates in the body, it affects the pancreas and interferes with insulin synthesis, the hormone that regulates blood sugar. This is a two way street meaning that insulin stimulates cellular uptake of iron creating a sort of vicious circle. 

There are some other clues that iron overload affects blood sugar negatively. Excess iron also deposits into muscle and damages it, inhibiting its ability to uptake glucose. Type 3 diabetes is a newer term for dementia due to diabetes. Excessive iron has been found in patients with Alzheimer's. Gout has been linked to insulin resistance, and phlebotomy (blood donation) leads to a decrease in gout flare ups. 

It’s important to note that iron is the least sensitive marker for iron, ironically. Only about 1% of the body’s iron is floating in the serum. Ferritin is the storage molecule for iron and is a much more reliable marker for iron stores. However, when the body is inflamed it will store more iron in ferritin because viruses and bacteria replicate with bacteria. It’s a protective mechanism but that can lead to a false positive if you are inflamed. So you have to look at other markers of inflammation and correlate it. 

Elevated ferritin levels have been linked to insulin resistance in even seemingly healthy people. In one study, ferritin was proportional to glucose concentration, blood pressure, and HDL. In epidemiological studies, the higher the ferritin levels, the higher the incidence of type 2 diabetes. 

Signs of iron overload are vague and overlap with many disease processes which makes it impossible to diagnose with symptoms alone. Fatigue, joint pain, impotence or loss of libido, skin bronzing, palpitations, depression, and abdominal pain. These are just some of the symptoms and because of its ability to damage all organs, the symptoms can vary wildly. 

So how do we accumulate iron? It can come from excess consumption, either from the diet or from supplementation. Or, we absorb too much of it. This is called hemochromatosis. Hemochromatosis is a genetic defect (one of the most common) causing the body to absorb more iron that it needs. Unfortunately, it’s often misdiagnosed or completely missed altogether. The average person will wait 9 years for a correct diagnosis. So what is hemochromatosis? The mutations C282Y and H63D are the genetic snips that can cause hemochromatosis. If you’ve had a DNA test and want to find out if you are at risk for hemochromatosis, you can download our worksheet here. 

Outside of hemochromatosis, there are some diet choices that may increase iron absorption. This includes food high in vitamin C, beta carotene, HCL supplements (digestive enzymes), red meat and liver, sugar, and alcohol. So these can be strategies if you are iron deficient, but should be avoided when your ferritin levels are high. 

Bloodletting, or blood donation is a reliable way to reduce iron stores. It also reduces blood viscosity, which is a risk for heart attack. Anecdotally, many have reported weight loss with frequent blood donation. This may be more evidence of the correlation between iron and diabetes. 

If you are worried about excess iron, let’s hop on a free functional medicine consult call:

References: 

Eugene D. Weinberg. (2008) Iron Out-of-Balance: A Risk Factor for Acute and Chronic Diseases. Hemoglobin 32:1-2, pages 117-122.

Facchini FS, Saylor KL. Effect of iron depletion on cardiovascular risk factors: studies in carbohydrate-intolerant patients. Ann N Y Acad Sci. 2002 Jun;967:342-51. doi: 10.1111/j.1749-6632.2002.tb04290.x. PMID: 12079862.

José Manuel Fernández-Real, Georgina Peñarroja, Antoni Castro, Fernando García-Bragado, Ildefonso Hernández-Aguado, Wifredo Ricart; Blood Letting in High-Ferritin Type 2 Diabetes : Effects on Insulin Sensitivity and β-Cell Function. Diabetes 1 April 2002; 51 (4): 1000–1004. https://doi.org/10.2337/diabetes.51.4.1000

Martinelli N, Traglia M, Campostrini N, Biino G, Corbella M, Sala C, Busti F, Masciullo C, Manna D, Previtali S, Castagna A, Pistis G, Olivieri O, Toniolo D, Camaschella C, Girelli D. Increased serum hepcidin levels in subjects with the metabolic syndrome: a population study. PLoS One. 2012;7(10):e48250. doi: 10.1371/journal.pone.0048250. Epub 2012 Oct 29. Erratum in: PLoS One. 2013 Jun 26;8(6):null. PMID: 23144745; PMCID: PMC3483177.

The Correlation Between Metabolic Dysfunction and Low Back Pain

Low back pain is the number one reason people visit a physical therapist. There are so many reasons why low back pain occurs, and pain can be extremely complicated. This article will just explore one way back pain can happen, and I think it’s grossly overlooked. 

Let’s start this discussion with what metabolic dysfunction is. Metabolism is your body’s ability to convert food into energy. We generally have 2 fuel sources (there are more) that our body prefers to use. That’s lipids (fats) and carbohydrates (glucose). Generally speaking, carbs are easier for our body to utilize and when we need energy quickly, our bodies will use carbs. Particularly when we are in a sympathetic state. The problem is that our modern lifestyle tends to keep many of us in a stressed, sympathetic state. Then our metabolic system is chronically drawing on carbs for energy. 

What happens next is that we become poorly adapted to draw energy from fat sources. This is what is called “metabolic inflexibility”. The toggle switch is no longer working well. We start getting an accumulation of fats, triggering chronic inflammation and insulin resistance. Then as we get a spillover effect, the body will start putting fats where it can. Namely our liver, heart, kidneys, pancreas, and skeletal muscles. This is a process known as ectopic lipid deposition.

This is where there is overlap with back pain. In 2022, there was a study published that showed a correlation between low back pain and morphology of the paraspinal muscles. Paraspinal muscles are a group of three muscles that line the vertebrae and create spinal stability. Subjects with smaller paraspinals and “fatty infiltrates” were more likely to have back pain. What is going on here? 2 things: Firstly, the muscles are weaker and theoretically decreasing spinal stability. The body is running the process of ectopic lipid deposition, i.e. the fatty infiltrates. 

You can think of the body as having two modes, sympathetic and parasympathetic. When we are in a sympathetic state, it is catabolic; in other words breaking things down. When we are in a parasympathetic state, it is anabolic; building things back up. Parasympathetic state is highest when we are sleeping. So, if we live a stressed life, sleep poorly, and don’t exercise much, we get a chronic state of breaking down muscle, and putting on fat. This is the link between back pain and lifestyle. 

So if you get an MRI of your back, and you see the words “fatty infiltrates” on it, pay attention. It could be a clue that you are developing metabolic syndrome. Some blood work would be a good idea at this point. Keep in mind that traditional bloodwork picks up on disease processes when they already have occurred. Functional medicine aims to catch it before it happens. If you want to learn more, let’s get on a free consult call. 

Reference:

Seyedhoseinpoor T, Taghipour M, Dadgoo M, Sanjari MA, Takamjani IE, Kazemnejad A, Khoshamooz Y, Hides J. Alteration of lumbar muscle morphology and composition in relation to low back pain: a systematic review and meta-analysis. Spine J. 2022 Apr;22(4):660-676. doi: 10.1016/j.spinee.2021.10.018. Epub 2021 Oct 27. PMID: 34718177.

A Hidden Reason for Fatigue: Pernicious Anemia

Anemia is a condition that reduces the ability of blood to carry oxygen, leading to fatigue and a whole host of other symptoms. This may be due to a reduction in hemoglobin, or a reduction of the production of red blood cells. Some common deficiencies that cause reduced red blood cells are B12 (cobalamin), folate, and iron. 

Unfortunately, it is common for someone to have low iron and low hemoglobin and get a diagnosis of iron deficiency. They are then told to supplement with iron. The problem with that is too much iron can be very detrimental, and even fatal in some cases. Although iron deficiency anemia is much more common, iron overload is also common and there is less awareness of it. So having an accurate diagnosis is very important. 

Pernicious anemia is the most common cause of anemia due to B12 deficiency. It can lead to irreversible blood and neurologic disorders. In fact, the word ‘pernicious’ means deadly. But don’t worry, it was named that way before we had answers. You can live a healthy life with pernicious anemia as long as you know what to do about it. However, that means you need to supplement it for life. 

Common symptoms of Pernicious Anemia: 

Feeling tired or weak

Shortness of breath

Feeling faint

Smooth red tongue

Pale skin

Chest pain

Nausea

Vomiting 

Loss of appetite

Heartburn

Numbness in the hands or feet

Memory loss

Blurred vision

Depression

These are just some of the symptoms of pernicious anemia. What exactly is pernicious anemia? It is an autoimmune condition that attacks the parietal cells of the stomach. The inner lining of the stomach has parietal cells and they have two functions; to secrete hydrochloric acid for digestion, and to secrete intrinsic factor. Intrinsic factor is a glycoprotein that binds to B12, where it then enters the small intestine where it is absorbed. 

There are other conditions that will inhibit the absorption of B12 such as SIBO (small intestinal bacterial overgrowth), low stomach acid, atrophic gastritis, H. pylori infection, celiac disease, and alcoholism. Use of metformin, a diabetes drug, also depletes B12 stores. B12 deficiency can also just be due to inadequate dietary intake. Plants do not need B12, so they do not store it. So you cannot get B12 from a plant-based diet despite what you may have heard. Some vegetables contain cobamides, a B12 analogue and actually inhibit the absorption of B12. B12 comes from animal products. 

B12 is an extremely important nutrient involved in the methylation cycle, genetic repair, and keeps your body’s blood and nerve cells healthy. Because of its role in blood cell production, when deficient, it can cause megaloblastic anemia. The important roles that B12 has explains the wide variety of symptoms. 

How do we detect pernicious anemia? Bloodwork is a good starting point. From there you can determine your B12 status and see your red blood cell levels. There is a test called a Schilling’s test that can help tease it out. You can also test antibodies for intrinsic factor. Seeing a functional medicine practitioner is likely your best bet. 

If you want to learn more about our practice and what we treat, please subscribe to our growing YouTube channel. We produce tons of free content and house our podcast here. 

An Update on Plantar Fasciitis

Have you been to physical therapy for plantar fasciitis and been disappointed in the results? Maybe it took way too long. Or mabye it didn’t help. That’s because our understanding of what it actually is was not accurate. This can completely effect how we go about treating it, as you’ll see. Read on.

We were told it’s all about the right shoes. We were told shoes should give us more stability and have an arch. This was not based on science and has potentially led to harming our feet. Plantar fasciitis is a debilitating, knife-in-the-foot kind of pain. Instead of getting into the right shoes, maybe it’s getting out of the wrong shoes.

We were told that this is an inflammatory condition (also wrong). In 2003, Harvey Lamont analyzed the tissues of 50 of his patients that had plantar fasciitis, and found none of them had inflamed tissue, rather they had necrosis (dead tissue). This was even found in younger patients. It turns out that an adducted position of the big toe (pointed laterally towards the second toe) causes a muscle known as abductor hallucis to compress an artery in the foot; namely the lateral plantar artery near the heel. This leads to decreased blood vessel diameter and blood flow. In a study in 2019, (Jacobs et al.) found that immediately following passive adduction of the big toe, there was a 60% decrease in blood flow, which in some individuals corrected to a 22.2% decrease, suggesting some individuals may be able to adapt. This may explain why some do fine with the wrong shoes, and some do not. 

When you decrease blood flow to a tissue, over time it dies. So it appears that plantar fasciitis is more of a problem of dead tissue, not inflamed tissue. So already out of the gate, we have a problem with the diagnosis. Let’s discuss how we were told to treat this condition and break down what we’ve been doing wrong, and what we should be doing. 

As a therapist, we were taught that you ice something inflamed. Well turns out that is a bad idea. You should never ice something that is inflamed, and if you want the details on that, check out this podcast I did with Gary Reinl. Although, this is a necrotic situation, so icing would reduce blood flow and still not be a good idea. 

We were told to strengthen and stretch the area. We got the strengthening part right but the stretching part totally depends on what you are stretching. This gets more into shoeware and how it probably causes plantar fasciitis in the first place.

So a shoe that has a narrow toe box, a toe spring, and elevated heel is bad for you. It causes the extensor tendons of the big toe and the gastroc (calf) to stiffen and shorten, and places the plantar fascia in an elongated and tensed position. On top of that, we have the toe box placing the big toe into adduction, cutting off blood supply and causing some of the plantar fascia to die and weaken. One of the roles of the plantar fascia is to support and stabilize the foot. Well a half dead and elongated tissue will not do a good job of stabilizing the foot. 

On top of all that, overly rigid shoes allow the muscles of the foot (especially the intrinsics) to relax and weaken over time. These intrinsic muscles play a vital role in supporting the arch. So if we have weak muscles and a destabilized plantar fascia, we have the recipe for a painful, collapsed foot. 

This is what I look for in a shoe:

So, get out of the wrong shoes, stretch the toe extensors, don’t ice, and be barefoot. Maybe even wear flip flops. Sound like the opposite of what you’ve been told? Well if your plantar fasciitis keeps coming back and you’ve been doing the classic rolling on a frozen water bottle and stretching your plantar fascia, it’s probably not working. 

Here are some exercises I recommend:

Here is the podcast version of the blog, share it with a friend who needs to hear it:

References: 

Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003 May-Jun;93(3):234-7. doi: 10.7547/87507315-93-3-234. PMID: 12756315.Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003 May-Jun;93(3):234-7. doi: 10.7547/87507315-93-3-234. PMID: 12756315.

Jacobs JL, Ridge ST, Bruening DA, Brewerton KA, Gifford JR, Hoopes DM, Johnson AW. Passive hallux adduction decreases lateral plantar artery blood flow: a preliminary study of the potential influence of narrow toe box shoes. J Foot Ankle Res. 2019 Nov 4;12:50. doi: 10.1186/s13047-019-0361-y. PMID: 31700547; PMCID: PMC6829837.

Stabilize, Strengthen, Dynamically Strengthen

I was treating a patient recently who was getting back pain while stretching his hip flexors. He said that always happens to him. I told him to squeeze his core and glutes. The pain immediately went away. Of course he wanted to understand why that was. I explained it, and then said we need to stabilize, strengthen, then dynamically strengthen. This is a general principle in physical therapy, and can be seen as a progression. What does this mean? What is the difference between these terms? Let me explain: 

Someone once said (I think it was Gray Cook?):

Strength enhances our ability to create movement, stability enhances our ability to prevent movement.

I’d like to add to it:

Strength enhances our ability to create movement, stability enhances our ability to prevent movement, dynamic strength enhances our ability to do both at the same time. 

Think of stability as the ability to keep a position when challenged. If someone throws a heavy medicine ball at you and you are able to catch it and create the exact counterforce to prevent yourself from falling, you have adequate stability for that task. Any good coach can usually find these ‘holes’ in your stability. You either apply enough load or speed and any stability issues will show themselves. Think of someone benching under heavy load. Once it gets too heavy for that individual, inevitably the elbows flare. The shoulder is losing its position and is ‘tension hunting’. For the shoulder, internal rotation twists the rotator cuff and creates a layer of stability, and that’s why the elbows flare. The problem is, this can sometimes lead to pain or injury. 

I won’t bother explaining strength, this is self evident. So I’ll get directly into dynamic strength. In a gym setting, most of the ‘machines’ are for isolation exercises which are great for making single joint motions stronger. The problem is we don’t move that way in real life. It is much more dynamic. If you are unloading a heavy box from your trunk, you have to be able to keep a stable leg position while picking up the object. Then the arms have to stay stable while you move your legs to wherever you are going. This is dynamic strength. We have to be able to simultaneously and/or alternate between stability and strength. 

It turns out that the majority of the stability muscles are slow twitch (postural) muscles, and the majority of the strength muscles are fast twitch muscles. We see decline in performance, and sometimes injury, when there is a large mismatch between these muscle groups. Imagine having a ferrari without power steering. When you drive fast and hit corners, you’ll likely lose control. 

So let’s go back to the athlete with back pain while stretching his hip flexors. What was going on there? I see this as two problems. First off, his hip flexors were stiff. They attach to the lumbar vertebrae. The other problem is that the muscles that line the spine and hold their position were weak, allowing the hip flexor to pull on the spine. When the nervous system senses a threat, it will send a pain signal to that area to get you to try to change your position. In this case, flexors the core muscles help keep the spine in its happy place. So for this athlete, we had to strengthen the muscles of the spine with some antirotation:

And then stretch the hip flexors with the couch stretch:

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Dry Needling and Its Benefits

What is Dry Needling?

Dry needling is a therapeutic technique used by some healthcare professionals including physical therapists to treat musculoskeletal and neuromuscular pain and dysfunction. It involves the insertion of thin monofilament needles into specific points into and around muscles, tendons, and other soft tissues. 

10 Benefits of Dry Needling:

1. Pain Relief: Dry Needling is an effective tool that can be used to alleviate pain through targeting trigger points, tight muscles, irritated nerves, and chronically painful areas for relief.

2. Improved Range of Motion: By targeting and releasing tension and trigger points in muscles, dry needling can contribute to increased flexibility and improved mobility aiding in rehabilitation and better exercise mechanics.

3. Enhanced Muscle Function and Neuromuscular Control: This technique can target and stimulate specific muscles to activate, helping muscles function more efficiently and promoting better muscle development, control, coordination, and overall health. 

4. Accelerated Healing: Dry needling causes microtrauma to the area that helps to facilitate the body’s natural healing processes by triggering an inflammatory response, promote blood flow that increases the delivery of oxygen and nutrients to the tissue, and increase the release of endorphins for pain control all of which aid in faster recovery. 

5. Localized Treatment: Dry needling allows for targeted treatment of specific areas enabling physical therapists to address localized issues with precision and avoiding unnecessary intervention in unaffected areas. 

6. Deeper Treatment: Through needling, tissues and joints can be reached at a depth beyond what the hands can do alone. 

7. Chronic Pain Management: With chronic conditions, the body gets stuck in a cycle of being unable to self heal the area. Dry needling causes microtrauma that can restart the inflammatory process and to facilitate the body to heal itself again. 

8. Treatment of Nerve Pain: Dry needling can influence the nervous system by affecting neurotransmitters and nerve signaling. This neuromodulation can help in managing and reducing nerve-related pain for conditions such as complex regional pain syndrome, fibromyalgia, and hyper-sensitivity. The micro trauma caused by the needling stimulates a rush of blood flow to the targeted areas which can nourish nerves and promote healing. 

9. Complementary to Other Therapies: Dry needling can be integrated into a comprehensive physical therapy plan complementing other treatments including manual therapy and exercise for a holistic approach to rehabilitation. 

10. Customized Treatment: Physical therapists can tailor dry needling treatments based on an individual’s specific needs, making it a versatile and personalized approach to pain management and rehabilitation.

B12 Deficiency and SIBO

We routinely send our clients out for bloodwork, and one of the most common deficiencies we see is B12. There are a number of reasons for this, and in this blog we’ll cover the most common ones.

B12 (cobalamin) is a water soluble vitamin and is part of the methylation cycle, and as such is important for DNA synthesis and repair. It plays a role in nervous system development and in neurologic functions, as well as formation of red blood cells. Deficiency can cause anemia,  tingling in the hands and toes, and has been correlated with dementia. 

B12 interacts with homocysteine and folate in the methylation cycle, so when homocysteine and folate are high, that usually indicates deficiency in B12. It’s an inverse relationship.

Humans cannot synthesize B12, so it has to be acquired in the diet. B12 is high in liver, red meat, eggs, and seafood. You may read that B12 can be found in plant foods such as algae, but that is a myth. B12 is cobalamin, and algae contains cobamides, which is pseudo B12 and can actually inhibit the absorption of B12. So this is one of the most common reasons for B12 deficiency, inadequate intake. 

Another common reason for B12 deficiency is malabsorption. This comes in two forms, hypochlorhydria and SIBO. Hypochlorhydria means low stomach acid. Stomach acid helps break down our foods and if it’s too low, you won’t get the appropriate amount of nutrients out of your food. Several factors can influence low stomach acid. It naturally decreases as we age, but certain things can influence that. Excess alcohol intake depletes stomach acid. Also, use of PPIs (omeprazole) reduces it almost to zero in some cases. If you are concerned about reflux, read this blog on the correlation between low stomach acid and reflux. 

If the food is not fully digested, it moves into the small intestine. This is where B12 is usually digested by the body. There is a natural balance of microbiota that occurs within our guts. Most of the beneficial bacteria should be in the colon, and only a small amount in the small intestine. When stomach acid is low, food is inappropriately broken down, and the small amount of bacteria in the small intestine get a crack at that food and then they proliferate. This is what is known as SIBO (small intestinal bacterial overgrowth) and has a laundry list of possible symptoms. The over represented bacteria also gobble up the B12, so B12 deficiency may be a sign of SIBO. 

Typical symptoms of SIBO include gas, bloating, fatigue, skin issues, brain fog, constipation or diarrhea, halitosis, and muscle aches. So the symptoms are not confined to the gut. SIBO can also negatively impact fat absorption, so some of the fat soluble vitamins may also be deficient such as D, K2, and A.

The good news is that there is a breath test for SIBO that is cheap and easy. It will determine what type of species of bacteria that have become overgrown. There are specific botanical protocols to correct it based on the results of the breath test. 

Warm Up and Cool Down For Sports

As we age, the importance of warming up prior to activity becomes increasingly important. This is because our overall flexibility and mobility decrease with age partially due to decreased elasticity and collagen levels in our muscles. As a result of these changes, our bodies become more vulnerable to injury. A proper warm up will help to improve blood supply to the muscles that will be required during physical activity and therefore help to improve both performance and safety during the activity.

In addition to a good warm up to reduce the risk of injury, a good cool down and recovery routine after physical activity is vital to improve the healing of the muscles. When muscles are used for physical activity such as lifting weights, micro tears form. Rest will help to allow the tears to heal, but a recovery routine after the activity can often speed up the healing process and make it more effective. Properly healed muscles are less likely to become injured during the next physical activity.  

Warm Up Routine:

The goal of a good warmup routine should be to get the body prepared for the specific physical activity; therefore the warm-up actions are slightly dependent on the upcoming activity. In simplest terms, the muscles that will be required for the activity are the ones that should be the target of the warmup. For nearly every physical activity, one muscle that needs to be considered is the heart. It is important to warm up the heart with gradually increasing exercise intensity that will build toward the goal activity. With the heart rate increased, blood will be pumped better throughout the body to move toward the other needed muscles. 

A common mistake made when warming up is performing prolonged static stretching prior to exercise. Research has shown that prolonged stretching prior to activity while increasing motion also decreases the strength output and can actually make the area more vulnerable to injury. Instead of static stretching, one should perform dynamic stretching instead. Dynamic stretching involves movement with the focus on taking the body through its full range of motion in a controlled way. 

For this example we will use running as the activity being prepared for, but this routine can be substituted in with any other activity by substituting the expected muscles needed for said activity. With the example of running, there are many muscles that will be used. Nearly all muscles in the legs will be involved as well as the arms for pumping and the abdominals and back muscles for trunk support and trunk rotation. Because so many muscles are involved, creating a good routine that will target as many muscles as possible with the fewest exercises will be the most efficient and effective. The most involved muscles in the activity should be the primary focus of the warm up. In the case of running, the glutes, quads, hamstrings, calves, and surrounding ankle muscles will likely be the most used and therefore the most important for the routine. Exercises such as walking lunges, butt kicks, and squats will involve activation and movement of a variety of these muscles through their full ranges of motion to help prepare them for the actions required when running.

Cool down routine:

Upon completion of the desired physical activity, a cool down routine will be vital to reduce any potential damage done to the muscles and ensure better healing and faster recovery. A cool down should also help to relax the heart by bringing heart rate and blood pressure back to their resting values. 

During the cooldown, prolonged static stretching is a great way to reduce tightness in the muscles that were used while also helping to relax the body. With the example of running, the muscles most used such as quads, hamstrings, and calves will all benefit from sustained holds stretching those muscles for between 30 and 60 seconds each. In addition to static stretching, the use of a massage gun or foam roller to the muscles used will help to bring blood to the areas to help provide vital nutrients that will promote healing. 

Both a good warm up and cool down will take about 10 minutes each. While this may seem excessive or inconvenient in that it may take time away from your desired exercise, they are vital to promote healing and reduce the likelihood of injury. In the long run, the warm up and cool downs will help to keep you performing your activities more frequently and more safely. They will help to keep you doing the activities you love even as you age. 

For ideas on active/dynamic warm ups, subscribe to our YouTube channel. There are playlists that are sorted by joint.

Brazilian Jiu-Jitsu and Groin Strains

Groin strains, or adductor strains, are common in a lot of sports, but particularly in Brazilian Jiu-Jitsu. This probably is due to being in a closed guard position. This asks a lot of the adductors, and if they are quite strong enough, strains can occur. 

The adductors are a group of 7 muscles that pull the femur towards the body and also stabilize the pelvis. However, their role can change depending on the position you are in, and they basically do almost all motions of the hip. So they have a big role in general, and an even bigger role in Brazilian Jiu-Jitsu.

Most exercises in traditional gym training routines happen in the sagittal plane, such as squats lunges, etc. Unless you specifically target the adductors, there is a tendency for them to get weak compared to the quads. 

Getting them strong should be paramount to your routine if you practice Brazilian Jiu-Jitsu. But what do you do if you strain them? A strain is technically a type of tear and we have put together a free protocol for you to try. Obviously, get it checked out first. This protocol is a general 3 phase guide to help you get back to your sport. 

5 Ways to Reduce the Risk For Achilles Tears

It seems like an epidemic in the NFL this year. In the last few weeks teams have lost crucial players such as Aaron Rodgers after being on the field just 4 plays and Tre’Davious White who came back late last season from an ACL tear just to go out after only 4 games this year. Post-surgical repair, these athletes will be sidelined on average for another 9-12 months before being able to return to sport. This injury is not exclusive to Professional athletes however. 

This article will help to explain how these tears can happen and how you can reduce your risk. 

The Achilles tendon is a strong fibrous connective tissue that connects the calf muscles (gastrocnemius and soleus) to your heel bone (calcaneus). Those calf muscles contract causing a pull onto the tendon which creates plantar flexion, or the motion of the ankle pointing the foot downward. Plantar flexion is used when performing exercises such as heel raises but also used while walking, hiking, running, jumping, and performing any other rapid, explosive movements. 

The Achilles tendon is actually the longest and largest tendon in the human body and is exposed to great stress. Tears most often occur from a sudden fast motion, sudden stop, or a fall that stretches the ankle beyond its limits. Think of the tendon as a thick rubber band that snaps when pulled beyond its limits. These tears are most common in people in their 30s and 40s and much more common in men than women. “Weekend warriors'' often experience this injury due to pushing their bodies to limits beyond what the body is trained to perform. People dealing with inflammation of the tendon (tendinitis) or breakdown of the tendon (tendinopathy) through overuse without appropriate recovery methods can significantly increase the risk of tears. Certain medications and antibiotics as well as steroid injections around the Achilles tendon can also weaken the tendon and increase tear risk.

5 Ways to Reduce Your Risk:

• Improve ankle dorsiflexion (bending the ankle upward). This motion is what directly stretches the calf muscles and Achilles tendon. Due to tightness in those muscles or restrictions in the ankle joint itself, many people are unable to perform this motion more than a few degrees past neutral. Any external force that pushes the ankle past its comfortable dorsiflexion range such as from a fall or even hiking up a sharp incline can add significant stress to the Achilles tendon that could cause a tear. 

Reduce tightness of the calf muscles and Achilles tendon through calf stretches. 

• Diet and supplementation can also help to protect tendons’ elasticity through improving collagen production. Collagen supplements as well as getting plenty of calcium and Vitamins C and D can all help with this. 

• Improve strength of the calf muscles and Achilles tendon through both weight training and plyometric exercises. 

Weighted calf raises are a simple but effective way to build calf muscle.

Plyometric activities such as jumping and agility ladders are effective ways to improve tendon elasticity for explosive movements. 

• Proper warm up. Achilles tendon tears are common when the muscles are “cold” due to being stiff with reduced blood flow to the area. If your physical activity is going to require sudden movements, jumping, or any impact to the legs, then a simple routine prior to starting your workout is a must. 

• Proper recovery. After your hike, workout, or have a gym session that involves the calves, you need a good recovery program. Some light prolonged stretching followed by use of a massage gun or foam roller is a great way to improve recovery and reduce the risk of tendon break down.

These 5 things to consider can help to reduce your risk of injury, but if you are already dealing with lingering pain in the calf or Achilles without relief, consider seeing a physical therapist. They can help assess the tissue and provide treatment that will help to encourage healing and reduce your risk of worsening injury. 

If you want more guidance, click the button below for a free consult call.

Why Stress is Giving You Diabetes

You may have heard there is a correlation between stress and diabetes (Type 2). Stress affects the autonomic nervous system in profound ways including secretion of hormones. In this blog we’ll explore the mechanism, and what to do about it. 

The autonomic nervous system is divided into 2; the sympathetic and parasympathetic systems. The sympathetic system is the fight or flight response. When it is triggered, it secretes cortisol, the stress hormone. 

Cortisol’s main function is to liberate sugar from the muscles and liver. Sugar (glucose) is a quicker energy source than fats. So this is a survival mechanism. The nervous system perceives threat and it is programmed to give you quick energy. And this is a good thing in an emergency. The problem occurs when we are chronically stressed and spiking this system. Insulin does the opposite of cortisol, it pushes the glucose back into cells. Over time, the body becomes insulin resistant and our blood sugar remains higher leading to diabetes.  

When we say stress, we don’t mean just perceived or emotional stress. Stress comes in many forms. There is hormetic stress which is a good type of stress but in the right doses. For example, exercise or an ice bath is a hormetic stressor. This is a stress that we rebound from and become more adaptable. It’s like sun exposure; some sun is good and you get a tan, making your skin more protected from the sun. This is something you build with time. Too much sun and you get burned which is not good. The problem is, we try to combat stress with more stress. So maybe work is tough, you got poor sleep, and you workout out, run on your lunch break, do an ice bath, or whatever your form of self inflicted torture is. It may be too much for you to handle and you won't recover. 

What is happening to you on a physiologic level is that you are constantly in a stimulated, fight or flight mode and you are maintaining high levels of blood sugar. Technically, blood sugar dysregulation is a form of stress so when this system is overactive, it’s a bit of a downward spiral. 

So what do we do about this? We have to seek more parasympathetic activity. This gives the nervous system a break and allows for recovery. It will also stop the pancreas from secreting so much insulin. It will also allow our bodies to burn fats rather than carbs for energy. There are lots of ways to do this, a walk in nature, massage, a relaxing book, breathwork, etc. Here is a video of some tips on the parasympathetic system: 

Life is about balance. You can’t fight fire with fire. It’s also important to note that prediabetes is reversible. However, when diabetes becomes too far gone, cells in the pancreas start to die and then you become dependent on medicine. Prioritize sleep, recovery, and the parasympathetic system, and you will thrive. You’ll also find that if you do this, the times you do want to exercise, you’ll perform better and get more out of it. 

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Does Anterior Tilt Matter?

A common complaint physical therapists will hear from patients is pain with prolonged standing. While this can be caused by a variety of factors, one of the first things we will look at is standing posture.

 In this posture, sometimes referred to as “Lower Crossed Syndrome” Posture, the person is standing with their back hyper-extended and hips protruding forward. For many people, this is a comfortable standing position that requires less effort to maintain, but for some people over time this can lead to pain across the lower back. This standing posture can lead to increased tightness across the low back and may eventually lead to an increased curvature in the lumbar spine. 

There are several factors that contribute to the development of this posture. The protruding forward of the hips, or Anterior Pelvic Tilt, can occur due to tightness in the hip flexor muscles pulling the front of the hips forward. Hip flexor tightness is common in many people but can worsen from living a sedentary lifestyle. The prolonged sitting can cause these muscles to shorten over time and pull the hips forward creating the anterior tilt. Any excess weight in the abdominal region will further add to the anterior tilt. 

In order to combat the pulling forward of the hips, multiple muscle groups must fire to posteriorly tilt the pelvis back into a more neutral position. The main muscle groups responsible for performing the posterior pelvic tilt are the abdominal muscles and the glutes. Many people struggle to engage these muscles properly or lack the strength or endurance to maintain engagement when standing or exercising leading to poor posture.

The problems of an anteriorly tilted pelvis standing posture is multi-faceted with issues related to tightness in the hips and excess abdominal fat pulling the hips forward combined with the lack of muscle engagement and strength to counter this motion. Therefore, to best help correct this posture, all issues must be addressed. 

Building the Posterior Pelvic Tilt:

Improving abdominal and glute activation and strength:

This exercise shows how to properly engage the abdominal muscles in order to perform the posterior pelvic tilt. This exercise is an excellent building block in working on strengthening your abdominals and should be performed while performing any other ab exercises. As this exercise becomes more natural lying down, it can then be performed in standing to help correct the anteriorly tilted posture. 

This exercise is one way to learn how to properly engage and strengthen the glute muscles. As glute activation becomes easier to perform, it can then be performed in standing in addition to the abdominal bracing to help create a posterior pelvic tilt.

Reducing the Anterior Pelvic Tilt:

Perform this stretch to gradually improve the flexibility of the hip flexor muscles to reduce the pulling forward of the hips that creates the anterior pelvic tilt. 

Weight Loss most specifically at the abdominal region will also help to reduce the anterior pelvic tilt. 

If you are struggling with low back pain from prolonged standing, consider your posture. These exercises may help to improve your posture and reduce your pain. If symptoms are still present, consider an evaluation with a physical therapist to further evaluate.

Why Pain is Worse at Night and What You Can do about it

Most ailments get worse at night, whether you are sick, or you are dealing with pain. There’s a simple reason for it; well two. It’s from the lack of two things: cortisol and movement. 

Cortisol has a bad reputation as it’s known as the stress hormone. What that really means is that it’s the primary driver when your sympathetic nervous system is activated. This is the fight or flight response. I think of it as “on mode”. Cortisol liberates glucose from the muscle and liver into the bloodstream as a quick fuel source (as opposed to fats). When you are “on”, the body upregulates some systems of the body and downregulates others. This is a good thing as it prioritizes survival. 

The sympathetic nervous system suppresses systems that aren’t vital when there is an emergency. For example, the digestive system (which is why you shouldn’t watch the news when you eat), and the reproductive system are suppressed. The immune system, which is responsible for the inflammatory response, is suppressed. So cortisol is an extremely potent anti-inflammatory. In fact, cortisone and steroids like prednisone are synthetic cortisol. 

Remember that inflammation is the first step of the healing process and some powerful things happen during sleep to help you repair. So the combination of inflammation and repair at night is a good thing. Herein lies the problem. The body doesn’t have any vacant space so even a few cc’s of extra pressure hurts. We don’t want to suppress the immune system too much because we want healing to occur, however at a certain point, it becomes difficult to sleep which will impair healing. 

Below is an example of what the daily pattern of cortisol looks like:

As soon as light hits your eyes, the sympathetic nervous system is triggered and you get a spike to start your day. Many of my patients tell me that their pain is bad in the morning, but once they get moving, it starts to go away. In part, this is due to the anti-inflammatory effect of cortisol.

By the way, melatonin has basically the opposite effect:

I think of melatonin as the “off mode”. 

So you see that cortisol is lowest in the evening (in a healthy person). So that cold you’re fighting off, or that swollen knee gets worse. We don’t want to spike cortisol because that will inhibit melatonin production and it’ll be difficult to sleep. You may be thinking, “why not take an anti-inflammatory”? That will certainly reduce inflammation, but here is an important point. Inflammation and swelling are not the same thing. Inflammation is the initiation of the healing process, swelling is the waste product left behind. If there was a car accident on the highway, you wouldn’t want to set up a blockade before the scene of the accident; you’d want the ambulance to arrive. This is similar, you may be inhibiting the healing process. Not to mention it’s tough on the cardiovascular system and the gut. However, you do want to mitigate swelling.

So how do we do this? Swelling is handled by your lymphatic system. The lymphatic system is analogous to your cardiovascular system; where there are blood vessels, there are lymph nodes and channels. The cardiovascular system has a pump (the heart) to create circulation, whereas the lymphatic system does not. It relies on the pump action of muscles to create circulation. This is problem number 2 at night, you tend to not move as much so swelling is allowed to fester. This can also be the solution, gentle movement stimulates lymph flow. It doesn’t take much, and it works well.

Generally, you want to move the area that hurts in as pain free of a manner as possible, and then you’d want to follow up with belly breathing. The main duct of the lymph system is the cisterna chyli which rests under your diaphragm. So belly breathing presses on that duct and gets it to your upper chest where it drains. You may feel the urge to urinate after doing this and that’s a good thing, your body is getting rid of the waste. The bottom line is that you want to mitigate, rather than inhibit, the inflammation and swelling process. 

Here are some examples:

For low back pain:

For knee pain: 

For shoulder pain: 

4 Ways to Build Resilience

Our modern world has become easy. We live in climate controlled houses, get in our climate controlled cars, and climate controlled offices and gyms. Over time, this makes us fragile. Ever notice that kids seem to be immune to swimming in cold water yet you get sick every time you travel? We have “endpoints” that our bodies get used to and if we don’t expose our bodies to difficult things, those endpoints narrow and then when we have to do something difficult, the body will let you know that it’s too much. Maybe you get sick, or maybe you develop pain. Whatever system in your body is most vulnerable, it shows up like a canary in a coal mine. 

Our bodies strive for homeostasis, or balance. We have 4 main homeostatic regulators; pH, CO2/O2, blood glucose, and temperature. The good news is that through systematic and progressive training, we can train our endpoints. This will make us antifragile, or resilient.

Here is an example: 

What is interesting is that if you improve the endpoints in one of these categories, it confers benefit in the other categories. Cold water immersion can improve your blood glucose control for example. Here are some tips to improve resiliency:

1. pH

This refers to your body's acidity/alkalinity in the bloodstream. It’s a 14 point scale, 0 is acidic and 14 is alkalinic. Our body rests at 7.4 and can typically swing between 7.35 and 7.45. You may have heard of the alkaline diet. Turns out it’s hard to have a large effect on pH through diet. The best way to affect pH is through breathwork. When you inhale, O2 goes up and it makes you more alkaline. As CO2 builds up in your bloodstream, it makes you more acidic. You can take advantage of this by doing things like breath holds while walking or Wim Hof breathing. 

Also, when you exercise, the muscles demand oxygen, that’s why you breathe heavier. The muscles also need fuel. Now, the body can use either fats or glucose for energy. Fats are more energy dense, but harder to break down whereas glucose is the opposite. So the harder you are working, the more glucose you are using. Glucose breaks down to lactate, which is the real fuel source, and hydrogen ions, which is acid. That is the burn you feel when you work out, literally acid. The more you can tolerate, the more you can exercise and the more resilient you become.

2. CO2/O2

Again, this comes down to breathwork. When CO2 builds up, there are sensors in our bodies that tell us to breathe to clear the CO2. CO2 has classically been described as a waste product, but that’s not accurate. The more it builds up, the more it scrubs oxygen off of the hemoglobin and delivers it to the muscle tissue. This is called the Bohr effect. So once again, the more CO2 we can tolerate, the harder we can work. 

3. Blood Glucose

This is tightly regulated in the body as high levels of glucose in the blood can be very damaging. In a healthy individual, there is on average about a teaspoon of glucose in the blood. When glucose is high in the blood, insulin is secreted to deliver the glucose to the muscles and the liver in the form of glycogen. As blood glucose decreases, glucagon is released to do just the opposite. 

With our traditional standard American diet, we eat way too much processed sugars and this leads to insulin resistance and type 2 diabetes. If you eat an excessively high carb diet (and we mean glucose, not just bread/pasta), your system gets adapted to burning glucose for exercise and burning fats become downregulated. If you get “hangry”, this is a sign that you have become metabolically inflexible and your ability to burn fats has decreased. You can improve this by running the “backup generator”. In other words, condition your body to burn fats from time to time. This can be done by exercising in a fasted state. Or you could consider a low carb/paleo diet. We don’t think there is one “right diet” for everyone. We advocate that you experiment and find the diet that works best, but it’s a good idea to sometimes focus on using fats for fuel to improve your metabolic flexibility as a strategy to become more resilient. 

4. Temperature

As stated earlier in the article, most of us live in a climate controlled environment. By intentionally seeking out cold and hot environments in a systematic way, we can improve the window of temperature swing that our body will tolerate before breaking down or getting sick. For starters, you can take a cold shower. Or exercise outside if you are in a warm or cold climate. You can use saunas and do cold water immersion. Cold plunges are all the rage now and for good reason. There are tons of benefits, but this is one of the big ones. We know that it upregulates the immune system, helps convert white fat into brown fat (which is more metabolically active), improves blood glucose, and reduces stress. Many people with hypothyroidism have poor cold tolerance. There is now emerging evidence that this is a 2 way street; if you improve cold tolerance, you may be able to improve thyroid function. Regardless, temperature is yet another homeostatic regulator that can be modified through graded exposure to make you more resilient. 

Building your resiliency is also called “physiologic flexibility”. This is a term coined by Dr. Mike T. Nelson and we are big believers in this approach. If you are interested in learning more and getting guidance on how to improve your physiologic flexibility in a systematic way, we’ve built a program for you. Click on the link below to learn more.

Fix Your Stiff Wrists

If you have difficulty doing push ups because you’re missing wrist range of motion, this blog is for you. 

Wrists can be limited, like any other joint, by muscle and capsule. A reminder; capsules are the ligamentous ‘sack’ around all joints. They can stiffen from lack of movement or injury. Muscles get stiff from underuse, or overuse. Or, as I like to say, ‘a weak muscle gets overused faster’. 

Most people will get stiff in wrist extension. That is the position your hand needs to be in to do a push up.

To address the muscle, you can stretch like this:

To address the capsule, you’ll need a thick band:

For wrist flexion, you can stretch the muscle like this:

And to address the capsule:

By the way, limited wrist range of motion can turn into elbow pain. Much like a knee problem is really an ankle problem, the same can occur in the arm.

If you’re having some elbow pain, and you think it may be coming from your wrist, check out this program which addresses all range of motion in the arm.