Author: Superadmin

Prediabetes is defined as a condition high risk for developing diabetes. Patient blood sugar levels are higher than normal but not high enough to classify a patient as diabetic. The prevalence of prediabetes is increasing and poses a serious public health problem. However, prediabetes is reversible, and proper diagnosis and management can delay or prevent the onset of diabetes (Mainous et al., 2016). 11.3% of the adult US population has diabetes, and 38% of the adult US population has prediabetes (“National Diabetes Statistics Report”, 2022). While medications also play a role, first line treatment of prediabetes primarily includes lifestyle modifications such as diet and exercise.  

Diagnosis of prediabetes often occurs during testing for diabetes. Some patients with prediabetes may experience symptoms, but not all will. Patients with prediabetes should be tested for type 2 diabetes mellitus every one or two years (“Myths about Diabetes”, 2022). Testing involves a 2-hour oral glucose tolerance test which demonstrates impaired fasting glucose and/or an impaired glucose tolerance. Impaired fasting glucose is generally defined as a fasting plasma glucose between 100.8-124.2 mg/dL, and impaired glucose tolerance is defined as plasma glucose values ranging from 140.4-198.0 mg/dL. HbA1c, known as glycosylated hemoglobin, within the rage of 5.7% to 6.4% can also be used to identify individuals with prediabetes (Mainous et al., 2016).  

Current guidelines from the American Diabetes Association state that a healthy meal plan for someone with diabetes is the same healthy eating plan for anyone. This means including nutritious foods such as non-starchy vegetables, limiting added sugars, and prioritizing whole foods when possible (“Myths about Diabetes”, 2022). Reducing caloric intake can lead to an improvement in glycemic control though it is not necessarily associated with weight loss (Sénéchal et al., 2014). During a randomized controlled trial with 34 diabetes/pre-diabetes participants, researchers found that a low carbohydrate diet was more effective at reducing HbA1c values at three months compared to a moderate carbohydrate diet (Saslow et al., 2014). Patients with prediabetes/diabetes do not need to completely avoid carbs, but starchy and high-carb foods will raise their blood sugar. One concern is that a low carbohydrate diet results in a higher proportion of calories from fat, which may also be a cause of concern, but researchers did not find significant elevations in LDL with this diet (Saslow et al., 2014). Continuing research should aim to understand how modifying other macronutrients and micronutrients affects blood sugar levels (Sénéchal et al., 2014).  

Exercise interventions are also essential for controlling prediabetes. Aerobic exercise is known to have transient effects on postprandial glucose metabolism and skeletal muscle insulin sensitivity (Rynders et al., 2014). Generally, a combination of aerobic and resistance training is recommended for prediabetic control (Sénéchal et al., 2014). One study found that although moderate intensity exercise and high intensity exercise did not have significant differences in improving postprandial insulin sensitivity, high intensity interval exercise may have greater postprandial effects compared to moderate exercise (Rynders et al., 2014). Further research is required to investigate the independent effect of exercise on glycemic control in individuals with prediabetes and understand how to optimize the effects of exercise (Sénéchal et al., 2014). 

Ultimately, while it is generally known that dietary and exercise interventions have a significant effect on prediabetes, further research should focus on understanding the independent effects of diet and exercise on individuals with prediabetes. Currently, most patients with prediabetes do not receive adequate care in managing their condition (Mainous et al., 2016). Primary care providers have a large role to play in the prevention of prediabetes/diabetes, and they must be equipped with the proper knowledge and skills to counsel patients.  

References 

Mainous AG 3rd, Tanner RJ, Baker R. Prediabetes Diagnosis and Treatment in Primary Care. J Am Board Fam Med. 2016;29(2):283-285. doi:10.3122/jabfm.2016.02.150252 

Myths about Diabetes. American Diabetes Association. https://www.diabetes.org/tools-support/diabetes-prevention. 

National Diabetes Statistics Report. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/data/statistics-report/index.html.

Rynders CA, Weltman JY, Jiang B, et al. Effects of exercise intensity on postprandial improvement in glucose disposal and insulin sensitivity in prediabetic adults. J Clin Endocrinol Metab. 2014;99(1):220-228. doi:10.1210/jc.2013-2687 

Saslow LR, Kim S, Daubenmier JJ, et al. A randomized pilot trial of a moderate carbohydrate diet compared to a very low carbohydrate diet in overweight or obese individuals with type 2 diabetes mellitus or prediabetes. PLoS One. 2014;9(4):e91027. Published 2014 Apr 9. doi:10.1371/journal.pone.0091027 

Sénéchal M, Slaght J, Bharti N, Bouchard DR. Independent and combined effect of diet and exercise in adults with prediabetes. Diabetes Metab Syndr Obes. 2014;7:521-529. Published 2014 Oct 31. doi:10.2147/DMSO.S62367

The connection between nutrition and mental illnesses of mood is less acknowledged than the negative effect of nutritional deficiencies on physical health. In recent years, nutritional neuropsychology has indicated nutrition is inevitably intertwined with human emotion, behavior, and mood. The newly established International Society for Nutrition Psychiatry Research (ISNPR) aims to understand the relationship between nutrition, metabolism and neuropsychiatric disorders [1]. Epidemiological studies have indicated an unhealthy diet (for example, a meal regimen revolving around fast-food or refined sugar) can increase a person’s risk of depression, while a balanced, healthy diet can protect against such neuropsychiatric disorders [2,3]. 

Macromolecules such as carbohydrates are known to release insulin, which increases the uptake of most amino acids into peripheral tissues, such as muscles. Tryptophan, an amino acid usually present at low levels in the bloodstream regardless of diet, is unaffected by insulin; thus with the secretion of insulin, the ratio of tryptophan to other amino acids drastically increases [4]. Without the competition of other amino acids, tryptophan is rapidly transported across the blood-brain barrier, where it enters the central nervous system and is converted into serotonin [4]. Increases in this “feel-good hormone” is the reason why diets low in carbohydrates often precipitate anhedonic conditions such as seasonal affective disorder (SAD), premenstrual syndrome (PMS), or major depressive disorder (MDD) [4,5]. The glycemic index (GI) is a caveat of this linear association which reveals fruits and vegetables (which have a low GI) tend to provide more long-lasting positive effects on brain chemistry and mood, while the reverse is true for high GI foods, for example processed foods or those high in artificial sugar [5]. 

Many neurotransmitters, which are signal molecules that allow for “communication” between neurons, are derivatives of amino acids. Among amino acids, 12 are made in the body and 8 are acquired from dietary intake. For example, the neurotransmitters dopamine and serotonin, both of which are related to emotional well-being, are synthesized from the amino acids tyrosine and tryptophan, respectively [5]. The extracellular-regulated protein kinase (ERK) pathway has been associated with protective processes such as plasticity and resilience in neuropsychiatric disorders including bipolar disorder and MDD [6]. Using Western blot analyses, researchers found lower levels of proteins within the ERK cascade in the frontal cortex of individuals with mood disorders compared to healthy controls [6]. In a murine model, stimulation of the ERK pathway was induced through administration of lithium or valproate, two commonly used mood stabilizers in the treatment of mood disorders [6]. 

Half of neural gray matter is composed of fatty acids that must be supplied through diet. Omega-6 and omega-3 polyunsaturated fatty acids (PUFAs) are critical in regulating the biochemical aspects of cellular membranes [5]. In a 4-month, double-blind, placebo-controlled study of 30 individuals with bipolar disorder, omega-3 fatty acids improved the course of illness indicated by a significantly longer period of remission for individuals receiving omega-3 treatment compared to placebo [7]. The authors of this study speculated that since omega-3 fatty acids were known to become highly incorporated in neuronal membranes, they could inhibit signal transduction mechanisms in the human central nervous system, much like many pharmacological mood stabilizers [7]. 

In addition, active areas of research include the effect of various vitamins and minerals on mental health and mood disorders. Although certainly many caveats between diet and mood disorders remain, the foundations of nutritional neuroscience provide a preliminary basis for future, more nuanced research, and current information demonstrates the importance of a balanced diet for all aspects of health.

References  

1. ISNPR 2019. (n.d.). International Society for Nutritional Psychiatry Research (ISNPR). Retrieved from http://www.isnpr.org/isnpr2019/  

2. Sánchez-Villegas, A., Toledo, E., Irala, J. de, Ruiz-Canela, M., Pla-Vidal, J., & Martínez-González, M. A. (2012). Fast-food and commercial baked goods consumption and the risk of depression. Public Health Nutrition, 15(3), 424–432. https://doi.org/10.1017/S1368980011001856  

3. Jacka, F. N., O’Neil, A., Opie, R., Itsiopoulos, C., Cotton, S., Mohebbi, M., Castle, D., Dash, S., Mihalopoulos, C., Chatterton, M. L., Brazionis, L., Dean, O. M., Hodge, A. M., & Berk, M. (2017). A randomised controlled trial of dietary improvement for adults with major depression (The ‘smiles’ trial). BMC Medicine, 15(1), 23. https://doi.org/10.1186/s12916-017-0791-y  

4. Wurtman, R. J., & Wurtman, J. J. (1989). Carbohydrates and depression. Scientific American, 260(1), 68–75. https://www.jstor.org/stable/24987109 

5. Rao, T. S. S., Asha, M. R., Ramesh, B. N., & Rao, K. S. J. (2008). Understanding nutrition, depression and mental illnesses. Indian Journal of Psychiatry, 50(2), 77–82. https://doi.org/10.4103/0019-5545.42391 

6. Yuan, P., Zhou, R., Wang, Y., Li, X., Li, J., Chen, G., Guitart, X., & Manji, H. K. (2010). Altered levels of extracellular signal-regulated kinase signaling proteins in postmortem frontal cortex of individuals with mood disorders and schizophrenia. Journal of Affective Disorders, 124(1), 164–169. https://doi.org/10.1016/j.jad.2009.10.017 

7. Stoll, A. L., Severus, W. E., Freeman, M. P., Rueter, S., Zboyan, H. A., Diamond, E., Cress, K. K., & Marangell, L. B. (1999). Omega 3 fatty acids in bipolar disorder: A preliminary double-blind, placebo-controlled trial. Archives of General Psychiatry, 56(5), 407–412. https://doi.org/10.1001/archpsyc.56.5.407 

            Cartilage is the fibrous and elastic connective tissue that exists throughout the body and serves various purposes.¹ Joint cartilage, known as articular cartilage, covers bones in locations such as the knee, hip, and wrist, allowing the bones in a joint to smoothly glide over one another and absorb shock.¹ Cartilage damage is a common injury that may occur from a sudden injury or from gradual wear and tear,² the latter of which can lead to osteoarthritis, a common form of arthritis characterized by pain, stiffness, and swelling in the joints resulting from the partial or complete breakdown of joint cartilage.³  Cartilage health is a significant public health issue: over 90 million Americans suffer from osteoarthritis alone.⁴ Many different approaches to support cartilage health exist, ranging from physical activity to dietary supplements.

            Cartilage, which lacks blood vessels, does not heal well on its own. While more severe cases of cartilage damage may require replacement of the entire joint or other surgical intervention, self-care measures exist for moderate cases. Supplements are a popular form of such treatment that have been found to alleviate joint pain and reduce joint inflammation. Specifically, the supplements glucosamine (GlcN) and chondroitin sulfate (CS) have been the subject of many studies, most of which corroborate their efficacy in improving cartilage health but some of which were inconclusive.

            GlcN is a type of glycosaminoglycan (a polysaccharide containing amino groups) that exists naturally in cartilage and that can delay degeneration and reduce osteoarthritic pain when administered orally.⁵ GlcN has multiple properties that enable it to achieve these physiological effects. Its primary mechanism of action is to reduce the inflammation associated with OA; it lowers the expression of p38 mitogen-activated protein kinase (MAPK) and c-Jun N-terminal kinase (JNK), factors associated with OA-related inflammation.⁶ GlcN also has antioxidant properties. Like the antioxidants curcumin and vitamin E, GlcN can alleviate pain and restore joint function in OA patients.⁷ There are several possible mechanisms for this effect, including the ability of GlcN to upregulate antioxidant enzyme levels and to suppress levels of damaging oxygen radicals.⁸ However, some studies have shown that glucosamine did not improve OA: Kwoh et al. studied the knee joint structure of those with chronic knee pain using magnetic resonance imaging and found no change after a 24-week GlcN treatment.⁹ Results such as these demonstrate the need for further studies on the efficacy of GlcN.

            Like GlcN, CS is also a natural component of cartilage and is in part responsible for its resistance and elasticity.¹⁰ In addition to its anti-inflammatory effect, CS also resolves the symptoms of OA by increasing the synthesis of type II collagen and proteoglycan, components of cartilage, in chondrocytes.¹¹ CS has anti-apoptic effects; it has been found to reduce the number of apoptosis events in vitro and in vivo.¹²

            S-adenosylmethionine (SAMe) is another compound among supplements for OA that, like the first two, has largely been found to be effective in improving cartilage health. SAMe is synthesized from methionine and ATP and is involved in several biochemical pathways.¹³ A possible mechanism of action unique to SAMe relates to its observed effect on the liver. Alcoholic liver disease can arise from decreased SAMe levels because SAMe functions to reduce oxidative stress.¹³ This same phenomenon may occur in the joints, which could explain why taking SAMe as a supplement helps reduce joint pain.

References

1. MD, E. K. What Is Cartilage? Arthritis Health https://www.arthritis-health.com/types/joint-anatomy/what-cartilage.

2. Cartilage damage. National Health Service https://www.nhs.uk/conditions/cartilage-damage/ (2017).

3. Osteoarthritis (OA) | Arthritis. CDC. https://www.cdc.gov/arthritis/basics/osteoarthritis.htm (2020).

4. Krishnan, Y. & Grodzinsky, A. J. Cartilage Diseases. Matrix Biol. J. Int. Soc. Matrix Biol. 71–72, 51–69 (2018). doi:10.1016/j.matbio.2018.05.005.

5. Al-Saadi, H. M., Pang, K.-L., Ima-Nirwana, S. & Chin, K.-Y. Multifaceted Protective Role of Glucosamine against Osteoarthritis: Review of Its Molecular Mechanisms. Sci. Pharm. 87, 34 (2019).

6. Wen, Z.-H. et al. Glucosamine sulfate reduces experimental osteoarthritis and nociception in rats: association with changes of mitogen-activated protein kinase in chondrocytes. Osteoarthritis Cartilage 18, 1192–1202 (2010).

7. Cheng, D. W. et al. An analysis of high glucose and glucosamine-induced gene expression and oxidative stress in renal mesangial cells. Arch. Physiol. Biochem. 112, 189–218 (2006).

8. Mendis, E., Kim, M.-M., Rajapakse, N. & Kim, S.-K. Sulfated glucosamine inhibits oxidation of biomolecules in cells via a mechanism involving intracellular free radical scavenging. Eur. J. Pharmacol. 579, 74–85 (2008).

9. Kwoh, C. K. et al. Effect of Oral Glucosamine on Joint Structure in Individuals With Chronic Knee Pain: A Randomized, Placebo-Controlled Clinical Trial. Arthritis Rheumatol. 66, 930–939 (2014).

10. Henrotin, Y., Mathy, M., Sanchez, C. & Lambert, C. Chondroitin Sulfate in the Treatment of Osteoarthritis: From in Vitro Studies to Clinical Recommendations. Ther. Adv. Musculoskelet. Dis. 2, 335–348 (2010).

11. Wang, L., Wang, J., Almqvist, K. F., Veys, E. M. & Verbruggen, G. Influence of polysulphated polysaccharides and hydrocortisone on the extracellular matrix metabolism of human articular chondrocytes in vitro. Clin. Exp. Rheumatol. 20, 669–676 (2002).

12. Jomphe, C. et al. Chondroitin sulfate inhibits the nuclear translocation of nuclear factor-kappaB in interleukin-1beta-stimulated chondrocytes. Basic Clin. Pharmacol. Toxicol. 102, 59–65 (2008).

13. Hosea Blewett, H. J. Exploring the mechanisms behind S-adenosylmethionine (SAMe) in the treatment of osteoarthritis. Crit. Rev. Food Sci. Nutr. 48, 458–463 (2008).

As work, school, and much of daily life become increasingly dependent on computers, concerns about the effect of screen use on sleep and brain functioning grow in the scientific community. Some studies indicate that exposure to light at night, especially blue light, may be linked to chronic health conditions such as diabetes, heart disease, and some cancers.^1–3 In a Harvard study, researchers shifted the sleep schedules of participants to alter their circadian rhythms and noticed that their blood sugar levels increased while their levels of leptin, a hormone that regulates the feeling of fullness, decreased.⁴ Research on the precise health effects of blue light at night is inconclusive as high screen use is often correlated with sedentary behavior and poor sleep hygiene, both of which are proven to be detrimental to human health.  

Light plays an integral role in human circadian responses, regulating sleep and alertness by suppressing release of the “sleep hormone,” melatonin. About 20 years ago, scientists discovered that the human eye contains not only visual photoreceptors for detecting changes in color and light, but also photosensitive retinal ganglion cells that trigger circadian responses.³ These cells are particularly sensitive to blue light, likely because these wavelengths of light (415-455 nm) are also found in the sky. During the day, exposure to blue light is associated with increased attention, mood, and reaction times, but at night, it suppresses melatonin and shifts circadian rhythms more than any other color of light.⁴  

Concentrated blue light may also have a direct effect on the retina of the eye, causing photochemical injury. Blue light contains higher energy than most other colors, and long term exposure can cause visual fatigue and nearsightedness.⁵ Increased exposure to sunlight, which is primarily composed of blue light, is a risk factor for cataract formation.  

A study published in 2020 found that a third of study participants used a blue-light emitting device 9 to 11 hours a day and another 16% used the devices 12 to 14 hours per day.⁶ Despite inconclusive research on the links between blue light and physical conditions, higher screen time is associated with moderate to severe depression.⁷ The implications of this research are particularly concerning for children and adolescents, who are more susceptible to fluctuations in circadian rhythms and negative effects of light on brain functioning and academic performance.  

There are several methods to ameliorate or diminish the effects of blue light, but the best solution is to reduce screen time at night. Scientists suggest using dim red lights for night lights, as red wavelengths are less likely to alter circadian rhythms and suppress melatonin production. For computers and phones, there are free apps that filter blue and green lights at night, including f.lux and Twilight. Blue light glasses may also be useful–a University of Toronto study found that participants wearing blue light glasses when exposed to bright light had similar melatonin levels as participants in dark environments at night.³ Many LED lights, while more environmentally friendly than their incandescent counterparts, emit more blue light than traditional bulbs that give off significantly more heat than light. As LED lights are relatively new, there are no long-term studies about the effects of LEDs over the course of the human lifespan. To reduce the emission of blue light, there are films and covers for LED bulbs that can make them warmer. Finally, spending time outside during the day can restore natural circadian rhythms and reduce unusual sleep patterns. Blue light may be necessary for much of daily life, but it is possible to reduce potential side effects of blue light, and it may be helpful to limit screen use outside of work and school.  

References 

1. Cho Y, Ryu SH, Lee BR, Kim KH, Lee E, Choi J. Effects of artificial light at night on human health: A literature review of observational and experimental studies applied to exposure assessment. Chronobiology International. 2015;32(9):1294-1310. doi:10.3109/07420528.2015.1073158 

2. Opperhuizen AL, Stenvers DJ, Jansen RD, Foppen E, Fliers E, Kalsbeek A. Light at night acutely impairs glucose tolerance in a time-, intensity- and wavelength-dependent manner in rats. Diabetologia. 2017;60(7):1333-1343. doi:10.1007/s00125-017-4262-y 

3. Fleming A. The truth about blue light: does it really cause insomnia and increased risk of cancer?https://www.theguardian.com/lifeandstyle/2018/may/28/blue-light-led-screens-cancer-insomnia-health-issues. Published May 28, 2018.  

4. Harvard Health Publishing. Blue light has a dark side: What is blue light? The effect blue light has on your sleep and more. Harvard Medical School. https://www.health.harvard.edu/staying-healthy/blue-light-has-a-dark-side. Published July 7, 2020. 

5. Li H, Zhang M, Wang D, et al. Blue Light from Cell Phones Can Cause Chronic Retinal Light Injury: The Evidence from a Clinical Observational Study and a SD Rat Model. Koike C, ed. BioMed Research International. 2021;2021:1-13. doi:10.1155/2021/3236892 

6. Bahkir F, Grandee S. Impact of the COVID-19 lockdown on digital device-related ocular health. Indian J Ophthalmol. 2020;68(11):2378. doi:10.4103/ijo.IJO_2306_20 

7. Madhav KC, Sherchand SP, Sherchan S. Association between screen time and depression among US adults. Preventive Medicine Reports. 2017;8:67-71. doi:10.1016/j.pmedr.2017.08.005 

Orthotics are assistive technologies that can address many musculoskeletal concerns by correcting position and/or supporting proper function [1]. The most common type is the shoe insert. Since the rise of rapid prototyping techniques, orthotics have become more personalized to individual patients and thus more effective than ever [1]. A central function of orthotics is to correct posture [1].

In a case study involving a 59-year-old male patient with ankylosing spondylitis (AS), an orthotic device was able to alleviate some of the patient’s postural problems and, thereby, postpone his later surgical treatment [2]. The patient received orthotic devices to treat his postural imbalance [2]. Within two weeks of wearing a 9-millimeter gel heel lift on one side, the patient’s posture had markedly improved [2]. The researchers believed that this successful correction could be explained by the heel lift leveling the patient’s hip posture so that he no longer had to walk on his tiptoes [2]. Although this study is but a single investigation into heel lift orthotics, it suggests that orthotics can promote better posture by leveling out patients’ gaits to correct any disruptive asymmetries.

A different study focused on the efficacy of plantar orthotics in promoting improved posture [3]. Foot health is crucial for correct posture because of the foot’s key role for support, weight transfer, and propulsion [3]. In this study, the device in question was an insole technology known as Regular Gait that supports the plantar arch [3]. The experimenters monitored 30 subjects as they wore the RG insoles [3]. None of the subjects suffered from any foot diseases or damage [3]. The orthotics stimulated plantar mechanoreceptors, which promoted a reorganization of users’ plantar stance up to the higher nervous system [3]. By influencing the kinetic biofeedback chains that originate at the level of the foot and travel up to the brain, plantar insole orthotics can significantly improve their users’ upright posture [3].

Another means by which orthotics can correct posture is by beneficially arranging limbs during sleep [4]. This was the case in a study following a patient who suffered from spastic diplegic cerebral palsy [4]. A defining characteristic of the condition is increased muscle tone, which can lead patients to adopt incorrect postures [4]. By arranging the patient’s knee in a way that would improve his posture while he was asleep, the orthosis reduced the chance that the postural corrections made in physical therapy would be nullified during rest periods [4].

Lastly, orthotics can also improve posture in conditions as high up in the body as the spine, as evidenced by experiments involving osteoporosis patients [5, 6]. Pfeifer and colleagues analyzed the effects of a spinal orthosis, which consisted of a system of Velcro-attached belts and a back pad, on women with one or more osteoporosis-caused vertebral fractures [5]. After six months, angle of kyphosis, body sway, and pain decreased, while muscle strength and functional ability increased [5]. Another study suggested that air chamber pads placed on the trunk can improve posture by activating muscles via sensorimotor stimulation [6]. However, the exact mechanism through which the orthosis promoted neurophysiological responses remains unclear, so further research is required on this point [6].

From leveling out asymmetries to favorably arranging limbs during rest periods, orthotics can help correct posture for patients with chronic musculoskeletal conditions.

References

[1] J. Barrios-Muriel et al., “Advances in Orthotic and Prosthetic Manufacturing: A Technology Review,” Materials, vol. 13, no. 2, p. 1-15, January 2020. [Online]. Available: https://doi.org/10.3390/ma13020295.

[2] J. A. Lipton and L. J. Mitchell, “Orthotic Correction of Postural Unleveling in a Patient With Ankylosing Spondylitis,” The Journal of the American Osteopathic Association, vol. 114, no. 2, p. 125-128, February 2014. [Online]. Available: https://doi.org/10.7556/jaoa.2014.026.

[3] C. Oro Nobili et al., “Plantar support for a correct gait,” Italian Journal of Anatomy and Embryology, vol. 121, no. 1, p. 53, 2016. [Online]. Available: https://bit.ly/3eQKQKo.

[4] M. Leite et al., “Design for personalized medicine in orthotics and prosthetics,” Procedia CIRP, vol. 84, p. 457-461, 2019. [Online]. Available: https://doi.org/10.1016/j.procir.2019.04.254.

[5] M. Pfeifer, B. Begerow, and H. W. Minne, “Effects of a New Spinal Orthosis on Posture, Trunk Strength, and Quality of Life in Women with Postmenopausal Osteoporosis A Randomized Trial,” American Journal of Physical Medicine & Rehabilitation, vol. 83, no. 3, p. 177-186, March 2004. [Online]. Available: https://doi.org/10.1097/01.PHM.0000113403.16617.93. [6] L. Vogt et al., “Postural correction by osteoporosis orthosis (Osteo-med): a randomized, placebo-controlled trial,” Prosthetics and Orthotics International, vol. 32, no. 1, p. 103-110, March 2008. [Online]. Available: https://doi.org/10.1080/03093640701838265.

Musculoskeletal pain is a leading cause of disability ¹ for which chiropractic care is key to alleviating ^2–4. Since 1897, when American chiropractor B. J. Palmer’s work led to the establishment of the chiropractic profession (literally meaning, “done by hand”), chiropractic practice has reached a global scale ⁵. Chiropractic practice has indeed grown steadily as a discipline over the last few decades, and chiropractors now operate in approximately 100 different countries ⁶ – with varying degrees of accessibility and practice guidelines.

Chiropractic management includes, but is not limited to, rehabilitation exercises, joint and soft-tissue manual manipulations, and patient education. Over half of patients seek out chiropractors for back pain, while the rest tend to seek treatment for other musculoskeletal pain, arthritic pain, and headaches, including migraines. Up to one tenth of patients present with an array of symptoms exacerbated by a neuromusculoskeletal disorder.

Most chiropractors work within the first countries to have established chiropractic schools, i.e. the U.S. (75,000), Canada (7,000+), Australia (4,000+), and the United Kingdom (3,000+). However, despite their strong global presence, chiropractic professionals (and related professionals) remain under-represented in low- and middle-income countries as regards service provision, educational institutions, and legislative and regulatory frameworks ⁶. In Zimbabwe, Malawi, and Zambia, for example, nearly three quarters of disabled patients have an unmet need for medical rehabilitation.

To date, nearly 50 different countries have established some degree of legislation to recognize, license, and regulate the profession, usually at the national level, but sometimes at the discretion of individual states or regions, such as in the case of the U.S. Legislation may be in the form of a separate chiropractic act, a chiropractic act under an umbrella health care policy, or a chiropractic act under an umbrella complementary and alternative health care policy. Legislation does not generally require that a patient obtain a prior medical referral to consult a practitioner, and varies across countries as regards chiropractors’ rights to perform or order diagnostic tests, such as spinal imaging and laboratory tests ⁷.

The educational standards of the U.S. Council on Chiropractic Education have been incorporated into the World Health Organization’s Guidelines on Basic Training and Safety in Chiropractic (2005). Interestingly, across the different chiropractic programs which now span 16 countries, most are within private colleges in the U.S., while most non-American schools are newer and embedded within the national university system ⁷.

The past decade has been met with dynamic chiropractic research as a result of the rising number of chiropractic trainees and new public research funding. Partly as a result of this, chiropractic and other medical professions have reached unprecedented levels of collaboration in research and the development of clinical practice guidelines, primarily anchored in an overlapping approach to preventive medicine as it relates to spinal ailments.

Chiropractic services today, however, continue to face a number of challenges. Not only is there little funding for education and research, but costs often remain hefty for patients, either because chiropractic services are not included in health insurance plans, or because these are linked to very strict co-payment plans. Furthermore, the input of chiropractic professionals on policy remains meagre. Alongside further research in support of the profession, representation in policy decision-making may provide the necessary foundation for the seamless integration of chiropractic services into a balanced, end-to-end approach to patient care.

Rehabilitation by chiropractors plays a critical role in minimizing the impact of musculoskeletal conditions and chronic disability. Overall, the chiropractic profession has seen rapid growth on a global scale, while is likely to persist provided sufficient research, funding, and pro-chiropractic practice policies.

References

1.       Hoy, D. et al. The global burden of low back pain: Estimates from the Global Burden of Disease 2010 study. Ann. Rheum. Dis. (2014). doi:10.1136/annrheumdis-2013-204428

2.       Garner, M. J. et al. Chiropractic Care of Musculoskeletal Disorders in a Unique Population Within Canadian Community Health Centers. J. Manipulative Physiol. Ther. (2007). doi:10.1016/j.jmpt.2007.01.009

3.       Dougherty, P. & Lawrence, D. Chiropractic management of musculoskeletal pain in the multiple sclerosis patient. Clin. Chiropr. (2005). doi:10.1016/j.clch.2005.03.004

4.       Hawk, C. et al. Best practices for chiropractic management of patients with chronic musculoskeletal pain: A clinical practice guideline. J. Altern. Complement. Med. (2020). doi:10.1089/acm.2020.0181

5.       Sportelli, L. The discovery, development and current status of the chiropractic profession. Integr. Med. (2019).

6.       Stochkendahl, M. J. et al. The chiropractic workforce: A global review. Chiropractic and Manual Therapies (2019). doi:10.1186/s12998-019-0255-x

7.       The Current Status of the Chiropractic Profession Report to the World Health Organization from the World Federation of Chiropractic. (2012).

Acute disc herniation is a common issue encountered by doctors and chiropractors alike. However, some studies have suggested that chiropractic care can actually increase the risk of complete disc herniation. To this end, a recent study by Hincapié et al. sought to elucidate the relationship between acute disc herniation and chiropractic care.

Acute disc herniation results from the collapse of the intervertebral disc. There are two primary causes of disc herniation. The first simply occurs over time, as aging leads to reduced proteoglycan production by disc fibrochondrocytes. In turn, the disc becomes dehydrated and more brittle, leading to strain on the annulus fibrosis, collapse of the disc, and herniation of the inner disc material.¹ On the other hand, biomechanical force can also lead to fissures in the annulus fibrosis and acute disc herniation in healthy, young or middle-aged individuals.¹ These types of acute disc herniations often occur in individuals who put immense strain on their back, such as athletes or individuals lifting heavy objects without protective form. The discs in the lumbar spine are most prone to herniation; however, injury-related disc herniation can also occur in the cervical or thoracic spine.²

Not only is acute disc herniation strongly associated with back pain, reduced mobility, and other adverse symptoms, but it is also notoriously difficult to treat. In fact, the primary recommendation for treatment is avoidance of motions which cause the patient pain.³ For this reason, it is best to simply avoid the risk factors for acute disc herniation in order to prevent the injury from occurring. While it is known that excessive strain and back injuries are associated with acute disc herniation, there has been debate as to whether chiropractic care increases risk of the injury occurring in the first place. Many people experience lower back pain as a prodromal symptom of acute disc herniation; as a result, a good proportion of these individuals seek chiropractic care, which is known to improve chronic low back pain. The relationship may be that people with lower back pain who are more likely to seek chiropractic care are separately at a heightened risk for developing acute disc herniation, or that chiropractic care itself increases the risk of acute disc herniation.

In order to answer this question, authors Hincapié et al. set out to evaluate chiropractic care and its relationship to acute lumbar disc herniation.⁴ The authors based their study in Ontario, Canada, where they used a self-controlled case series and population-based healthcare databases to investigate patients who made visits to the emergency department from April of 1994 to December of 2004. A total of 195 patient cases met the inclusion criteria, which was history of acute lumbar disc herniation and early surgical intervention. Using this data, the authors analyzed the association between chiropractic care and acute lumbar disc herniation requiring early surgery. They used patients who had visited their primary care physician for prodromal symptoms of lumbar disc herniation as a control.

First, the authors found significant positive associations between both previous chiropractic and primary care appointments and lumbar disc herniation requiring early surgery. This finding would suggest that patients typically seek care prior to complete herniation, whether that be chiropractic or medical. Notably, the frequency of acute lumbar disc herniations was comparable for patients who previously sought medical care and those who sought chiropractic care. Therefore, the authors reported that chiropractic care was equally likely to precede acute lumbar disc herniation as a visit to one’s primary care provider. In other words, there is little reason for concern that chiropractic care could disproportionately lead to acute lumbar disc herniation.

While the findings of Hincapié et al. are certainly reassuring, further investigation into the subject of acute disc herniation and chiropractic care might prove interesting. For example, do primary care visits or chiropractic appointments confer any preventative benefit when it comes to acute disc herniation? Do different chiropractic approaches to prodromal symptoms of acute disc herniation lead to varied outcomes? As studies reveal more about the relationship between acute disc herniation and chiropractic care, these questions will continue to be answered.

References 

¹ Schoenfeld, A. J., & Weiner, B. K. (2010). Treatment of lumbar disc herniation: Evidence-based practice. International journal of general medicine, 3, 209–214. https://doi.org/10.2147/ijgm.s12270 

² Herniated Disc. Retrieved from https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Herniated-Disc 

³ Herniated disk. (2019, September 26). Retrieved from https://www.mayoclinic.org/diseases-conditions/herniated-disk/diagnosis-treatment/drc-20354101 

⁴ Hincapié, C. A., Tomlinson, G. A., Côté, P., Rampersaud, Y. R., Jadad, A. R., & Cassidy, J. D. (2018). Chiropractic care and risk for acute lumbar disc herniation: a population-based self-controlled case series study. European spine journal, 27(7), 1526–1537. https://doi.org/10.1007/s00586-017-5325-y 

Deficiencies in bone health are common among elderly populations [1]. Associated musculoskeletal conditions, particularly osteoporosis, can result in significant physical disability and psychological impacts [1]. Fortunately, following guidelines for physical activity, nutrition, and pharmacological therapies can promote bone health and avoid the musculoskeletal problems that have become characteristic of old age.

Exercise is one of the most impactful ways through which people can improve their bone health [1]. Optimally, exercise should occur frequently during maturation to ensure that young people reach their peak bone mass and, accordingly, prevent or delay osteoporosis later in life [1]. Although exercise earlier in life can be very beneficial, it is impactful during middle and older age as well [1]. While the optimal form of exercise to promote bone health is not known, researchers recommend high-impact exercises that involve dynamic movements such as hopping or jumping [1, 2]. Alternatively, odd- or high-impact movements paired with resistance training can also be beneficial [2]. People who cannot engage in high-impact activities may benefit from certain yoga postures, lower-impact resistance training, or even walking [2]. Research indicates that habitually engaging in these forms of exercise for at least two or four short (30 minute or less) sessions each week is a good guidelines for maintaining or improving bone health [2].

Better nutrition is another lifestyle change that people can adopt to promote their bone health. Multiple studies have pointed to protein as highly influential for bone health; however, protein can be either detrimental or beneficial, depending on several factors [3]. Protein source is one hypothesized factor. Shams-White and colleagues investigated the differential effects of animal-based protein versus plant-based protein [3]. Their primary outcomes included lumbar spine (LS), femoral neck (FN), and total body bone mineral density (BMD) biomarkers [3]. Despite the two sources’ dissimilar amino acid profiles, research did not show a difference in benefits [3]. Another study conducted by the same researchers found that higher protein intake was more beneficial than lower intake for LS BMD, but otherwise, the two levels of intake were comparable in terms of FN, total hip, and total body BMD markers [4]. On another note, dairy products are a greater source of bone-beneficial proteins than any other food characteristic of the adult diet [5]. Indeed, in certain populations, calcium from dairy products appears to increase bone mineral density and improve total body bone mineral content when consumed over the long term [5].

When bone conditions have already progressed significantly, doctors often need to turn to pharmacological interventions [1]. Medications for bone conditions tend to be effective, but their benefits are often short-lived and associated with rare but drastic side effects [1]. For example, treatments such as bisphosphonates are known for their high success rates in treating patients who suffer from glucocorticoid-induced osteoporosis [6]. Unfortunately, bisphosphonates may not serve as an optimal long-term solution for certain patients, in which case additional management is required [6].

Ultimately, bone health can perhaps best be achieved by regularly following guidelines that have been established by thorough research, including a high-intensity impact workout regimen and consuming bone-nutrient-rich foods, such as dairy. When bone diseases have already progressed, pharmacological treatments can be highly effective, but their success may be limited to the short term. Therefore, maintaining healthy nutritional and exercise habits is of the utmost importance to avoid persistent bone problems.

References 

[1] L. Santos, K. J. Elliott-Sale, and C. Sale, “Exercise and bone health across the lifespan,” Biogerontology, vol. 18, no. 6, p. 931-946, October 2017. [Online]. Available: https://doi.org/10.1007/s10522-017-9732-6. 

[2] K. L. Troy et al., “Exercise Early and Often: Effects of Physical Activity and Exercise on Women’s Bone Health,” International Journal of Environmental Research and Public Health, vol. 15, no. 5, p. 1-17, April 2018. [Online]. Available: https://doi.org/10.3390/ijerph15050878. 

[3] M. M. Shams-White et al., “Animal versus plant protein and adult bone health: A systematic review and meta-analysis from the National Osteoporosis Foundation,” PLoS One, vol. 13, no. 2, p. 1-24, February 2018. [Online]. Available: https://doi.org/10.1371/journal.pone.0192459. 

[4] M. M. Shams-White et al., “Dietary protein and bone health: a systematic review and meta-analysis from the National Osteoporosis Foundation,” The America Journal of Clinical Nutrition, vol. 105, no. 6, p. 1528-1543, June 2017. [Online]. Available: https://doi.org/10.3945/ajcn.116.145110. 

[5] E. G. H. M. van den Heuvel and J. M. J. M. Steijns, “Dairy products and bone health: how strong is the scientific evidence?,” Nutrition Research Reviews, vol. 31, p. 164-178, March 2018. [Online]. Available: https://doi.org/10.1017/S095442241800001X. 

[6] A. Caplan et al., “Prevention and management of glucocorticoid-induced side effects: A comprehensive review: A review of glucocorticoid pharmacology and bone health,” Journal of American Academy of Dermatology, vol. 76, no. 1, p. 1-9, January 2017. [Online]. Available: https://doi.org/10.1016/j.jaad.2016.01.062.