Tag: inflammation

Don’t Forget Your Back

Most of us spend a large portion of the day hunched forward.  Think about when you are working on the computer, cooking, driving or even relaxing.  Your typical posture during these activities is head and neck forward, shoulders rounded forward, back curved and hips flexed.    When you remain in this position for an extended period of time, the muscles in the front of the body tend to shorten or contract, while the muscles in the back of the body tend to weaken.    This can be a set up for back, neck and shoulder problems and in addition, tends to make you look shorter, heavier and less confident.

Stretching before and after exercise as well as during the day is often overlooked in the rush to “get your workout in”.   Stretching however, has numerous benefits.   According to a study published in the Annals of Physical Medicine and Rehabilitation Medicine in September 2016, by I Fekhfekh, et al, dynamic muscle stretching of the knee musculature actually resulted in an increase strength gain in those muscles.  Interestingly, this study also found a decrease in the postural stability of the knee after stretching.    In English, it appears that stretching helps your to build strength, but may decrease the stability of the muscles you stretch at least temporarily.

In general, stretching helps to improve flexibility, joint range of motion, and usually is helpful for injury prevention.    Stretching helps by increasing blood flow to the muscles stretched.  This increased blood flow carries important nutrients to your muscles to allow for muscle growth and repair.  In addition, the increased blood flow helps to wash away muscle “waste” which leads to decreased soreness and inflammation of the muscle.

If allowed to remain in a contracted position for a prolonged period of time, our muscles will shorten.  For example if you spend a large portion of your day sitting in a chair or driving, the muscles in the front of the hips, your hip flexors will shorten.  These muscles have a direct effect on both your posture and your back health.

 

So what should you do?

It is important to stretch the muscles in the front of the body at least daily.

Exercises that focus on the hip flexors:

-Kneeling hip flexor stretch  – in the position of a lunge, allow your back knee to touch the floor and drive the hip of your front leg forward.  This will stretch the hip flexor of the knee on the floor

–Pigeon stretch – extend your right leg straight back and bring the heel of your left leg underneath your right hip.  Then drive your hips forward towards the ground.  Stretch and repeat on the other side.

– Yoga poses such as: low lunge, crescent lunge, upward facing dog, and revolving side angle pose

 

Stretches that focus on the chest muscles and prevent rounded shoulders:

– Door Frame stretch- stand in a doorway or at the corner of a room with your arms up like you were going to stop traffic.  Line your arms up from the elbow to the hand with the doorframe or in the corners of the wall.   Step towards the door and you should feel a stretch in your chest (pectoralis “pec” muscles) and hold for 20-30 seconds.

– Wall slides – stand with your back to the wall and keep your shoulders against the wall.  Walk forward 1-2 steps and slide your arms up and down the wall and squeeze your shoulder blades together.  You should feel a stretch in your upper chest muscles.

–Shoulder squeeze stretch –  clasp your hands together behind your back and slowly try to lift your hands.  Squeeze your shoulder blades together to stretch out the chest wall.

– Yoga poses include : bridge pose, camel pose, cobra pose and cow face pose

 

Stretches for your neck:

– Chin Tucks (Neck Retraction) – keep your shoulders back and your head in a neutral position (eyes facing forwards, chin level) slowly move your head backwards until you feel a slight stretch in the back of your neck.  Hold for 10-20 seconds and repeat.  If needed you can apply a gentle pressure on your chin with your fingertips to press your chin backwards and deepen the stretch.

Incorporating these exercises into your daily routine will help to prevent shortening of the muscles in the front of the body which leads to poor posture and often pain of the neck and back.  As always, if you are having pain which persists you should be evaluated by a certified health care professional to ensure that these exercises are safe for you.

This week we primarily discussed stretching exercises to prevent muscle contraction, and next week we will discuss the importance of strengthening the back muscles to further combat the issues of a hunched posture.

Why No Gluten?

Gluten is one of the proteins found in wheat (durum, emmer, spelt, farina, faro, KAMUT ®, Khorasan wheat, and einkorn) as well as rye, barley and triticale.   Gluten is commonly found in breads, baked good, sauces, salad dressings, cereal, pasta, soups and sauces.  Barley is commonly used in malt, food coloring and beer as well.

Gluten has been around for only about 10,000 years.  Its use in food dates back to the Industrial Revolution where it was used as a type of food glue to help foods maintain their shape.  Because gluten was not part of our evolutionary diet, our bodies are not equipped with the proper enzymes to fully digest this protein.  There are no nutritional benefits derived from eating gluten.  In addition, though the quality of the gluten in our foods has not changed significantly over the past few centuries, the quantity found in foods has increased significantly.

Approximately 70-80% of the population are able to tolerate gluten with no problem.  Because we all lack the enzymes to fully digest gluten, gluten is only partially broken down by the GI tract.  According to studies done by Dr. Alessio Fasano, the head of the Department of Pediatric Gastroenterology and Nutrition at Mass General Hospital for Children, the undigested fragments of gluten and gliadin cause transient intestinal inflammation and can release a molecule called zonulin.

Zonulin causes an opening in the barrier of the GI tract.    Essentially the spaces between the cells lining the gut wall open up and allow foods and other toxins to cross into the blood stream, which would not normally get through.  In 70-80% of the population this is not a problem because the immune system works properly and can remove any offending bacteria, toxins, etc.

The immune system is remarkably complex, however essentially it is composed of two branches.  The innate and adaptive immune system.  The innate immune system is the first line of defense in the GI tract.  The innate immune system is immediate and is not very specific. It will release molecules that destroy or eliminate anything it thinks is foreign.  For example, when the innate immune system is exposed to gluten and gliadin fragments, cytokines (small proteins released by cells that are important in cell signaling and can affect the behavior of other cells) are released in an attempt to breakdown these gluten and gliadin fragments.  Cytokines can induce an attack on the gluten, but can also cause a local inflammation in any tissues nearby.  This can cause very microscopic damage to the gut wall which is not always seen on biopsy because repair occurs fairly quickly.

If the innate immune system is unable to handle the “foreign invader”, then the adaptive immune system takes over.  This branch of the immune system is much more specific, sophisticated and takes more time.  The adaptive immune response can lead to either an antibody-mediated attack or to a cell-mediated attack.

In the case of the antibody-mediated the body customizes antibodies to attack the gluten and gliadin protein fragments.    Occasionally, the immune system malfunctions and the antibodies customized to attack the gluten and gliadin can cross-react or get activated by cells in our body.  When this happens, in addition to destroying the gluten fragments, these antibodies also destroy important tissues in our bodies. Depending on which tissue is being attacked will determine a person’s symptoms.  For example, if the antibodies cross-react with joint tissue, a person can develop arthritis.

According to Dr. Fasano, there are three scenarios which could occur when you eat gluten.

  • The gluten is eaten and partially digested. The undigested gluten causes the release of zonulin which opens up the spaces between the gut lining and these protein fragment breach the intestinal barrier.  The innate immune cells respond appropriately and eliminate the fragments and the tiny amount of local inflammation is repaired quickly and the person has no consequences from eating gluten.
  • A person eats gluten and the partially digested fragments activate the immune system as above. However, the innate immune system is unable to eliminate the protein fragments and the adaptive immune system gets activated.  There is a miscommunication between the two branches of the immune system.   The adaptive immune system builds antibodies (or cells) to attack the gluten and gliadin fragments which cross-react with the cells found in the intestinal tract.  The immune cells stay locally in the gut and inflammation persists.  In this scenario the person will develop celiac disease.
  • The third possibility is that the scenario 2 occurs, except that instead of the antibodies (or cells) staying the in the gut and cross-reacting with tissues in the GI tract, the antibodies and/or activated cells travel throughout the body and cross react with different body tissues. In this case, there will be minimal damage in the GI tract, but the personal will have chronic inflammation elsewhere in the body.  Depending on the tissues which cross-react with the antibodies or activated cells, will determine the person’s symptoms.   This scenario is termed non-celiac gluten sensitivity.

Non-celiac gluten sensitivity can cause multiple symptoms.    Symptoms can often be vague, such as abdominal pain, headaches, foggy mind, chronic fatigue, and depression.

People can live for years without any issues with gluten intolerance.  However, it appears that a change in gut flora (as was addressed last week) can be one of the inciting event which can activate gluten intolerance.   There are no nutritional benefits from ingesting gluten, in addition, it causes inflammation in the gut and the release of zonulin leading to increased intestinal permeability.  Interestingly, it appears that zonulin also causes an increase in permeability of the blood brain barrier and may be associated with inflammatory disorders of the brain.

 

Exercising With Arthritis

 

We have all different levels of fitness. Some individuals have been exercising for years, while other individuals have never exercised a day in their lives.  We are all at different levels in terms of our cardiovascular fitness, our muscle strength and flexibility and our overall health.   It is quite important to remain active in spite of arthritis.  In fact, movement in people with arthritis is crucial to health and well-being.

Despite what we once thought, it is my experience that it is possible to modify the severity of certain types of arthritis.   In my mind, arthritis, chronic pain and other autoimmune diseases are the result of multiple factors.  All these factors such as genetics, environmental exposures, nutritional deficiencies, dietary influences, and gut health to name a few factors, all line up as if you were to “win” in the slots.  When this potent combination occurs in your body, havoc ensues.   The result is inflammation and chronic disease.   While you can’t change your genes per se, it is now thought that you can change or modify your gene expression.  In addition, you can certainly modify some of the other risk factors just mentioned to offset the severity of your debility.

In most cases, moderate exercise is essential to health and well being.  Proper, varied forms of exercise raises heart rate, raises endorphins, improves muscle strength, improves balance, improves flexibility and increases blood flow throughout the body including the muscles and joints.  In the case of arthritis, there is inflammation in the joint capsule and the bones themselves which leads to severe pain and often deterioration.     The nerve endings in the joint become super sensitive and pain can be unbearable.

Believe it or not, your choice of diet can directly impact your ability to exercise. When you consume an Anti-Inflammatory Diet, often you will notice you will able able to exercise with less pain is because this diet eliminates many known triggers for arthritis.

 

Some examples of arthritis triggers include:

  • Fried and processed foods
  • Thought to be due to compounds called AGE – (advanced glycation end products) These products are the result of heating, grilling, and frying foods.  The body utilizes pro-inflammatory molecules called cytokines in an effort to break them down and the result is excess inflammation in general as well as in the vascular system (blood vessels).
  • Sugary foods
  • Dairy
  • Alcohol
  • Foods/Oils with Omega-6 fatty acids – such as vegetable oil (safflower), corn oil, fried foods, certain nuts and seeds, mayonnaise

 

Some examples of beneficial foods include:

  • Foods containing high levels of Omega-3 Fatty acids – (ex. salmon, herring)
  • Avocados
  • Flax seed
  • Cherries and other berries (contain anthocyanins that are thought to be anti-inflammatory)
  • Leafy vegetables, broccoli – contain vitamin D
  • Green tea – has EGCG (epigallocatechin-3-gallate) a powerful antioxidant
  • Vitamin C containing foods (ex. papaya, brussel spouts, broccoli, citrus fruits)
  • Garlic, onions and leeks

 

It is very important to listen to your body.  Pay attention to the foods you are eating and the way you feel.  Often times, foods that are considered healthy may cause issues for you.  If you suffer from arthritis, try rotating your foods (i.e. do not eat the same food everyday).   If there are certain foods you think might bother you, wait 3 days in between eating them.  Then pay attention to the way you feel when you re-introduce those foods.  If you notice you have more difficulty with pain or decreased ability to exercise try eliminating the offending foods for a week or two.

Typically, it will take several weeks of following the diet closely before you see results with regard to decreased pain from inflammation.

When exercising with arthritis, it is important to modify your exercises as per trainer recommendations.  If exercises hurt, if possible, discuss with your trainers to find another way to exercise that muscle group.  In the beginning, there may be some exercises you simply cannot do.  What is important is that you are attempting to exercise.  With each passing week you will find that you can do a little more than the previous week.  Progress may be slow, with ups and downs.  As always, if despite closely following the diet, you are still having issues, it might be time to seek the advice of a health care professional.

Numbness in The Feet When Exercising

 

Numbness and tingling in the feet during exercise is a fairly common complaint I have come across during my years of treating patients. There are multiple etiologies for numbness, some of which are benign, and others that may indicate a more serious underlying issue. In this article we will focus on some of the causes of numbness and tingling and several factors that can be modified to alleviate these complaints.

Some common words used to describe pain related to nerve injuries include:

  • Numbness
  • Tingling
  • Burning
  • Electric Shock
  • Freezing
  • Pins and Needles

In addition, sometimes nerve pain can cause a sensation that is out of proportion to the amount of pressure or stimulation applied to an area. For example, when you lightly touch your skin, you know you are being touched, but it should not feel painful. When the nerves in the area you are touching are damaged, the light touch can actually stimulate a painful sensation.

One of the most common causes of foot pain and numbness during exercise is due to poorly fitting shoes or socks that are to bulky. The easiest fix is to have your shoe wear evaluated by a medical professional or even a specialty shoe store. If you are wearing shoes with a toe box that is too small or have stiff shoes with an exceptionally high arch support these might be the causes for your pain. By getting proper fitting shoe-wear for your body type, you maybe able to completely eradicate your pain.

The nervous system has two parts, the central nervous system, and the peripheral nervous system. The central nervous system is composed of the brain and the spinal cord, and the peripheral nervous system is made up of all the peripheral nerves in the body found outside of the spinal cord. The nerves themselves are composed of two basic parts the axon and the myelin. The axon is like a wire that carries the information from one part of the body to another. The myelin is the covering outside the nerve, like the insulation of a wire. In a nerve injury, the axon, the myelin, or both can be damaged. The type of damage sustained by the nerve determines the symptoms that are present and the duration of the injury.

Pain in the foot can be due to compression, inflammation, or infection anywhere along the path of the nerve. Pain during exercise is most likely due to intermittent nerve compression. There are certain places in the body which are prone to nerve compression because of our anatomy and the tight spaces the nerves need to pass through. It is important to assess the areas of the foot that are numb because this can help to localize where the compression is occurring.

Morton’s Neuroma
One example of nerve compression is a Morton’s Neuroma. This is the result of compression, stretching, or repeated irritation of the interdigital nerve usually between the 2nd and 3rd or 3rd and 4th toes. It is more common in females than males, and is sometimes described as walking on marbles. Typically the pain radiates into the toes closest to the neuroma and the forefoot. The pain is usually intermittent in nature and can be alleviated by removing shoes. Often sneakers with small toe boxes “tight shoes” and high-heeled shoes aggravate the neuroma. It is also more common in people with tight calf muscles and very flat feet due to their body mechanics. It can be treated temporarily with a nerve injection into the foot. In addition, changing your shoe wear and possible use of shoe insert or pad may be helpful. Physical therapy may also be indicated. If physical therapy and conservative interventions fail, then surgical removal may be necessary.

Tarsal Tunnel Syndrome
Another reason for nerve compression is a condition called Tarsal Tunnel Syndrome.  The tarsal tunnel is the canal formed between the inside of the ankle bone and a band of ligaments that stretch across the foot. The tibial nerve runs inside the tunnel and can get compressed. Pain and sensory disturbances due to tarsal tunnel syndrome is usually located in the bottom of the foot. Some causes for tarsal tunnel syndrome include, bony anatomy, ankle swelling (due to cardiac issues, inflammation, or injury), flat feet, arthritis or bone spurs. Non-surgical treatment options include, steroid injections, orthotics (braces, shoe inserts, and splints), anti-inflammatory medications and dietary modification (removal of inflammatory foods). If conservative treatments fail, a tarsal tunnel release may be indicated.

Common Peroneal Neuropathy
The common peroneal nerve can get compressed at the fibular head, which is the bony prominence just below the outside of the knee. If this happens, pain and numbness is present along the outside of the leg from the knee down into the top of the foot. The common peroneal nerve then further divides into two branches. If one of these branches gets compressed, the numbness and tingling will occur in a more specific distribution.

It is also possible for the nerves of the leg to become entrapped or compressed in the muscles of the back of the thigh, (i.e. Sciatica)or at the level of the spine (Disc Herniation, or Radiculopathy) . However with Sciatica and Radiculopathies the pain, numbness and tingling tend to include the leg as well as the foot.

Other mores systemic but common causes of foot numbness include, but are not limited to:

  • Diabetes peripheral neuropathy
  • B12 deficiency
  • Disk Herniation
  • Radiculopathy
  • Vasculitis (inflammation of the blood vessels)
  • Stroke (more likely if numbness is only on one side of the body)
  • Raynauds phenomenon

As always, if you suffer from foot pain during exercise, it is a good idea to have it looked at by a health care professional.

Plantar Fasciitis

Plantar fasciitis is a common cause of foot and heel pain. Typically this pain is located on the bottom of the foot just in front of the heel pad on the inner or middle side of the foot. The plantar fascia is a thick tendon that connects the heel bones to the toes. This tendon serves as a shock absorber for the foot and helps in supporting the arch of the foot. Overuse or excessive stress on this tendon can cause small tears that lead to inflammation and significant pain.

 

 

Some common risk factors for plantar fasciitis include:

  • Obesity
  • Poor foot mechanics
  • Improper shoe wear
  • Long distance running
  • Jumping exercises
  • Prolonged standing

Exercise regimens that consists of a fair amount of jumping or plyometric exercises are very good for cardiac conditioning and development of muscle power. Generally speaking the heart muscle gets conditioned faster then skeletal muscle. Therefore, your skeletal muscles will fatigue more quickly and your form will break down before you get exhausted due to deconditioning from the heart.

There are muscles on both sides of the foot and leg that help to support the foot and ankle. The peroneus longus and peroneus brevis insert on the outermost or 5th metatarsal (mid bones of the foot) and the tibialis anterior inserts on the inner or 1st metatarsal bone. When these muscles are strong and conditioned, they help with stabilizing lateral (side-to-side) foot motion and control the rate of movement in the foot during jumping exercises. If however, these muscles fatigue quickly or are not yet strong, the foot and ankle has more mobility and collapse in the arch, which in turn can put more strain on the plantar fascia.

This is one of the reasons that plantar fasciitis typically develops in an exerciser after several weeks or months of exercise. It generally occurs when the aerobic or cardiac conditioning out paces the skeletal muscle conditioning. In other words, your heart endurance allows you to jump or run for longer periods of time, but your leg muscles are not conditioned enough to control your ankle motion. If in addition to decreased muscle strength, you are carrying around extra weight, are wearing improper shoes, have poor foot mechanics or are increasing the amount of time or the intensity of your jumping, you are a set up for plantar fasciitis.

So what should you do?

It is important to know what type of foot you have and have the proper shoe wear before embarking on exercise and lifestyle changes. There are several very good running stores and even some online stores which will question you about your feet and recommend proper shoe wear. Podiatrist or Sports Medicine/Rehabilitation Medicine physicians are also useful for providing recommendations and treatment plans. It is important to note that not one type of sneaker is good for everyone. Sometimes due to foot or even hip and knee mechanics you will need an orthotic insert to place in your shoe.

In general, a helpful guideline for shoe wear and orthotic use is to fix what is too flexible (i.e put in arch support in a very flat foot or over-pronating foot) and to accommodate foot deformities that are fixed (i.e. relief or padding around bony deformities such as bunions). A common mistake is to over correct too much (using too rigid or too high an arch support). This can lead to other issues higher up the kinetic chain such as knee, hip or back issues.

Plantar Fasciitis is typically worst in the morning just after getting out of bed. Pain is usually severe with initial weight bearing and then subsides throughout the day with walking and weight-bearing. Pain can also be severe after prolonged sitting or immobility. It is often helpful to wear nighttime splints to keep the foot/Achilles tendon stretched out overnight. This will decrease the initial severe morning pain because the fascia will have more mobility and will not be able to scar down overnight.

Aside from using proper shoe wear and night time splints, occasional use of anti-inflammatory medications such as Motrin will be helpful. Adding anti-inflammatory foods such as turmeric, (curcumin), boswellia, and Omega-3 fatty acids in addition to decreasing intake of Omega-6 fatty acids may also be helpful. Icing can be helpful as well. Sometimes, despite the above interventions, you will might need a cortisone injection into the plantar fascia to decrease inflammation and pain.

During the acute inflammatory phase of plantar fasciitis, it is important to limit the activities such as high impact jumping and running that can aggravate the condition. Modify your exercise to limit jumping until pain resolves during activity and upon wakening. As pain decreases is it imperative to resume jumping/high-impact exercises slowly over a period of weeks to even months to prevent recurrence. As with all my recommendations, if you have persistent heel pain that is refractory it is important to seek the advice of a medical professional to make sure other modifications or treatments are indicated.