Back Sprains and Strains

Low back muscular strains and/or ligament sprains are exceedingly common in the general population. These injuries may be the result of demands placed on the low back by everyday activities, or may be related to an acute injury. Symptoms are believed to be caused by a partial stretching or tearing of the soft tissues. For the vast majority of patients, these conditions are of short duration with a complete recovery as a general rule. Most individuals recover rapidly, with 50 to 60% of patients recovering within one week and 90% of patients recovering within six weeks.

Low back pain may begin suddenly or develop gradually over the first 24 hours following an injury. Pain is usually relieved by rest and exacerbated by motion. The patient may stand in a flexed position or tilted to one side. Almost all patients with low back injuries can be treated satisfactorily. The main objectives of treatment are to relieve pain, improve function and prevent recurrence.

Treatments include:

1. Limited period of bed rest, generally not to exceed 48 hours after injury.

2. Therapeutic cold or heat, instruction in proper body mechanics, and exercise.

3. Spinal manipulation therapy.

4. Medications including: muscle relaxants, NSAIDS, analgesics (narcotic and/or non-narcotic), and steroids.

5. Epidural steroid injections in selected cases.

Consultation with an appropriate specialist should be obtained if conservative treatment has not led to significant clinical improvement within four weeks of the reported injury.

When someone is injured, either in an acute trauma, or from gradual injury with repetitive postural stress and strain, they should be concerned with doing all that they can do to promote proper tissue repair. While simple rest may be enough for some patients, a great percentage of us wind up with chronic pain and decreased mobility from soft tissue injuries. Incomplete healing of soft tissues also leaves us open to further injury in the future, as well as chronic degenerative conditions, such as arthritis, cartilage degeneration (chondromalacia), and degenerative disc disease. While our society tends to promote the notion that the individual should do nothing and depend completely on drugs, surgery and minimal physical therapy to achieve healing, the truth is that the patient should be the primary therapist and utilize various professionals to heal properly. The patient conducts healing 24/7, while the therapist may only be with the patient for one hour a week. To ignore this proactive approach to healing may leave you with a debilitating chronic pain.

In 2010, we have seen an enormous increase in the number of patients ignoring proper tissue repair, and being denied proper conservative medical care to restore injured tissue. Narcotic pain killers now account for over 7 percent of all prescribed drugs, with dependency increasing dramatically over the last decade (see NY Times article link below). Pain medications are ideally suited for short term relief of pain while proper phyisotherapy restores healthy tissue, but too often we are settling for drug addiction in the injured population. Such unnecessary addiction to narcotic pain medications have serious consequences that the patient is not informed of. A study in Washington state that prompted laws requiring better use of conservative care when chronic dependency on narcotic pain medications is seen, found that there are significant devastating side effects to chronic use of these drugs, including debilitating lethargy, increased sensitivity to pain, and in an alarming number of cases, unintentional fatal overdoses.

There is now much concern over the prescription of narcotic pain medication alone to treat chronic pain syndromes, and denial of soft tissue therapies and acupuncture, with long-term consequences of debilitating side effects and even accidental deaths from chronic use of common narcotic pain relievers.

“This is not just about addicts but little old ladies with arthritis starting to die because of this kind of medical practice. There is a dissonance in not recognizing the nexus between poor pain management and the hyperconsumption of opioids.” Dr. Alex Cahana

Dr. Cahana, who works at the University of Washington Medical Center in Seattle, is using the medical term opioids to refer to synthetic narcotic pain killers like OxyContin. Dr. Cahana, a pain specialist, was involved in devising regulations in Washington State to mandate better conservative care before increasing a dangerous dependency on pain medications.

Not only narcotic pain relievers, but anti-inflammatory drugs, or NSAIDS, have elicited much concern in the medical community in the last decade due to serious harms to health with chronic use. The Vioxx Cox-2 inhibitor case was a well publicized example, with withdrawal of this drug from the market due to a threat of FDA action, and billions of dollars involved in patient lawsuits. Research and publicity of the Vioxx case revealed extensive proof of cardiovascular risk from inflammatory dysregulation from nearly all NSAIDS, though. In 2009, the U.S. government issued the largest criminal fine in its history, $1.3 billion, on a charge of illegal marketing of the painkiller Bextra, which was a Cox-2 inhibitor, like Vioxx, that was also finally withdrawn from the market in 2005. The final Cox-2 inhibitor still prescribed, Celebrex, was also the subject of numerous lawsuits alleging patient injury from heart attacks, strokes and other cardiovascular disease, and Pfizer acknowledged that it had settled more than 90% of these lawsuits with an $894 million deal in 2008, concerning Bextra and Celebrex. These lawsuits and research into the effects of chronic use of NSAID pain medications has prompted black box warnings to be required on most NSAID medications. While patients do not completely want to give up on pain medications, despite evidence of risk, more and more intelligent patients are looking to decrease use and risk by integrating conservative therapies into the treatment protocol.

Complementary and Integrative Health Care, especially acupuncture combined with traditional physiotherapies and herbal/nutrient medicine, and its long successful history of healing acute and chronic tissue injuries

Traditional Chinese Medicine (TCM), sometimes simply called acupuncture, utilizes a wide variety of treatment modalities to promote optimal soft tissue healing, and combines these with patient instruction to achieve the best outcome. The training specialty of the Licensed Acupuncturist may include physiotherapies such as Tui Na (soft tissue mobilization), myofascial release, acupuncture, trigger point needling, herbal and nutrient medicine, and topical herbal remedies. TCM is also an Integrative and Complementary Medicine, meaning that it is meant to integrate and complement other specialties, such as that of the Physical Therapist, Chiropractor, Surgeon, etc. A well trained and experienced TCM physician is able to show the injured patient the best targeted stretch and exercise, correction of postural mechanics, and guide the patient toward an improved dietary approach to healing.

Soft tissue is a term that encompasses muscle, tendon, ligament and joint tissues. The most difficult tissues to heal are the tendons, ligaments and joint capsules, including the cartilage, which is the soft tissue over the bone at the joint. These tissues do not typically have their own blood supply, and depend upon movement of surrounding tissues to push nutrient fluids in and out of these harder soft tissues. Patients that wind up with chronic pain and limited mobility usually have a problem with these tissues, due to the limitations of circulation of blood, which contains the nutrients and inflammatory mediators so important to soft tissue repair. This is often due to the advice that they should just immoblize the injured body part and rely on pain medication. This typical advice in allopathic medicine has dominated the standard treatment of soft tissue injuries for decades, but has no sound physiological basis. Such treatment protocol is useful in the very acute stage, where rest, ice, compression and elevation (RICE) is typically recommended for moderate to severe sprains and strains. Continued use of this protocol has been perhaps suggested in standard medicine just to prevent the patient from reinjuring the tissue, but is detrimental to tissue healing. This article helps the patient understand the physiology of soft tissue repair so that the individual can choose the intelligent course of activity to achieve the best healing outcome.

Of course, the best form of mobilization of soft tissue after injury is passive mobilization, meaning that the patient is passive while an expert mobilizes the tissues in the best way. This soft tissue mobilization, or Tui Na in Chinese, has long been a hallmark of Traditional Chinese Medicine. TCM is usually referred to simply as acupuncture, and today more and more medical doctors are recommending this treatment approach. Standard medicine has tried unsuccessfully in the past to promote an allopathic approach to soft tissue injuries, suggesting that a limited treatment protocol of surgical repair when needed, pain medication and corticosteroid therapy is enough. Recent additions to the protocol, such as platelet-rich plasma injections, are proving ineffective, and long-term benefit from corticosteroid injections has not been shown in clinical trials, while risks from overuse of synthetic steroids is now well documented. All of these allopathic approaches have their benefits, but as more and more medical doctors are now admitting, this limited approach cannot replace a thorough holistic approach to aiding soft tissue repair with an integrated multidisclipinary and comprehensive conservative treatment strategy. Limiting rehabilitative care has been partly the fault of the insurance companies as well. But by refusing to pay for adequate therapy with rehabilitation, and failing to utilize herbal and nutrient chemistry to promote better tissue healing, many soft tissue injuries have turned into painful chronic problems, and the eventual cost of chronic health care to insurers has not been healthy financially. Patients are now becoming educated to the need for a treatment protocol that insures the best long-term outcome, and are increasingly turning to Complementary and Integrative Medicine to achieve this goal.

Each specialty in medicine has its focus, and each provides the injured patient with a set of skills and knowledge. Medical doctors are increasingly specialized in the United States, and the surgical skills are greatly appreciated when needed. Often, though, the medical doctor offers little more than surgery, immobilization, and pain medication, and their education does not extend into areas of manual physiotherapies, or herbal and nutrient medicine. The terms Integrative Medicine and Complementary Medicine are used to describe physicians such as Licensed Acupuncturists that add these skills and knowledge to the overall treatment protocol. Physical Therapists and Chiropractors, as well as Osteopaths also offer a unique set of skills and knowledge to aid tissue healing and rehabilitation, and may be integrated into a mulitdisciplinary approach when needed. Too often, the advice from the primary physician, though, is to immobilize the injured body part for too long and avoid other therapy. These other specialties generally realize that prolonged immobility and pain medication alone is not the most scientific approach to tissue healing. When looking at the physiology of tissue healing, we see many therapeutic steps that can be taken to help our injuries heal quickly and optimally.

Understanding Injury to Better Understand Healing needs

Each patient that suffers injury to muscle, tendon and joint tissues experiences a unique injury that must be rehabilitated according to the individual needs of the patient. That person's body will do the work of repair, which is an amazing physiological process, and even patient's with severe injury will experience a regrowth of tissue that is often stronger than the original tissue. During this repair process we must provide the optimum conditions for the body if we are to expect optimum outcomes. The person that should be in charge of this responsibility is the patient themself, and this requires gaining knowledge and choosing the right team of therapists. Various physicians and therapists provide skill and expertise to help the patient, but only the patient is there every day and every hour to insure that the right conditions are being provided for their body to heal properly. Understanding of the healing process, and the time frame of tissue healing, helps guide the patient to take a logical and individually tailored step-by-step therapeutic schedule. Eating the right foods and taking the right herbal and nutrient chemicals that can optimize the cellular environment to achieve the best healing results is also important. Patients with chronic health problems that could impede tissue healing need to understand the special needs that must be addressed. By taking the time to better understand tissue repair, you can feel more confident in the process, and avoid the disability of chronic pain and dyfunction. How your body heals is not out of your control, but you must understand that your own body does the work, not some outside force.

Soft tissue injuries basically are comprised of what we call strain and sprain in most cases. In acute injury, strain refers to injury of a muscle or tendon in which the fibers of these tissues tear as a result of overstretch, or overload. In repetitive and postural stress injuries, or subacute injuries, strain is defined as pathological tissue reaction to prolonged stress, usually sustained overload from repetitive use, or maintaining postural positions that strain. In overuse injury that does not happen suddenly, with a strong trauma, which is called subacute, excessive cumulative loading leads to microtrauma, and often a chronic inflammatory response, as collagen is deformed under consistent low level overloading. The deformed collagen and inflammatory response leads to unwanted scar tissue and adhesion, which must be broken up and rehealed. The least elastic part of the muscle is the tendon, and the most frequent site of injury in muscle strain is the myotendonal junction. This part of the strain injury is called an enthesopathy, and must be treated by decreasing contractile tension with myofascial release, gently breaking up tissue lesions with active release technique, and increasing nutrient delivery to the tendon tissue with mobilization.

In most acute injuries with a chronic underlying tissue injury, we rarely see tendon inflammation, which accompanies acute rupture or tear, but instead see a degenerative tendon condition that is exacerbated by the acute injury. This is called a tendinosis. Chronic inflammatory problems with the joint capsule itself are common, though, and this is called arthritis. The patient must understand that arthritis is a symptom, not a disease, although over 50 types of arthritic disease are classified, usually utilizing the term arthritis in the name, such as Rheumatoid arthritis. As we approach the subject of sensible treatment protocol for acute injury with underlying tissue problems, we must usually treat degenerated tendons and chronically inflamed joints. Although the term partial tendon tear is often used to describe tendon injuries viewed with MRI, many experts feel that this term has been routinely used to justify arthroscopic surgeries, and the partial tendon tear is in actuality more rarely seen than degenerative tedoninosis. In recent years, studies showing poor long-term results in many cases of arthroscopic repair if the underlying degenerative tendinosis and arthritis is not addressed with proper conservative care, has greatly reduced the number of these surgeries. To correct underlying tendinosis and chronic arthritis, mechanical tension on these tissues must be reduced, tissue perfusion restored, stabilization of the joint must be accomplished, and proper joint mechanics must be taught to the patient.

The subject of physiological aspects of tendon healing are still controversial, with experts disputing the time frame of restoration of normal tensile strength of tendons after acute injury and tearing. While muscle may achieve restoration of normal tensile strength in 7 to 11 days, even if inflammation persists, tendons and ligaments may take 4 months for 85-95% of normal tensile strength to return, and many experts claim that this time frame is 10 to 12 months. The lack of a uniform finding in this area reflects the differences and challenges in restoration of tendon strength for various tendons in the body and between individuals. Individuals with tendon injuries often do not restore the tendons to normal tensile strength for even longer periods of time than a year, and this is thought to be responsible for the recurrent injuries in sports or at work. Because of this long time frame for restoration of functional strength, and because of the fear of recurrent injury, the patient will often be afraid to use the joint affected by a tendon or ligament injury. This is a mistake. Movement, mild to moderate gradated exercise, restoration of normal range of motion, therapeutic stretch, and mild breaking of adverse tissue adhesions and scar tissue is very important to a speedy and efficient tissue remodeling and restoration of tendon tensile strength. Of course, sudden heavy activity on the injured tendon will come with a risk of reinjury and should be avoided. Too often, the patient will stop all normal use of the injured joint area for a few months, and then try to immediately resume the normal sport and exercise routine. This is the major cause of reinjury. A gradated step-by-step approach to restoring functional remodeling and tensile strength of tendons and ligament after injury is very important, and can be guided by a professional skilled in soft tissue therapies, such as a knowledgeable Licensed Acupuncturist with training in Tui Na, herbal and nutrient medicine.

Sprain refers to injury to the ligament and joint capsule that is caused by stretch beyond their normal capacity, also involving tissue tears and other pathological reactions, such as the pulling of the tissues off of the bone attachment, and eventual degeneration of the cartilage and meniscus. Often, chronic tissue injury underlies the acute strain and sprain injury, with calcified and degenerative arthritic tissues more susceptible to injury. If the past injuries were not treated with a thorough protocol, the possiblity of future reinjury is greatly increased. By taking a holistic and individualized approach to therapy, both the acute and chronic underlying tissue problems can be addressed to maximize successful outcomes. If the tissue tears are partial, or composed of many small tears in the tissues, surgical repair is usually unnecessary. This does not mean that the patient should do nothing to promote healing of these partial tissue tears and microtears, as well as other degenerative tissue problems that can lead to prolonged pain and dysfunction. Proper conservative care is needed. Soft tissue mobilization, acupuncture, and related physiotherapies, combined with herbal and nutrient medicine, offers a complete package of conservative care that is now supported by much research. Decreased range of motion, weakness, and positional pain may all result from incomplete repair of strain and sprain injuries, and the smart patient persists with effective therapy until the tissue is again healthy and fully functional.

By first defining your injury as acute, subacute, or acute with chronic underlying conditions, you can better understand the individualized needs of your body in tissue healing, and choose the right therapeutic routine to promote quick and healthy healing. If you promote the best healing in the individual case, you might be surprised to find that in many ways your body heals with new tissue that in some ways is stronger and healthier than what you had before. You might also develop new skills in maintaining tissue health that will stick with you and benefit you in the future. Time and money spent in proper healing from injury is an investment in your future health.

Standard treatment of tissue strains and sprains has involved rest, ice, compression and elevation (denoted by the acronym RICE). Proper use of ice and compression can reduce excess swelling and pain within the first 24 hours, and rest and elevation may aid circulation and drainage. These therapies should be applied judiciously, though, as normal swelling and inflammation protect the injured tissues, and excessive icing and compression may reduce circulation and impede the natural processes of tissue healing. Excessive rest and elevation of the injured area may also decrease circulation and impede natural tissue repair. Within 1-3 days, in most injuries, mobilization is very important, and mild exercise to regain strength and prevent muscle wasting is very important to long term outcomes. To treat soft tissue injury with too simplistic of an application of RICE, and to avoid other therapies and therapeutic activities that could speed healing and prevent complications, is not an intelligent approach.

Factors that may retard healing of tendons, ligaments and joint capsules include aging, poor nutrition, lack of Vitamin C, cool temperature, and steroids (Walter Israel 1978). Unfortunately for patients, the standard medical treatment today suggest prolonged use of icing and corticosteroid injections, and does not address the aspects of nutrition in the healing process. Local causes that inhibit soft tissue healing include poor circulation (ischemia), tissue irritation from chronic infection or hematoma, dryness of the wound tissue, excessive repetitive stress, and adhesion to underlying bone or surrounding tissues. Soft tissue physiotherapies should be utilized to increase circulation locally and break up tissue adhesions, and patient instruction in proper body mechanics and self-administered therapeutics, such as targeted stretch and exercise and gentle range of motion, should be utilized to speed healing rather than retard it. Use of a heating pad before targeted therapeutic stretch and exercise is important to increase blood flow locally, and use of a heating pad before bed may also increase circulation during the night, when peripheral circulation is lowered normally. Proper sleep posture is often important as well, as various prolonged sleep positions will greatly impede local circulation and put a postural strain on affected muscles. A competent physicians will be able to instruct the patient in these simple protocols, and this may be the most important part of the therapy. Standard medical doctors are concerned with pharmacological and surgical interventions and rarely provide this guidance.

Understanding the physiology of tissue repair

To best understand what the individualized approach to therapeutic protocol should be, it is best to understand the physiology of tissue repair. The first three days after tissue injury are considered the acute inflammatory phase, where platelets in the blood stick to injured tissue and form clotted material, preventing excess blood loss, triggering a release of various inflammatory mediators and growth factors, and allowing blood fluids to accumulate as swelling. The degree of swelling corresponds to the degree of tissue injury, and inflammatory mediators both cause broad vasoconstriction, and local vasodilation and vascular permeability, allowing a large number of immune cells, mainly neutrophils, to attract to the growth and clotting factors, and to clear cellular debris via phagocytosis and oxidation. The large number of neutrophils also clean the wound by secreting protease enzymes to help break down glycoprotein membranes, which speeds tissue replacement and new cell growth. Excess accumulation of protein breakdown products from damaged cells may contribute to further edema, though, if circulation is not maintained. During the second and third day, monocyte white blood cells and macrophages are attracted to the injured tissues and clear the spent neutrophils, as well as tissue debris. The level of oxygen in the tissues, or lack of it (hypoxia), stimulates the macrophages to secrete chemicals that stimulate increased angiogenesis, or creation of new blood vessels, as well as new epithelium. This new epithelial tissue is called granulation tissue, and will be replaced eventually by normal epithelium. At first, collagen type 3 is produced to build new tissue, but forms misaligned fibers with less strength than the subsequent tissues, which are composed largely of collagen type 2. By aiding circulation with movement and warmth following icing, and not overdoing the rest, ice, compression and elevation, this acute healing phase is helped, and the next phase of tissue healing will begin sooner.

About day 2 or 3 of tissue repair, the reconstruction phase, or proliferative phase, of tissue healing is under way. This phase lasts from 48 hours up to 6 weeks, depending on the severity of tissue injury. Even after surgery, the reconstruction phase achieves fairly strong regrown tissues in 2 to 6 days. During this phase, fibroblast cells accumulate and the ordered process of recreating the tissues like they were before has begun. Fibroblasts, or fibrous tissue creating cells, are the main cells in the new tissue during this phase, creating tissue adhesions, new scar tissue to bridge gaps, and depositing much ground substance and collagen type 2 into the bed of the repairing tissue. Ground substance is the non-cellular components of the connecting matrix between cells, and is primarily composed of hyaluronic acid as fluid, glucosamines, and proteins. Up to 80 times the normal amount of collagen type 2 is produced, and these fibers align in a complex network that creates tissue strength. Alignment of the collagen matrix is accomplished with the help of electromagnetic properties of mineral ions. This reconstructive activity in the tissue creates even more oyygen free radicals that need to be cleared from the tissue. Supplementation with collagen type 2 and tissue antioxidant may be very helpful to tissue repair in this phase. Proteolytic enzymes may also be helpful to clear protein fragments from the protease activity.

As new cells are laid into the collagen matrix, the high level of collagen type 2 production continues. In weeks 1 to 3 this collagen production by fibroblasts peaks, and may continue at a high level for the next 2 to 4 weeks. The collagen matrix is what makes the tissue strong and elastic, reistant to further damage. The tissue has knit and is durable by this time, as stated, between the fifth day to about the sixth or seventh week, depending upon the degree of tissure tearing. Therapeutic stress may follow this time frame. If the tissue is subjected to mobilization and mild stress, the growth produces stronger tissue. Full stress of the injured tissue is sometimes avoided until the seventh week to be certain to avoid reinjury. A competent and experienced therapist will be able to judge this time frame accurately. Rebabilitating without professional guidance can involve some risk of reinjury. Muscle will heal faster than tendon, ligament and joint capsule, and gentle toning exercise of the muscles can be initiated at an early phase of rehabilitation. Heavy stress upon the tendon and ligament should be limited, and the degree of tearing of these tissues should determine the degree of stress in therapy in each individual case. Eventually, eccentric loading of the muscle and tendon has been shown to produce the best recovery in tendon injury. This technique utilizes a therapist who elongates the muscle as the patient applies contractile force. The force applied by the therapist is greater than the force exerted by the patient.

The remodelling phase of the soft tissue injury may last from 3 weeks to 12 months. This phase involves continuing replacement of the collagen fibers, with improved cross-linking to promote healthy scar tissue where needed. Healthy scar tissue does not produce pain or limitation, and does produce a tissue that is usually stronger than the pre-injury tissue. Unhealthy scar tissue creates chronic dysfunction. If the tissues are properly stressed and stretched during this phase of remodelling, optimum functional capabilities of the muscle, tendon and other tissues are achieved. Therapeutic activities should continue during this entire period, and much of this therapy can be performed at home by the patient. During the remodelling phase, more vigorous activity can be utilized without fear of reinjury. A TCM physician often is skilled in patient instruction, and provides the time in therapy to achieve this instruction. This is complemented by the work of the physical therapist, who offers much expertise in patient instruction as well.

To summarize, the acute inflammatory phase of tissue repair involves the first 1-3 days, depending on severity of the injury. The second phase of healing, the reconstruction phase, then lasts from 2 days to 6 weeks, depending on the type of injury. The third phase, remodelling of tissue, replaces strong reconstructed tissues with even stronger remodelled tissues, and lasts from 3 weeks to 12 months, depending on the type of injury. These 3 phases of tissue repair and remodelling may overlap. If the tissue is stressed properly during these phases of tissue remodelling, circulation is maintained at an optimal level, proper body mechanics are restored quickly, unhealthy scarring and tissue adhesions are gently broken up, and proper nutrients are delivered to the healing tissues, then you will see optimal results.

The array of therapies available from the experienced Licensed Acupuncturist

The physiotherapies of Traditional Chinese Medicine, called TuiNa, address many of the needs of the tissues during the healing phases. Soft tissue mobilization stimulates new growth, gently breaks up adhesions, and increases circulation. One problem often encountered as injuries heal are contractures or shortening of the various tissues, especially the tendons. If the shortened tendon and muscle is left in an immobilized and shortened position, the outcome may be poor for regaining full range of motion. In the joint, ligament and capsule may regrow in a position that also restricts movement and range of motion. Gentle soft tissue mobilization will prevent this undesirable outcome. Active release techniques will gently break up the adhesions and tissue lesions near the joint. Myofascial release will reduce spasms and contracture, taking the pressure off of tendons, myotendinous junctions, and joint tissues that are difficult to heal. Neuromuscular reeducation will help the patient focus on the restoration of proper joint mechanics and postural stress, as well as targeted stretch and excercise that can be continued at home. Often, the continued use of improper body mechanics, with overuse of the crutch or cane, will cause more long-term problems than the injury itself, as improper body mechanics put unnatural stress on the healing tissues, itself a cause of strain and sprain.

Both acupuncture and herbal medicine offer great advantage to the overall protocol. Acupuncture may stimulate both local circulation and healing, as well as address better systemic health, and also treat underlying health problems that may impede the healing from injury. Studies have proven that electroacupuncture treatment speeds cellular growth and accelerates repair in tendon, ligament, and joint capsule tissues. Acupuncture also stimulates healthy pain relieving neurotransmitters, endorphins, dynorphins, and enkephalins, providing sustained pain relief to allow greater ease with therapeutic protocols. Both topical herbs and oral consumption have proven benefits in tissue repair. Herbal formulas address many aspects of tissue healing, and may be combined with various food nutrients, such as antioxidants, proteolytic enzymes, amino acids etc. Professional herbal companies continue to utilize the latest research to provide better formulas and higher quality products. Since this industry is not properly regulated, it is best to depend upon professional products from a Licensed Herbalist and Acupuncturist to achieve the most assured results.

Therapeutic protocol during the stages of rehabilitation of soft tissue injuries

Stage 1: Acute inflammatory phase: various injuries may involve acute swelling, redness, noticeable warmth to touch, and pain that can last from a few hours to 3 days. Initial treatment usually involves some sort of immobilisation or restriction of motion, perhaps with use of sling, brace or wrap. This period should not be extended more than necessary. For example, immobilisation of the knee joint has led to muscle breakdown and atrophied weakness in as little time as 6 hours in studies. Use of rest, ice, compression and elevation is preferred, with icing applied just until the cold penetrates the deep tissues, about 5 or 10 minutes, and followed by mobilization and warmth. This both decreases excess sweilling and then increases circulation to clear edema and bring blood nutrients to the tissues. Mobilization usually involves non-weight bearing range of motion, but can also utilize mild contract and release toning with an elastic therapeutic band (isometric excercise). Cardinal motions are preferred, and complex elliptical joint movements discouraged.

Herbal and nutrient medicine, as well as acupuncture, is very helpful during phase 1. Antioxidants, collagen supplement, proteolytic enzymes, and various herbs that modulate inflammatory processes and promote tissue regeneration are prescribed. Topical herbs have long been used in the treatment of acute tissue injury in Traditional Chinese Medicine, and recent scientific studies have proven remarkable efficacy with the delivery of herbal nutrients directly into the area. Examples of herbs used in therapy for acute tissue injury include Boswellia serrata, or frankincense. At one point in history, frankincense and myrrh resins, along with dragonsblood, were some of the most valuable trade items in the world due to their medicinal effects in treating acute trauma. Modern research has revealed 17 chemicals with potent anti-inflammatory activity in Boswellia, mostly triterpene acids (see study cited below). Notoginseng, or San qi, is another of the key herbs used for acute tissue injury. This herb has exhibited marked hemostatic and anti-inflammatory effects in study, and potent antiplatelet and anticoagulant effects have been noted (see study cited below). By combining various herbs, antioxidants, and enzymes in formula, the combined effects are very beneficial to modulating inflammatory response and promoting circulation and healing in acute tissue injury.

Stage 2: Regeneration and Repair: this phase lasts from the second day up to 6 weeks, and the body's requirements for optimal tissue regeneration include good circulation, tissue nutrients, inflammatory modulators, and mobilization of tissue. As tissue heals, regrowth and inflammatory mechanisms create tissue adhesions and scar tissue. Unhealthy tissue adhesions occur when the body part is kept immoblized, especially in an unnatural position. Shortened tissue fibers may result is the body part is kept in a flexed position. Gentle mobilization and stretch insures that unwanted adhesions and unhealth scar tissue is cleared. Mobilization is also important to deliver nutrient fluids to the tendons, ligaments and joint capsule, as these tissues do not have their own vascularity, and depend upon movement of surrounding tissues to push fluids in and out of the tissues. As time progresses, gentle breaking of adhesions, and gentle stress of the regenerating tissues encourages faster and stronger regrowth. The tissues need a very large amount of collagen at this stage, and a high degree of antioxidant clearing, as regenerating tissues create a large amount of oxidant free radical debris. While the body produces collagen and antioxidants, oral supplementation of these nutrients may also significantly help to insure optimal nutrient and antioxidant activity. A study by Dr. David Trentham of Harvard Medical University, published in Science, Vol.261;5129;pp1727-1730, demonstrated that purified collagen extract type II, given for 3 months to rheumatoid arthritis patients, demonstrated significant benefits in tissue repair, and in delivering and replacing the autoantigen collagen with healthy collagen from the supplement.

Scientific study with human trials in tissue repair and regeneration are problematic, especially when attempting to measure manual therapies such as acupuncture and physiotherapy against a placebo and keeping the patient and physician blinded to this process. Study of herbal and nutrient supplements are also problematic in human trials, although much evidence of in vitro effects of the herbal chemicals in the laboratory has been demonstrated. Two therapies that have undergone human testing in recent years in the repair of tendon and ligament tissues are eccentric loading and pulsed stimulation, which have demonstrated significant benefit. These are but two of the many therapeutic techniques utilized in standard therapy by the TCM physician with training in soft tissue moblization. Eccentric loading is a technique that the therapist used to apply gentle stress to the tendon as it heals by exerting a lengthening of the muscle and tendon against the mild contracting force of the patient. Pulsed stimulation via electroacupuncture is a technique that is also commonly used. These are but two of the standard techniques used in the overall protocol when the therapist is skilled in acupuncture and Tui na physiotherapy. The Licensed Acupuncturist is able to utilize an array of proven therapies in the overall treatment protocol, in combination.

Stage 3 of tissue healing and regeneration lasts from 3 weeks to 12 months, and involves remodeling. After the tissue is regenerated, the body still needs to continue to replace new tissue with stronger tissues. Periodic physiotherapy and a sound program of self-administered therapy is very important during this phase to insure optimum results and avoid chronic problems. Choosing the right therapists to help with this protocol is very important. The tissues during this stage are very strong, and vigorous soft tissue mobilization is recommended, as well as more vigorous excercise and stretch. Continued use of herbs and supplements to aid the body in tissue replacement could also be very helpful, as well as continued acupuncture stimulation. If underlying health problems may inhibit tissue maintenance and replacement, these should also be addressed.

Bone fracture and the process of healing

The patient with bone fracture needs to understand the physiology of bone healing and the basic types of fracture to approach the subject of the proper rehabilitative course. Since the patient is the key therapist, having to deal with the healing from injury 24/7, patient understanding is key to optimum results. Like soft tissue repair, there is basically 3 phases of fracture healing, the reactive, reparative, and remodeling phase. Much of the physiology of bone repair follows the basic outline of soft tissue repair described above. The bone has its own blood supply and a tissue matrix composed largely of collagen. When the bone is fractured, bleeding and clotting occur, limiting the loss of blood, and releasing many chemicals to begin bone tissue healing from the platelets and blood proteins in the clot. Cells that generate new fibrous tissue, called fibroblasts, survive and are stimulated by these chemicals to replicate rapidly. Like soft tissue, this initial phase is usually limited to 1 to 3 days, and then repair of the fracture begins. Subsequent phases of bone healing and the healing protocol and level of use and stress on the bone depend upon the type of fracture.

Medicare guidelines for bone healing describe 5 stages of healing: 1) bleeding and callus formation in the first 1-3 days; 2) migration of bone cells to the callus and an initial viscoelastic bridge of bone matrix formed approximately 2 weeks after fracture; 3) calcification of the basement layer of cartilage and full bridging of the fracture gap appoximately 4 weeks after fracture; 4) acceleration of calcification and revascularization at approximately 8 weeks after fracture; and 5) rigid bone development and return of normal bone strength that would take a full stress at approximately 2 months to 2 years post fracture. Both the severity of fracture, and the degree to which a proper treatment protocol accelerates bone growth, should be considered when judging how much mobility and stress should be applied within this time frame. We see that some stress may be safely applied, even to the open fracture, at least by the end of 8 weeks. Of course, during this time of bone repair, it is important to maintain the strength and tone of stabilizing muscles, which account for much of the supporting strength of the body part that has suffered a bone fracture.

The second phase of bone repair, the reparative phase, begins within a few days of the fracture. The bone covering, or periosteum, forms scar tissue and adhesion to fill the gap of the fracture, and these periosteal cells then develop into bone producing cells, or chondroblasts. The most prolific and direct blood supply exists in the shaft of long bones, and the periosteum covers this bone and is highly vascularized. The heads of the long bones, at the joints, are covered by cartilage, which is similar to periosteal tissue, but is poorly vascularized. Blood and nutrient flow to the heads of the bone and cartilage depend again on movement. This is why hard casting is used less and less these days. Complete immobilization in bone fracture has been shown to be inhibitory of healing and often has a worse outcome than a mobilized joint. Once again, excess early mobilization and stress must be avoided during the early phases of bone repair to avoid reinjury, but excessive caution produces poor long-term results. The usual time frame for formation of a sturdy callus and new bone matrix is 6 to 12 weeks. Full stress of the bone should be avoided, but a gradual increase of stress at about 10% per week is often recommended.

Cartilage is composed mainly of hyaline, and is covered by a vascularized membrane called the perichondrium. The cartilage over the bone at the joints grows from the top layers to the bottom layers, and eventually, the bottom, or basement layers, turn in bone cells. Hyaline is mainly composed of collagen type 2 and chondroitin sulfate. Damage to the cartilage is common in joint injury, and tissue repair is similar to that of the ligament and other joint capsule tissues. The difference in cartilage repair is that a form of D3 hormone (mistakenly called Vitamin D3), stimulates the rate of transformation of cartilage cells to bone cells (ossification), and sufficient production of chondroitin sulfate by the cells is needed. We have tried for years to supply the cartilage with dietary chondroitin, but studies show that this supplement probably breaks down before it reaches the target tissues with most supplements. The exception to this was found with purified extract of chicken embryonic cartilage, collagen type 2. Transforming growth factor beta induces chondroitin sulfate proteoglycan production, and may be induced by D3 cholecalciferol supplementation as well, to insure sufficient bioavailability of chrondroitin in the healing process. Professional products that deliver this combination of usable collagen extract and cholecalciferol may be very helpful. In my practice these include Health Concerns' Collagenex 2 (based on research at Harvard Medical College), and a liquid cholecalciferol (Vitamin D3) supplement. Topical herbal products with glucosamine included, topical products with boswellia and other tree resins, which have been proven successful in promoting tissue repair, and stimulation of cartilage cells with electroacupuncture (also proven to stimulate cartilage growth), form a complete package of treatment that utilizes scientific research to achieve the best cartilage repair.

If the bone fracture is at the head of the bone, attention must be paid to cartilage repair as well as bone repair and remodeling. If the fracture is in the shaft of the bone, attention must be paid to the periosteum and vascularized bone. In both cases, a bone callous is formed quickly, providing sufficient strength for the bone to accept moderate stress. In time, this bone callous is remodeled. In the remodeling phase, bone cells first create much collagen to create a bone matrix, then secrete much alkaline phosphatase, an enzyme that stimulates mineral deposition in the collagen matrix. This enzyme stimulates release of alkaloid phosphates from proteins and other molecules, creating a large number of protein fragments that must be cleared from the new bone matrix. Production of alkaline phosphatase can be inhibited in various underlying health conditions, such as anemias and postmenopausal hormone deficiencies. Lowered levels have been observed due to taking of hormone replacement drugs, as well as standard drugs to treat osteoporosis (biphosphonates). Hypothyroid states, pernicious anemia, chronic myelogenous leukemia, magnesium deficiency, and inflammatory bowel conditions have also been associated with deficient alkaline phosphatase. During the remodeling phase, these underlying conditions should be addressed if needed, and proteolytic enzymes, collagen supplement, antioxidants, and a mineral formula that combines magnesium with calcium hydroxyapatite in a alkalinizing phosphate base can be taken. To further strengthen the remodeling bone, a strontium supplement can also be used. Strontium is a mineral very similar to calcium, and thus is easily accepted into the bone matrix, yet is not easily pulled out of the bone, creating a stronger mineral base to the remodeling bone.

In some circumstances, the body has excess need for alkaline phosphatase, and this is primarily associated with liver stress and underlying systemic acidity conditions. Alkaline phosphatase is an enzyme that is found in abundance in white blood cells as well, and this is why marrow disease or anemia may inhibit proper bone remodelling. Inflammatory bowel disease is associated with altered levels of alkaline phosphatase because we derive much of the enzyme, or raw materials for the enzyme, from normal bacteria in the gut, which are deficient in states of chronic inflammatory bowel disease, as well as functional GI disorders such as irritable bowel syndrome. Restoring a healthy lower GI function and health with herbs and supplements, and taking a quality probiotic is thus also potentially helpful in some cases to recovery from a fracture.

A sound study of fracture healing impairment by the use of biphosphonates, drugs used to treat osteoporosis, was conducted by Japanese researchers, and supported by the American Study for Bone and Mineral Research, in 1999. The findings: “With respect to clinical usage, the present study suggests that the process of fracture healing would not be disturbed if the biphosphonate treatment is stopped when fracture occurs. However, continuous biphosphonate treatment even at a possibly clinical dose could delay callus remodelling and maybe further delay reconstruction of bone structure.” (Journal of Bone and Mineral Research; Vol.14, No.6, 1999. Jiliang Li, Satoshi Mori et al). Unfortunately, the cessation of osteoporotic drug therapy when a fracture, or when microfractures occur, has not been standard clinical practice in the United States.

In summary, bone healing and treatment protocol should follow an individualized course, but even with open fracture, a cone callus should form and provide significant strength for performance of gentle therapeutic protocol at 4 weeks. Strength of the bone to withstand normal weight bearing stress should be adequate at 8 weeks, but high impact stress may have to be avoided for up to 2 years in the most severe and difficult fractures. Maintaining tone of stabilizing muscles, mobilization of the surrounding tissues to encourage circulation of nutrients to the tissues, and use of various herbs and supplements, will all be helpful to achieve the optimum outcome. The use of D3 cholecalciferol, purified collagen extract from chicken cartilage, antioxidants, proteolytic enzymes, magnesium, calcium hydroxyapatite, and various amino acids may all be helpful in aiding bone repair. Use of strengthening minerals, such as strontium, may achieve stronger mineral matrix. Various herbal strategies will be helpful to achieve the best results and speed bone healing. During healing, gentle breaking up of tissue adhesions and restoration of tissue stretch and length is important. Quick restoration of normal body mechanics will also be helpful to avoid long term problems. Treatment of underlying health problems may also be very important to outcomes, and discussion with the medical doctor of discontinuation of drugs that could impede bone healing should be considered, especially if osteoporotic therapy with biphosphonates is ongoing.

Chronic pain and restriction of mobility after an acute injury

If your injury has healed, and you are left with underlying chronic joint pathology that has worsened, this is the time to focus your energies on restoring healthy tissue where chronically degenerated tissue has ensued.

"Modern medicine is turning to less invasive and more holistic protocols such as prolotherapy, laser surgery and other minimally invasive surgical techniques combined with a comprehensive package of support therapy to promote healthy restoration of the arthritic joint. This is where the use of Complementary Medicine comes into play."

Prolotherapy is an example of the new attitude taken by the medical community to degenerative joint conditions. In this therapy, also called sclerotherapy, sugar or nutrient solutions are injected repeatedly into the deteriorated or degenerative ligaments, joint capsule soft tissues and tendon attachments to stimulate regrowth of the fascia, or connective tissue. Prolotherapy produces an inflammatory response in these soft tissues to stimulate regrowth, but as the Mayo Clinic reports on their website, prolotherapy alone is not proven to be beneficial. It must be combined with an array of Complementary therapies to achieve success. Utilizing acupuncture, topical herbal medicines, and nutrient medicines, all of which have shown clinical proof of benefit to arthritic joint conditions, along with direct soft tissue physiotherapies, such as TuiNa and myofascial release, the ultimate success with prolotherapy is greatly enhanced.

Prolotherapy produces an inflammatory response in the joint tissues to promote healthy growth. While anti-inflammatory medicines such as ibuprofen and naprosen may relieve pain temporarily, the inhibition of inflammatory processes may result in long term degeneration rather than healthy tissue restoration. Corticosteroid injections will also cause joint degeneration if repeated too often, and a new clinical trial comparing long-term outcomes of PRP and corticosteroid injection showed that corticosteroids provided no improvement in long-term outcomes of pain and disability (see NY Times article cited below). Corticosteroids come with considerable health risk when a patient is taking multiple products with synthetic steroids chronically, and synthetic steroids are now found in many prescription and over-the-counter products. The real benefit of corticosteroid injection is a short-term relief of pain that provides a window of opportunity for the patient to utilize an array of conservative treatments to achieve better tissue healing. Complementary and Integrative Medicine provides this array of treatments, combining phyisotherapies with acupuncture, herbal medicine, topical herbs, nutrient medicine, and patient instruction to ahcieve maximum results. Complementary Medicine also utilizes the inflammatory mechanism to do what it is supposed to do, not just create pain, but to repair the tissue. Herbal and nutrient medicine may optimize the inflammatory response to promote the natural tissue healing mechanisms built into the body. For this to work a comprehensive and holistic approach must be taken that insures that your immune response and inflammatory tissue repair works optimally.

One type of injection that has been utilized more frequently in recent years for degenerative joints, especially for osteoarthritic knee joints, is hyaluronic acid. A multicenter placebo-controlled trial of the effects of this therapy in France was completed in 2008, and the results indicated that a single injection of hyaluronic acid produced no better results than placebo (see additional information). Hyaluronic acid is a substance found in normal joint fluid and tissue, and is a major component of synovial fluid, which lubricates and protects the white tissues of the joints, which have no direct significant blood supply, and thus depend upon movement to push fluids in and out of these tissues. The white tissues are the cartilage, meniscus, ligaments and tendons, and these are the tissues that degenerate in the joint. One reason that they degenerate so severely in osteoarthritis is because the bone covering, or periosteum, which does have abundant blood and lymphatic vessels, is absent where cartilage covers the bone at the joint. Instead we normally have layers of cartilage where bone meets bone, and these layers are supplied with nutrients from two directions, the vascularized muscles, and the vascularized bone. When degeneration occurs in the bone and cartilage, spurs or osteophytes, and changes in the bone underlying the cartilage, occur, where this outer bone is converted into a dense smooth ivory-like substance (eburnation), preventing the lower layers of cartilage from getting the necessary blood supply from the richly vascularized bone and also preventing the normal conversion of cartilage into new healthy bone. This basement layer of your cartilage is composed of a type of cartilage cell that creates hyaline and type II collagen. This layer of cartilage near the bone is normally oxygen-rich, from the bone blood supply, and a lack of oxygen accounts for poor hyaline formation. Injection of hyaluronic acid alone will not correct this problem, and only restoration of these cartilage cells that produce hyaline will achieve proper lubrication and decrease of pain. A step-by-step therapeutic approach is necessary to regain the healthy metabolism of lubricating hyaline and formation of new collagen. A combination of passive joint mobilization, stimulation with acupuncture and electrical stimulation, increased blood flow, healthier immune reaction, antioxidant clearing, and tissue nourishment with type II collagen, and perhaps hyaluronic acid included in the comprehensive treatment protocol, is the logical course to increase the success of this therapy.

More advanced study of the physiology of this cartilage near the bone has indicated that activated Vitamin D3 hormone, or 24,25-(OH2) D3, is essential to regulation of the healthy calcification of this layer of cartilage. When calcification slows, the cartilage near the bone becomes hypertrophied, or swollen, preventing both circulation to the tissue, as well as inhibiting the growth mechanism of the more surface layers of cartilage. Restoration of this D3 hormone mechanism involves more than just taking Vitamin D. Hormone balance is essential to the Vitamin D3 metabolism. Restoration of healthy hormone balance may thus be needed in certain patients with degenerative cartilage. In the healthy individual, most of our Vitamin D3 cholecalciferol prohormone is generated in our skin with frequent exposure to sunlight for short periods at midday. This cholecalciferol is then transformed, via a number of enzymatic steps, tightly controlled by endocrine feedback regulation, into the activated hormone D3 forms that we need. This occurs mainly in the kidneys. To restore potential D3 deficencies that may be greatly contributing to your degenerative cartilage and joint conditions, a thorough holistic approach is recommended, and professional guidance may be necessary. The book entitled Cartilage, by Brian Keith Hall and Stuart A. Newman thoroughly outlines these findings, and states: ”What distinguishes chondrocytes (cartilage cells) of the growth plate from other chondrocytes would appear to be their ability to respond to environmental regulation by Vitamin D metabolites in a manner not shared by other chondrocytes.“ What this means is that for patients with chronic degenerative cartilage, no matter what the cause, surgical correction and supply with nutrients such as glucosamine and chondroitin will not achieve ultimate goals of restoration without a healthier hormonal support. This type of increased hormonal health can only be achieved with a holistic approach.

A second type of joint degeneration occurs with repetitive wear and tear to the upper layer of cartilage, and this is called chondromalacia, or commonly ’runner's knee‘. In this degenerative condition, the upper layers of cartilage, usually under the patella, degenerate due to poor regrowth when patellar motion wears away the surface of the underlying cartilage. Uneven muscle tension and/or joint subluxation may be the cause of this abnormal abrasion of the patella against the cartilage. Most cases occur in young athletic individuals, especially women, whose wider pelvic structure may create more lateral force on the patella. Masking of the pain with non-steroidal anti-inflammatories and steroid injections may actually contribute to the degeneration because these allow the athlete to continue with harmful activities instead of resting and affecting repair. Using conservative therapies early in the syndrome may be the best advice one could get. After the chondromalacia has become chronic, there are few standard treatment options. Surgical correction has produced very few good outcomes, and often the patient is told that they may have to endure chronic pain until a full knee replacement is justified later in life. The patient wants to hear a more optimistic treatment plan than this. Since our body's tissues constantly regenerate, there is never a reason to believe that with proper treatment protocol, that restoration of healthy cartilage surface cannot by achieved. It only takes work, time, and the care of a knowledgeable Complementary Med physician who combines the various treatment strategies in a logical manner.

Trust and Confidence: the need for the patient to take a realistic and objective assessment of the health care industry and influence on government when deciding the course of treatment

There is a history of enormous monetary intervention by the health care industry in both influencing government, and influencing the health care provider and public with treatment recommendations and data. The current health care debate has revealed that the health care industry accounts for over 15% of the entire economy, and could potentially account for up to 30% in the future. Of course, with this amount of profit as a motive, common business sense requires the industry to try to control how this enormous sum of money is spent. Lobbying and political contribution by the health, insurance and pharmaceutical industry accounts for over half the direct campaign donation to congress in 2008, and anaylysts report that a similar figure might be applied to lobbying money spent. Advertising budgets have soared, and the finance committee in the U.S. Senate, leg by Republican Charles Grassley, has uncovered massive amounts of money spent on fraudulent ghost-written scientific studies and payments to researchers and those who control university health research.

As published studies of efficacy in knee surgery emerged, there was a large decrease in the number of surgeries to repair degenerative knee joints. New devices, promising a more natural and “biologic’ approach to surgery, have emerged. In 2009, the FDA admitted that its own former commissioner unduly influenced the fast-track approval of such a device, a biologic meniscus patch, because of intense pressure from three Congressman and one Senator, all whom received significant campaign donations from the company manufacturing this device. The FDA agency director overrode the advice of its science advisors to approve and endorse this surgical device. The story can be read by clicking on the site in additional information at the end of this article.

Both the patient and the surgeon must not be unduly swayed by data and recommendations pushed by the industry, but must make a decision based on the realistic, safest and best course of therapy by analyzing objectively what could realistically work. Hopefully, this article helps the patient and their doctor decide to look into, and try conservative therapies. The course of therapy presented in Complementary Medicine is not simpler, and requires a proactive approach by the patient, but may produce the best long-term outcome for many patients.

Joint degeneration of the Lumbar vertebrae

A similar profile of degenerative joint conditions and unnecessary surgeries has been shown in large studies of lumbar spine pathologies. The New York Times article quotes Dr. Michael Modic, chairman of the Neurological Institute at the Cleveland Clinic, who scanned hundreds of study participants with MRI and concluded that as many as 60 percent of healthy adults with no back pain have degenerative conditions in their spines, and that between 20 and 25 percent that receive MRI studies of the lumbar have herniated or bulging discs. Dr. Modic states that one-third of these herniated or bulging discs disappear in six weeks when repeat MRI studies were performed, and about two-thirds disappear in six months. His study found no definitive correlation between worsening disc bulging, resolving disc bulging, and symptoms. He recommended that a person with low back and leg pain should be treated conservatively for at least eight weeks before considering surgery, and that MRI scans should be used as a presurgical tool, and not as a definitive diagnosis suggesting surgical correction.

Unfortunately, we live in a culture that wants a quick fix, and patients usually look at their situation as a choice between one type of therapeutic agent or regimen versus another. This will result in failure in the majority of cases. The successful approach utilizes a variety of agents and therapies to accomplish all 3 of the above goals, namely pain relief, elimination of the causes and contributors to tissue degeneration, and restoration of healthy tissues. By trying to choose a simplistic treatment approach, rather than a comprehensive treatment protocol, the patient is usually prolonging their suffering and at best will only slow the degenerative process. Surgery may be necessary, and may clean up some of the problems with unhealthy tissues, but without a comprehensive treatment plan, degenerative conditions will recur and continue to cause pain down the road.

In many patients, the same vascular pathology that worries them about risk of future cardiovascular problems also contributes to the spinal degenerative condition. In the medical text, Myelopathy, Radiculopathy, and Peripheral Entrapment Syndromes by David Durrant, and Jerome True, the authors state: “Many of the patients that develop degenerative stenosis fall into the same age group at risk for acquiring cardiac and peripheral vascular disease. Some of these individuals may also have a coagulation disorder from disease or from therapeutic intervention (blood thinners). Clinicians who identify cardiac, vertebral, and/or aortic diesase should pay attention to the possibility of a history suggestive of an undiagnosed intermittent myelopathic (spinal cord) presentation.” The arteries run alongside the nerve roots, spinal cord, and supply the needed nutrients to maintain the vertebral discs and lamina. Attention to vascular health should be part of the therapeutic protocol for degenerative lumbar conditions.

Much scientific research is devoted to understanding the underlying health problems leading to secondary osteoarthritis, or degenerative joint disease. The National Institutes of Health estimates that 18.2% of the U.S. population will have some form of arthritis or rheumatic condition by 2020. Osteoarthritis is the most common form of arthritis, affecting 12.1% of U.S. adults in 1998, and was the second most common diagnosis in the population. It is estimated that 80% of the aging population will experience secondary osteoarthritis. Research reveals that this slowly developing degenerative condition is likely related to a syndrome of anabolic dominance leading to an eventual catabolic excess. Anabolism is the metabolic construction of complex molecules in our tissue which is balanced with catabolism, the breaking down of complex molecules in the tissues to resupply energy and the building blocks of larger molecules. This process is stimulated and regulated mainly by hormones and the endocrine feedback system. In TCM terminology, this would be referred to as a balance of Yin and Yang, with anabolism being a yang process balanced by the bioavailability of catabolic yin nutrients and energy. When this balance is dysfunctional, a gradual disease process occurs leading eventually to Osteoarthritis.

The anabolic hormones include insulin and insulin-like growth factors, testosterone, estradiol, and growth hormone. When we have problems with hormonal balance and insulin resistance, or relative excess of estrogen from progesterone deficiency, we may develop anabolic dominance. Excess adrenal stress that is chronic may not only stimulate high blood pressure, but excess androgens and testosterone. Testosterone may aromatize to estradiol in our tissues, or to dehydroepiandosterone, and stimulate breast tumors, prostate hypertrophy, and other tissue abnormalities. In a similar way, these hormones play a significant role in tissue repair and maintenance, and imbalances may lead to degenerative arthritic conditions. Insulin resistance and anabolic dominance may lead to metabolic syndrome and inability to lose weight from the midsection, high cholesterol and poor cardiovascular maintenance. Such syndromes of imbalance lead to poor inflammatory regulation and tissue remodeling, and eventually degenerative joint disease is discovered, often too late to fully correct. The smart patient will seek help to prevent these problems be utilizing preventative medicine and TCM. The knowledgeable TCM physician can test for your hormonal profile, look at the circadian rhythms of cortisol imbalance, and gradually correct the Yin and Yang of hormonal imbalances that lead to degenerative disease. TCM may thus be a valuable Complementary Medicine in prevention of osteoarthritis as well as a comprehensive treatment strategy.

Achieving pain relief with medication does not mean that the degenerative condition is resolved, and when the patient focuses only on pain relief as a measure of success, this success is usually temporary. Dependence on pain relieving medication can be very harmful to the health and create other serious problems, such as stomach and gastrointestinal problems, and cardiovascular inflammation. A whole treatment protocol, directed by a competent physician, utilizing physiotherapy, patient instruction, acupuncture, herbal prescription, dietary supplements and changes, and correction of postural mechanics is effective, especially when the physician, who is a Licensed Acupuncturist, identifies contributing health problems and addresses these as well. The ultimate benefits of this comprehensive approach are many, and the patient will emerge with not only pain relief, but lasting tissue health, a healthier daily routine, and decreased risk of serious health problems related to aging.

Popular supplements and herbs are frequently advertised with exaggerated claims and give the patients false hope. Prescription of herbal formulas and nutriceuticals by a Complementary Physician with a Medical License and education in herbal medicine, and utilizing professional products, will be much more effective. Along with the proper herbal formulas, acupuncture and physiotherapy, there are a variety of specific herbs and supplements of use. These products are usually helpful but are not a cure by themselves, and quality varies considerably between products due to the lack of regulation by the FDA. Professional products insure quality control, and these are available only to the Licensed herbalist. Here are the facts on some of the popular therapeutic aids available to the public:

Oral Glucosamine supplement: studies show that oral glucosamine had no effect of increasing glycosaminoglycan content when the cartilage was normal, but had some mild beneficial effect if the cartilage was in a rebuilding phase. Rebuilding cartilage has a much increased demand for glucosamine. Studies show that rates of collagen repair in the cartilage & meniscus were not affected by the amounts of oral glucosamine or injected glucosamine. These studies point to the fact that the patient must improve the body’s response to tissue repair in order to utilize the glucosamine supplement, and then this supplement will be effective. Thus, oral glucosamine, or glucosamine delivered locally to the tissue, in the form of topical agents or injections, will benefit only as part of a program that improves the overall tissue repair response. In patients that have no rebuilding of cartilage or meniscus, the glucosamine supplement is a waste of money. When the patient utilizes a complete conservative care treatment plan with passive soft tissue mobilization, gentle breaking up of tissue adhesions, and various stimulation techniques, the cartilage goes into a rebuilding phase, and the glucosamine is utilized fully (refer to PubMed PMID: 12355498)

Cartilage extracts with Matrix Proteins: sharks cartilage and bovine cartilage extracts have been available for some years. In many cases of degenerative joint problems, these have been ineffective. Studies that looked at patients with autoimmune cartilage diseases such as Rheumatoid Arthritis and Polymyalgia Rheumatica showed that these supplements could be useful to modify the course of the disease. The studies showed little effect in cases where the degeneration or joint inflammation was induced by medication side effect. The effectiveness of the cartilage protein extracts was linked to the immune stimulation of proteoglycan synthesis, and thus, concurrent use of immune stimulants or modifiers that enhanced interleukin or other cytotoxic immune response could greatly improve the effect. Once again, alone, these supplements may not benefit, but integrated logically into a treatment plan, they may have dramatic results for the right patients.

Collagen extracts and antioxidants: when the joint is receiving physiotherapy, with gentle breaking of chronic adhesions and improved circulation, there is a great need for large amounts of collagen in joint tissue repair. Studies show that the tissues may need up to 80 times the normal supply of collagen. Along with this nutrient material, antioxidants are required to help with clearing of dead tissues and debris. I use Health Concerns Collagenex to supply usable collagen type 2 (glucosamine, chondroitin etc.) derived from compatible tissue extracts from the chicken, along with whole grape extract, which is proven to be a potent tissue antioxidant. I also utilize a topical herbal cream that delivers glucosamine and chrondroitin with the carriers MSM and emu oil, so that these nutrients can get to the tissues directly. When used within the course of physiotherapy, this combination can benefit greatly. A study at Harvard University School of Medicine by Dr. David Trentham found significant improvement in rheumatoid arthritis patients with the use of low dose collagen type 3 extract derived from chicken tissue for 3 months, with the effects attributed to both increased collagen supply and an inflammatory modulating effect on cytokines. Since a purified type II collagen extract is needed, many collagen supplements on the market are insoluble and insufficient, and a professional product such as Health Concerns Collagenex is recommended.

Maca and Cat's Claw: studies have shown significant benefit for cartilage repair with the use of these herbs. Of course, cartilage cells, or chondrocytes, will not regrow until manually stimulated. Studies have also shown that chondrocytes will regrow when the tissue is stimulated with gentle cross-fiber massage, or if this is not possible, with passive joint mobilization techniques and electrical stimulation. Studies showed enhanced mRNA (insulin like growth factor) expression and production in human chondrocytes when joint mobilization was utilized, and certain herbal chemicals have shown efficacy in promoting insulin like growth factor as well./p>

Gotu Kola: this herb has also demonstrated significant benefit in regrowth of joint tissues and cartilage. Chemicals act on collagen formation, anti-inflammatory activity, and antioxidant clearing. Amino acids and triterpenoids in Gotu Kola are considered to be essential to tissue healing. If there is a problem with varicosities or veinous insufficiency, combine this with Butcher's broom and Stone Root (Formula V).

Amino acids: certain amino acids are essential for repair of soft tissue such as ligament and tendons. L-Arginine, L-Lysine, L-Leusine and L-isoleucine are all effective, and should be combined with Vitamin B6 to increase utilization. The olympic swimmer Dara Torres claimed that an amino acid formula was extremely helpful in healing her tissues and helping her get to another Olympic tournament at age 41.

Manganese or Manganese SOD: manganese deficiency has been shown to be a significant factor in many cases of degenerative cartilage. Manganese deficiency results in the poor utilization of chondroitin, glucosamine and other mucopolysaccharides in the normal repair and maintenance of cartilage. Manganese SOD (super oxide dismutase) is a combination of a potent antioxidant with manganese, and thus may aid cartilage repair even more.

Proteolytic enzymes: Serratiopeptidase and Seaprose-S are two researched enzymes that help clear the rebuilding tissues and are proven to aid in both cartilage repair and decrease in chronic joint pain with a long course of use.

Pomegranate extract with seed oil and polyphenol antioxidants enhanced by fermentation: a study by the Case Western Reserve University School of Medicine, published in the September 2005 issue of the Journal of Nutrition, demonstates that a properly prepared concentrated extract of pomegranate exherts significant antioxidant and anti-inflammatory properties, such as the inhibition of interleukin 1b, which plays a key role in cartilage degeneration in osteoarthritis.

Boron and Vitamin D3: boron along with activated vitamin D3 hormone may increase cartilage formation. Boron helps regulate calcium metabolism and helps activate estrogen and vitamin D3, as well, preventing tissue calcification and aiding tissue repair. Food sources of boron include dates, raisins, prunes, almonds, hazelnuts and honey. Like many individuals, you may be deficient in activated vitamin D3, which is a hormone activated by exposure to sunlight on circulating D3. A simple blood stick test is available to determine D3 deficiency. Daily exposure to sunlight on the face and arms for 10 minutes insures activation, and so a midday walk in the sun is helpful. Exposure through glass in the car or office is not effective. You might take a cholecalciferol D3 supplement as well as chelated boron supplement combined with amino acids to aid utilization. Current study on boron supplementation is insufficient to definitively confirm that boron supplementation will treat arthritic conditons. Vitamin D3 is not really a vitamin, but rather a prohormone. D3 cholecalciferol is created daily in your body by exposure to sunlight, health cholesterol metabolism, and minimally from food sources. This cholecalciferol goes to the kidney to produce hormone D3. Two types of D3 hormone are known to science, and recent research has found that one isomer is integral to cartilage remodeling, regulating the basement membrane of the cartilage near the bone, and may be responsible for successful cartilage remodeling and repair. Since D3 hormone is tightly regulated in your body, not only supplementation with cholecalciferol and increased midday sun exposure is recommended, but also treatment to correct hormonal imbalances and improve the functions of the kidney and liver metabolism. Studies show that a high percentage of the population is deficient in D3. Utilize a holistic medical regimen to best advantage when taking these supplements.

Information Resources

A 2010 NY Times Health article outlined the dangers of depending on pain medication rather than utilizing conservative healthcare and such safe treatments as acupuncture to properly heal tissue injury and manage pain. New laws, such as this one in Washington state are mandating better conservative care for chronic pain:http://www.nytimes.com/2010/07/29/business/29pain.html Underlying health problems should be addressed to facilitate better tissue healing and pain reduction. This National Institute of Health study outlines how deficient estrogen syndromes increases pain perception and decreases tissue healing in women:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1808228/ NY Times Health article on recent evidence supporting conservative care with meniscus tears http://www.nytimes.com/2008/12/09/health/09scan.html?partner=rss In 2006, pharmaceutical research in Japan found that a common Chinese herb used to treat tissue injury, Boswellia, or frankincense, contained 17 chemicals with marked anti-inflammatory activity: http://www.ncbi.nlm.nih.gov/pubmed/16621377 In 2010, further research showed that Boswellia (frankincense tree resin, or Ru xiang) significantly stimulated anti-inflammatory modulators and reduced collagen matrix breakdown to treat cartilage degeneration - Cardiff University, United Kingdom:http://www.www.ncbi.nlm.nih.gov/pubmed/19943332 In 2009, research at the National University of Singapore measured the in vitro and in vivo collagen-induced anti-platelet and anticoagulant effects of Panax notoginseng in animal studies, and found that the effects were greater than aspirin. These are just two of the many beneficial effects of the various chemicals in this herb:http://www.sciencedirect.com/science Harvard Medical University conducted a double-blind placebo human trial of collagen type 2 extract derived from chicken tissues and found a significant benefit in tissue healing in patients with rheumatoid arthritis: http://www.chickencartilage.com/harvardstudy/ Environmental Health Perspectives gives a peer-reviewed in depth analysis of the benefits of boron supplement at http://www.ehponline.org/members/1994/Suppl-7/newnham-full.html Serratiopeptidase is clearly explained athttp://www.purebodysolutions.com/Merchant2/graphics/00000001/PDF/serratiopeptidase.pdf Hyaluronic acid injections are not the same as prolotherapy; a large randomized trial in France was completed in 2008 and showed no benefits:http://www3.interscience.wiley.com/journal/122220639/abstract?CRETRY=1&SRETRY=0 A 2009 article in the New York Times outlines current research that shows that platelet-rich plasma injections found in rigorous study to provide no better healing than saline injections, and that steroid injections provide temporary benefit, but do not change long-term outcomes of pain and disability. : http://www.nytimes.com/2010/01/13/health/13tendon.html?ref=health A 2001 study by the Univerisidad Nacional in Lima, Peru, demonstrate that Cat's Claw, or other species of Uncaria, had proven beneficial effects on human study participants with osteoarthritis of the knee, both reducing pain and with antioxidant and anti-inflammatory mechanisms, especially the inhibition of TNFalpha:http://www.ncbi.nlm.nih.gov/pubmed/11603848?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=2&log$=relatedarticles&logdbfrom=pubmed A 2009 NY Times article reveals manipulation of FDA approval of new biologic surgical devices: http://www.nytimes.com/2009/09/25/health/policy/25knee.html Medicare guidelines for treatment of bone fracture are described, and the evidence for use of pulsed electrical stimulation is presented: http://lobby.la.psu.edu/

The information on this website is not intended to be used as a specific medical advice or cure. Please consult with the practitioner or an appropriate physician, such as a licensed acupuncturist, naturopath, or medical doctor, to discuss the proper application of the information contained on this website.