Anterior Cruciate Ligament Injuries Intrinsic Risk Factors – Structural differences – Quadriceps Femoris angle – Femoral Notch – Joint Laxity and Flexibility – Hormonal Influence Extrinsic Risk Factors – Muscular Strength and muscular activation patterns – Knee Stiffness – Jumping and Landing Characteristics Structural Differences Pelvic Width Tibiofemoral angle Magnitude of the Q angle Width of the femoral notch Quadriceps Femoris Angle(Q Angle) Average male and female = 8-17 degrees Women avg. at high end; contributes to wide pelvic base and shorter femoral length resulting in more lateral proximal reference point Q angles greater than 20 degrees for women are abnormal Inc. lateral pull on quadriceps femoris muscle on the patella and put medial stress on the knee Lower extremity alignment cannot be altered, but the dynamic position of the tibia can be improved with internal rotation exercise of the tibia(medial hamstring) Femoral Notch Early as 1938, postulated that the dimensions of the intercondylar notch (height, width, ratio of height to width, and overall shape) contribute to anterior cruciate injuries A narrowed anterior or posterior notch width increases the risk CT testing necessary A-shaped notch Joint Laxity and Flexibility Inherent in the individual Support by strengthening the quadriceps, hamstrings, gastrocnemius Caution in attempt to increase flexibility Nutritional support Hormonal Influence Estrogen affects soft tissue strength, muscle function, CNS Relaxin can drastically diminish collagen tension Estrogen and progesterone receptor sites have been found in the ACL More non-contact ACL injuries during the ovulatory phase of menstrual cycle(day 10-14) During this time there is an estrogen surge and relaxin peak at day 14 and again midway through the luteal phase PMS influence BCP: hormonal stability Muscular Strength and Activation Patterns In response to anterior tibial translation females prefer to recruit the quadriceps whereas the male athlete first contract the hamstrings Adequate strength and reaction time of the hamstrings is critical in knee stability Coactivation of the hamstrings with quadriceps is necessary to aid the dynamic component of joint stability, to equalize articular surface pressure distribution, and to regulate the joint’s mechanical impedance. Plyometrics and agility-type exercises, running through cones, tires, and figure eights to improve muscle reaction time Knee Stiffness Intrinsic component is the number of active actin-myosin crossbridges in the muscles at a specified point(1st point of protection) Extrinsic component is dependent on the excitation provided by the alpha and gamma motoneurons (potential of protection is greater) Varus and Valgus stiffness Functional training program that emphasizes the hamstring and gastrocnemius muscle groups Jumping and Landing High percentage of ACL injuries occur when athlete is landing from a jump More knee extension on landing produces greater maximum impact force Women perform with less knee flexion, more knee valgus, and less hop flexion.(Orthopedic Society for Sports Medicine Specialty Day, 1999) Specific Jump and Landing training program is recommended for women who participate in sports that require jumping and pivoting (Hewett 1996) Rehabilitation of ACL injuries Early Phase – Weight-bearing and proprioceptive exercises to provide neuromuscular reeducation and improve functional knee stability Return-to-Activity Phase – Dynamic exercises involving jumping and pivoting to retrain the athlete for high impact loading of the knee joint Follow-through Phase – Continuation of the thrusting leg into a position of full hip and knee extension. This position causes a valgus force at the knee and tibial external rotation Back Injuries in the Young Athlete Acute Injuries Fractures – T/L spine compression fx occur with axial loading in a flexed or vertical posture Acute Disc Herniation – Usually without sciatica – May present with back spasm, neurogenic scoliosis, hamstring tightness, buttock pain Contusions, Strains, and Subluxations – Adolescent growth spurt may predispose to an acute apophyseal avulsion of at the lumbodorsal fascia to the apophysis of the iliac crest or spinous process Overuse Injuries Risk Factors – Growth Cartilage- immature ossification centers are often the weakest link of force transfer – Biomechanics • Kinematics: body motion • Kinetics: force to mass and its motion – Intrinsic-musculo tendinous inflexibility – Extrinsic-collision and ground reactive forces – Nutrition- may result in irreversible osteopenia and stress fractures such as spondylolysis Extension Injuries Spondylolysis and spondylolisthesis Lordotic Low Back Pain Transitional Vertebrae Facet Syndrome and Sacroilitis Spondylolysis Stress fracture of the pars interarticularis Repetitive flexion and extension AP/Lat films Symptomatic fracture treated with anti-lordotic lumbosacral orthosis(Boston brace), PT modalities, restricted activities Return to sport after there is demonstrated union, pain-free and manifests a full range of motion Spondylolisthesis A forward slippage that occurs with one vertebral body over the inferior vertebral body. The isthmic type is concern for athlete. Graded by degree of slippage(0-25% grade 1). Athletes are at low risk for progression Progression is associated with rapid growth and is symptomatic Above Grade 3(>50% slippage); risk for progression and surgical candidate Lordotic Low Back Pain Tight thoracolumbar fascia is a consequence of rapid growth. Presents as hyperlordosis with a flat midback and thoracic kyphosis Several pain syndromes may ensue – Traction apophysitis at the iliac crest, spinous process, anterior vertebral ring – Pseudarthrosis (Baastrup’s syndrome) Transitional Vertebrae Incomplete segmentation of the lower lumbar and upper sacral vertebrae Pseudarthrosis may form b/t a bony lumbar extension to the sacral ala or iliac wing Rapid flexion/extension may cause severe inflammation(Bertolotti’s syndrome) which may mimic a spondylolysis Treatment to quiet inflammation and stabilize surrounding structures Facet Syndrome and Sacroiliitis Flexion Injuries Scheuermann’s Kyphosis Disc degeneration Internal disc derangement Non traumatic Causes of Back Pain Scheuermann’s Kyphosis Three consecutive anterior vertebral bodies wedged at least 5% each Vertebral end plate changes Schmorl’s nodes Apophyseal ring fractures Upper trunk and postural exercises Atypical Scheuermann’s is associated with the lower T/L spine due to rapid flexion/extension Aggressive thoracolumbar fascia stretching and spinal stability Disc Degeneration In the young athlete it is usually due to microtraumatic overuse. Internal Disc Derangement Radial tear of the inner anulus. The nucleus pulposus is irritating to the outer annulus. The tear is contained and pressure Non-traumatic Causes of Back Pain Consideration must be given from the beginning. Rule out infections with discitis and osteomyelitis, tumors , juvenile RA, and other Breast Conditions Breast Cancer Lymph edema Fibro adenoma Fibrocystic Breast Changes Breast Augmentation Mastitis Breast Cancer Malignant neoplasm – Classified: in situ (contained) invasive (infiltrated surrounding tissue) Several types: – Two most common: • ductal carcinoma (epithelial cells lining the ducts) • lobular carcinoma (milk-secreting glands of the breast) Ductal Carcinoma Most common of all breast cancers “Ductal carcinoma in situ” has the highest cure rate of all the cancers Growth Patterns: – Micropapillary – Cribriform – Solid – Comedo (most aggressive) Who Gets It? 20-20y/o… 1:2000 30-40y/o… 1:250 40-50y/o… 1:67 50-60y/o… 1:35 60-70y/o… 1:28 Lifetime…. 1:8 Etiology and Risk Factors Personal and family history of Breast cancer Hormonal influences: – high/sustained estrogen levels – HRT – BCP(high estrogen) Exposure: – Foods treated with hormones • Xeno estrogens Genes: BRCA 1 BRCA 2 – 50-85% lifetime risk of breast ca, ovarian ca, both. Signs and Symptoms Silent Mass-typically not movable “orange-peel” appearance of breast Dilated venous pattern Mass in armpit Nipple discharge Non-healing sore on breast or nipple Swelling in arm or hand Back (bone) pain Stages of Breast Cancer Stage O: In situ ductal carcinoma in situ (DCIS) Stage I: Tumor < 2cm, no spread Stage II(A,B): Tumor 2-5cm, with/without spread to axillary lymphnodes Stage III(A,B): Tumor >5, spread to axillary lymphnodes or penetrated the wall to the skin or chest wall Stage IV: Metastasized Dietary Support Indole 3-carbinol: liver metabolism of estrogen to 2hydroxy estrogen derivative cruciferous vegetables broccoli, kale, cauliflower, cabbage, bok choy Lignans Green tea catecins Lycopene (tomatoes, red peppers, grapefruit) Eliminate xenoestrogens (eat organic) Nutritional Supplementation Calcium D-glucarate: aid in elimination of xenoestrogens, assist intestinal flora Coenzyme Q 300mg/day Selenium 60 mcg/day Vitamin C 5000 mg/day Vitamin E 400 IU/day Folate Vitamin B6 50-100mg/day 10 Lymphedema Complication of procedures to treat breast cancer Accumulation of lymph fluid that accumulates in the arm resulting in swelling. Etiology – Removal of lymph channels – Compromised immune system Management Avoid excessive heat to arm, lifting heavy objects, restrictive clothing, strenuous activity Compression sleeves Pneumatic pumps Lymphatic drainage massage Mild range of motion exercise Fibroadenoma What is it? – Benign tumor of the breast Who gets it? – Women in their menstruating years, most common breast tumor in adolescent girls What causes it? – Unknown Signs and Symptoms: – – – – Movable tumor Non-tender Not attached to skin Clearly delineated How is it diagnosed? – Signs and symptoms, biopsy, mammography, Fibrocystic Breast Changes Aka: Cyclic Mastalgia: An exaggerated response of the breast tissue to hormonal changes. Etiology: Unknown Signs and Symptoms: – – – – – Lumpy breasts Breast pain and tenderness Swelling of breasts (feeling of fullness) Soft, movable lumps Symptoms progressively worsen after ovulation and improve after menses Management Decrease caffeine Trans fats excess salt hormonal treated foods Exercise Breast Augmentation: Risks and Complications Anesthesia Rxn Asymmetry Bleeding Breast droop Capsular Contracture Deflation(7%) Displacement Hematoma(3-4%) Impact leak Infection Nerve damage Pain Permanent numbness(15%) Rupture of implant Skin irregularities Slow healing Symmastia(merge into one) Visable scar Sensation Loss/Change 15% risk of having permanently numb nipples Implants placed above the muscle have greater risk. All incisions have a risk of diminished sensation Capsular Contracture Scar tissue hardens around the implant Less common and less severe with saline implants vs. silicone implants Baker Grade I - IV Studies suggest 17% saline implants have some lasting problem Rupture or Leak Rupture of Saline Implants: deflates and the salt water is absorbed by the body. Rupture of Silicone-Gel implants: pain, tingling, swelling, burning. According to FDA, 69% have at least one rupture. Mastitis What is it? – Inflammation/Infection of the milk ducts in the breast Who gets it? – Women who are breast-feeding. If non-breast feeding, look for CA. Etiology? – Improper drainage of the milk ducts. Signs and Symptoms: – Triangular flush: redness on the underside of breast – Swelling, Pain, Tenderness of breast – Flulike symptoms – Fever Prevention/Management Nurse infant on demand Adequate rest Frequent nursing Support bra Hot packs/massage Drink fluids ** Chaste berry (cyclic mastalgia) contraindicated b/c prolactin-lowering abilities Cardiovascular Disease Any disease of the heart and blood vessels, including CAD, atherosclerosis, DVT, varicose veins, strokes, aneurysms, stenosis Women affected after age 55. Men-45 y/o Leading cause of death in women, regardless of race. Cholesterol(a fat) plays a major role – LDL: bad – HDL: good Cholesterol Necessary for variety of functions, primarily the production of hormones It is not soluble in the blood, must bind to a protein that forms a lipoprotein – LDL: not good because it moves away from the liver to target tissues, such as the heart – HDL: the protein removes cholesterol from the target tissue and blood vessels and returns to the liver, for preparation for The role of Estrogen Estrogen raises HDL and lowers LDL Prevents oxidation, making the LDL’ less harmful in the blood vessels. Decreases at menopause – Women in perimenopause typically have total cholesterol 200-240 with desirable HDL and LDL levels. Lifestyle changes Smoking cessation – 4800 chemical substances: many can damage heart and blood vessels • Nicotine-constricts blood vessels, increase HR and blood pressure • Carbon monoxide in smoke- replaces oxygen in the blood, increasing blood pressure, heart has to work harder to get oxygen to tissue • Women who smoke and take birthcontrol pills are 20-30x greater risk of having stroke or heart attack Exercise alone reduces CVD by 30-50% Diet: decrease saturated fats Vitamin C: 2000mg/day Folate, B12, B6: decreases homocysteine levels Homocysteine: Amino acid that, in excess, damage coronary arteries and make it easier for platelet aggregation, predisposing to heart attack and stroke Omega-3 fatty acids Manage weight Female Organ Conditions Fibroids Polycystic Ovary Syndrome(PCOS) Pelvic Inflammatory Disease(PID) Reproductive Tract Malignancies Fibroids What is it? – Noncancerous tumors of the uterus. Who Gets it? – Women during their reproductive years. Silent in 20’s, symptomatic mid-30’s. Etiology: – Heredity – Estrogen/Progesterone Imbalance: • growth is dependent on high estrogen. – Grow during high estrogen times-pregnancy, use of BCP, insulin resistance. – Shrink with low estrogen times-menopause, progesterone only BCP Signs and Symptoms Feeling of hardness in lower abdomen Frequent urination Menorrhagia Anemia Blood clots Asymptomatic Dysmenorrhea Dyspareurnia Mittelschmerz Reproductive problemsmiscarriage and infertility Low Back Pain Uterine Fibroids Attach to muscle wall Pre-menopausal #1 reason for hysterectomy Diagnosis Uterus appears lumpy on pelvic exam Pelvic ultrasound MRI CT Laparoscopy Hysterosalpingogram Dilation and curettage Management Manage insulin resistance: – Can increase estrogen and occurs in times of prolonged stress. Eliminate Caffeine Increase Phyto estrogens: cruciferous vegetables Anti-inflammatory Diet Calcium, magnesium, potassium – decrease muscle/menstrual cramps Fiber: – Food types provide B vitamins that help body’s synthesis anti-inflammatory prostaglandins Psycosocial factors: – Stress causes a rise in cortisol, affects other hormones Acupressure/Acupuncture Spinal manipulation: – Uterus and Ovaries T12-L5 Pain control: massage Vaginal depletion packs-suppositories containing vitamins, minerals, herbs – – – – – Improve circulation of the pelvic organs Draw fluid and infectious exudates out Inhibit local bacteria growth Stimulate slough off abnormal cervical cells Promote lymphatic drainage Surgery Myomectomy or Hysterectomy Uterine artery Embolization – Excessive bleeding – Risk of hemorrhage – Inability to tell if tumor is benign – Familial hx of reproductive tract cancer Polycystic Ovary Syndrome(PCOS) Umbrella term used to label a group of symptoms that all appear to be connected to the menstrual cycle and to have a strong correlation with insulin sensitivity PCOS Most common hormonal disorder in women of reproductive age in US (5-10%) Commonly diagnosed in 20’s but begins during adolescence. Etiology of PCOS Ovarian Failure: Follicles mature but do not release an egg, resulting in cyst formation on and around the ovaries, which subsequently cause infertility and amenorrhea Insulin Resistance: Direct relationship Insulin Resistance Cells do not respond to stimulus from insulin… Blood sugar levels rise, pancreas accelerates insulin production… Blood sugar floods into cells… Blood sugar levels fall… Hypoglycemic state DIABETES INSULIN RESISTANCE IS MARKED BY ELEVATED BLOOD SUGAR LEVELS AND BLOOD INSULIN! Glucose from sugars is converted to energy in cells; in the absence of this critical source of energy, fatigue and food cravings result The liver responds to elevated Blood sugar levels by rapidly converting excess sugar to fat. The excess fat results in increased hormone load; more estrogen is stored in fatty tissue and synthesized by the aromatase enzyme. Aromatase enzyme synthesizes estrogen via the androstenedione pathway…excess testosterone Signs and Symptoms Amenorrhea Obesity Infertility Acne Hirsutism Polycystic ovaries Pelvic pain Thinning Hair Signs and Symptoms Hair loss Insulin resistance Type 2 Diabetes • Cardiovascular disease • Elevated blood pressure • Elevated cholesterol Diagnosis Gynecologic history Vaginal/abdominal ultrasound Blood chemistries – Elevated LH – Low FSH – Elevated glucose – Hyperandrogenism – Elevated blood lipids Management Dietary: Ingesting simple carbohydrates and high glycemic index foods can compound the problem b/c they cause a rapid rise in blood sugars. Exercise: Restore monthly Bleeding: Mild to moderate aerobic activity; intense activity may increase symptoms. – Progesterone cream during luteal phase – Spinal manipulation to ovaries innervations – Muscle stripping: adductors Pelvic Inflammatory Disease (PID) Infection of the uterus, fallopian tubes, or other reproductive organs Common complication of STD: Chlamydia and gonorrhea Organisms migrate from vagina and cervix into uterus and pelvis 10% PID are iatrogenically induced: abortion, IUD, D&C Diagnosis: – – – – Signs & Symptoms Differential Diagnosis Ectopic pregnancy Appendicitis tests immediately following menstruation Acute PID – Presenting complaint is dull lower abdominal pain; exacerbated by movement or sexual intercourse – Fever or chills – Rebound tenderness – Procedures that involve dilation of the cervical canal: miscarriage, abortion, IUD • Subacute PID • Low back pain • Acute PID • Chronic PID • Constant/intermittent low back pain • Low grade fever/infection Reproductive Organ Malignancies Vulvar cancer: rare form that primarily affects the labia Vaginal cancer:vaginal bleeding in 60% cases Cervical cancer:arises from unmanaged cervical dysplasia Ovarian cancer: BRCA1 & BRCA 2 Fallopian tube cancer: mild but chronic lower abdominal or pelvic pain Uterine cancer(endometrial ca):75% postmenopause; primary cause is unopposed or excess estrogen. Physiology of the female reproductive system 1. Different periods of Female Neonatal period : 4 weeks childhood: 4 weeks to age of 12 adolescence: menarche, age of 12-17 sexual maturity: begain 18, maintains for 30 years peri-menopausal period:begain 40, maintains for 10-20 years pre-menopause, menopause(last time of menorrhae), post-menopause senility 2.The definition of menstruation Menarche: the onset of the first menses occurs about two years after the onset of pubert occurs between 13 and 15 years of age anovulatory for first two years The first day of menstrual bleeding is considered day 1 of the menstrual cycle The length of menstrual cycle is 28 – 30 days The duration of flow is 2-7 days The volume of menstrual blood loss is 30ml-50mL(<80mL),darkness and nonclotting. The Founction of ovary Produce oocyte Endocrine: produce female hormone 3.Reproductive cycle Devided into 3 phases Menstruation: 1-4days the follicular phase:5-14 days a number of follicles developing, only one dominant follicle others become atretic ovulation:14th, releasing oocyte luteal phase: 15-28 days unless pregnancy occurs 1) Development of ovary Ovarian cycle is divided into four phases Development of follicles primitive folliclesprimary follicles secondary follicles antrun/ developing follicles maturity follicles ovulation corpus luteum 2)Ovarian steroid hormones Estrogens rise in plasma by 4th day of cycle from granulosa cells and theca cells negative feedback to FSH positve feedback to LH Progesterone: from corpus luteum maximal production occurs 3-4 days after ovulation and maintained for 11 days negative feedback on FSH and LH 4.Clinical manifestations of hormone changes 1)Endometrium be sloughed to a basal level in menstruation proliferative phase: 5-14 days (stroma thickens,gland elongated) in follicular phase, a maximal thickness in ovulation Secretory phase :15-28 days (stroma loose, edematous, vesseltwisted, gland tortous) in corpus Menstrual phase:1-4 days Endomitrium is sloughed and bleeding onset 2)endocervix Cervical also changes in response to the reproductive cycle Cervical gland secrete thin,clear,watery,mucus in follicular phase maximal in ovulation Mucus becomes 3)vagina Thickening and maturation of the surface epithelial cells responed to E2 in follicular phase thickening and secretory changes of vaginal epithelium in corpus luteum phase 4)Hypothalamic thermoregulating center Progesterone shifts the Basal body temperature upward(BBT) BBT record is a useful tool to evaluate the reproductive cycle 5.H-P-O axis The control of menstruation is based on a feedback loop of H-PO axis Hypothalamus Producing GnRH(gonadotropin-releasing hormone) be secreted in a pulsatile manner be a pulse generator of cycle be influenced by E and neurotransmitters Pituitary Producing Gonadotropins follicle-stimulating hormone(FSH) luteinizing hormone(LH) be protein hormones secreted by the anterior pituitary gland be pulsatile manner be influenced by E,P, and other factors Ovaries ovarian sex steroid hormones estradiol (E), progesterone(P) Feedback of H-P-O axis Concept of feedback the magnitude and the rate of GnRH, FSH, LH are determined by E, P, negative feedback : resulting in decreased secretion ofGnRH FSH,LH positive feedback: resulting in increased secretion of LH,which triggers ovulation Key words reproductive cycle menstruation ovarian cycle H-P-O axis feedback Fibromyalgia Aka fibrositis or fibromyositis Most common cause of widespread muscular pain Affects 2% of all Americans Women 10:1 20-60 y/o; peak at 35 y/o Etiologies Sleep disturbances Viral Infection Lack of exercise Chemical Imbalance Micro-trauma Emotional State – GH, Serotonin – Low cortisol levels – Elevated substance P Autoimmune(RA) Clinical Diagnosis of Fibromyalgia: American College of Rheumatology 1990 History of Widespread pain – – – – – Left side of body Right side of body Above waist Below waist Axial skeletal(C-T-L) Pain in 11/18 tender point sites on digital palpation – – – – – – – Occiput Lower cervical Trapezium Supraspinatus Second rib Lateral epicondyle Gluteal Greater trochanter – Knee In addition:The following must be present Diffuse musculoskeletal pain for at least three months Stiffness that is worse in the morning Tenderness to digital palpation:11/18 Modulation of symptoms by physical activity, weather or stress Poor or non restorative sleep Fatigue Anxiety Headaches Irritable bowel syndrome Subjective swelling and numbness CBC/Thyroid/Anemi a/Antibody negative Fibromyalgia vs. Myofascial Pain Metabolic Causes vs. Musculoskeletal Injury Mitochondria damage in muscle cells Disruption of glycolysis: Energy crisis Small blood vessel distortion in muscle during contraction: tissue hypoxia Decrease cortisol/DHEA: anxiety Leaky gut syndrome: bacteria, fungi, parasites, toxins, undigested protein, fat and waste Underactive Liver: free radicals not eliminatedinflammation Prognosis Prognosis if favorable with Integrated/supportive treatment Treatment Protocol Manipulation/gentle distraction Exercise regime Physical Modalities Sleep Homeopathy/medicine Nutrition Bio behavioral therapies Liver Detoxification Normalizing intestinal flora Boost immune system Decrease – Fat consumption – Refined carbohydrates – High protein-increase uric acid levels Weather Sensitivity Increase Humidity Decrease barometric pressure +temperature Women 67% ; Men 37% Fibromyalgia 80%(cold,damp) Migraines not affected Ligamentous type of pain syndrome assoc. with DJD Reactive Depression Chronic Fatigue Syndrome Sudden onset of flu-like illness Post-exertional malaise: pain and weakness of muscles or exacerbation of “systemic” symptoms Night sweats- 50% patients – Dramatic-associated with chronic infection CFS vs. Fibromyalgia Persistant fatigue that does not resolve with bed rest and severe enough to decrease ADL 50% for 6 months R/O chronic clinical conditions Epstein-Barr antibodies History of viral infection CFS symptoms Achy muscles/joints Anxiety Depression Cognitive changes Fever Headaches Intestinal problems Irritability Muscle spasms URI Sensitivity to light/heat Sleep disturbances Sore throat Swollen lymph glands Treatment Liver Detoxification Normalizing intestinal flora Boost immune system Decrease – Fat consumption – Refined carbohydrates – High protein-increase uric acid levels Iliotibial Band Syndrome ITB is continuation of the tendinous portion of the TFL Indirectly attaches to the gluteus medius, maximus, and vastus lateralis muscles The inter-muscular septum connects the ITB to the linea aspera femoris until just proximal to the lateral epicondyle of the femur Distally, the ITB spans out and inserts on the lateral border of the patella, lateral patellar retinaculum, and tubercle of the tibia Assists the TFL in abduction of the thigh and controls and decelerates adduction of the thigh Anterolateral stabilizer of the knee by moving anterior to the epicondyle as the knee extends and slides posteriorly as the knee flexes, remaining tense in both positions What Causes ITBS? Runners mileage Knee Flexion/extension weakness Excessive pronation Hip abductor weakness The Female Athlete Title IX: Prohibites sexual discrimination in any federally funded educational institution 1972 Health Concerns Unique to the Female Athlete Musculoskeletal Gynecological Psychological Nutritional Musculoskeletal Issues Osteoarthritis Spinal injuries Ilio-tibial Band friction syndrome Patellar Tracking disorders Sport Specific Injuries Anterior Cruciate ligament Stress Fractures Female Athlete Triad Disordered eating: 15-62% female college athletes have self-reported eating disorders. – Anorexia/ Bulimia Amenorrhea: 66% – Primary, Secondary, Oligomenorrhea Osteoporosis Disordered Eating Decrease in performance may not be seen for some time, thinking the habits are harmless Complications include depression, fluid/electrolyte imbalances and changes in endocrine/thermoregulatory systems Factors contributing include enviromental, mood, performance pressures Amenorrhoea Altered rhythemic secretions of (GnRH) leads to decreased levels of FSH and LH leads to decreased levels of Estrogen and progesterone Results in Amenorrhea Amenorrhea Primary: Absence of spontaneous uterine bleeding by 14 Y/O; w/o secondary sexual characteristics or by 16y/o with normal development Secondary: Six-month absence of menstrual bleeding with Oligomenorrhea Infrequent menses Osteoporosis BMD loss is a silent process 95% peak BMD by 18 y/o Puberty accompanied by deposition of 60% of final bone mass: any nutritional inadequacy and high exercise intensities may more severely alter bone formation Moderate exercise is beneficial, extreme loads may be detrimental to bone health Primary function of estrogen is to inhibit osteoclastic activity. – Hypoestrogenic state, osteoclast-mediated bone resorption in uninhibited, resulting in osteoporosis Etiology of Female Athlete Triad Sports or Activities that emphasis lean physique or a specific body weight such as gymnastics, ballet, distant running, diving, swimming Mental and psychosocial issues: low self-esteem Parents and coaches who place undue expectations on the athlete Misinformation about nutrition Societal pressure to be thin Physical, sexual, or substance abuse Signs and Symptoms Recurrent stress fractures Amenorrhea/Oligomenorrhe a(<9 cycles/yr) Erosion of the tooth enamel from gastric acids: recurrent vomiting Very thin Recurring muscle injury Parotid swelling as a result form frequent stimulation of salivary glands: vomiting Tooth marks on hand from induced vomiting Fatigue/decreased ability to concentrate Sensitivity to cold Heart irregularities Chest pain Endothelial dysfunction Reduced cardiovascular dilation response to exercise Eating alone Frequent trips to bathroom after meals Diagnosis History – Menstrual history • Delayed onset of menarche • Hormonal therapy use – Diet history • • • • Diet diary List forbidden foods Questions about weight Diet pills/laxatives – Exercise history • • • • Patterns Training intensity Fractures Overuse injuries Examination Height/weight/BMI Sexual maturity rating Scoliosis Neglect/abuse screening Blood pressure BMD Labs – Anemia – Serum electrolytes – Enzymes: amylase lipase Treatment Diet – Decrease High-phosphate substances (diet soda) – High protein diets cause increase calcium excretion, potential for bone loss – Decrease red meat: uric acid from protein synthesis Vitamin and Mineral Supplementation – – – – Calcium Vitamin D Vitamin C Folic Acid Peri-Menopause Treatment Protocols Vasomotor (hot flashes, night sweats) Spinal adjustments: L1/2 ovarian function C0/1 and L5/S1 parasympathetic function Acupuncture/pressure Bioidentical hormones: Estrogen, testosterone, progesterone and DHEA. Black cohosh: 500-1000mg dry (20-40mg extract)/day. Isoflavones (45-50mg/day) Vitamin E (400-800 IU/day) HRT: estrogen; progesterone; est. + prog. Genitourinary Atrophy/Prolapse Correcting leg length deficiencies Avoid medication that cause mucosal dryness: antihistamines and decongestants Chaste berry 150-500mg/day, Black cohosh Zinc 15 mg/day, magnesium, vitamin C Exercises – Kegal – Knee-chest pulls on slant board – Gluteal contractions – Pelvic rock with pillow between knees Psychosocial/Psychological Sleep: aids the function of pineal gland that is responsible for melatonin synthesis. Melatonin is needed for sleep Diet: omega-3, isoflavones, lignans Exercise St. John’s Wort: inhibit serotonin uptake in brain and inhibit the enzyme catechol-O-methyltransferase, which degrades the neurotransmitter dopamine. Manage adrenal fatigue – DHEA: CAREFUL(testosterone-estrogen) – Licorice root Management of Pregnant Patients Established patients that become pregnant New Patients for management of pregnancy New patients with Activities of Daily Living Biomechanics: neuro-musculo-skeleton Balance: center of gravity Nutrition Sleep Exercise Stress Ergonomics Established patients Treatment schedule – 1st trimester: 12 weeks • Regular schedule – – – – – – – Fatigue, nausea and vomiting, general malaise Headaches Constipation Hemorroids Varicosities of legs and vulva Breast changes Menstrual like cramping 2nd trimester No more than bimonthly – – – – – – – – Weight gain, greater fatigue, fluid retention Backache Indigestion Food cravings Light headedness(syncope) Muscle cramps Ligament pain Excessive salivation, Pica, change taste and smell 3rd Trimester 1-2x/wk – – – – – – – Braxton-Hicks contractions, indigestion Difficulty breathing, sleeping Low back pain, groin pain, symphysis pubis pain Edema Anxiety, depression, emotional Joint ache and pain Dyspepsia New Pts-pregnancy management 1st trimester: 1x/wk – Establish good alignment and repore • 2nd trimester: 1x/2wks Less osseous adjusting • 3rd trimester: 1x/wk Decrease symptoms Prepare for delivery • Post-partum ligamentus stability alignment Nutrition behaviors NP’s w/ Assoc. Conditions No xrays Treat with normal protocols Modify technique for comfort Understand that the condition will likely resolve at end of pregnancy 1st Trimester Nausea/Vomiting: Ginger, carbonated beverages, acupressure(seabands), cold compress(throat,gastric sphincter) Fatigue/general malaise: Nutritional counseling, food diary, prenatal vitamin, decrease stress, sleep, readjust to a new schedule Headaches: Vascular-inc. circulatory volume & vasodilation responding to high progesterone, caffiene-withdrawl, stress, low blood sugar, muscle spasm. – They may resolve in second trimester. Introduce stress-reduction activities, massage, heat/cold, adjustments – Fatigue: Educate that she may have to alter daily activities such as • Move away from aerobic activity to isometric activity • Stress reduction technique • Nutritional balance 2nd Trimester Backache: Center of gravity change resulting in muscle strain. High levels of circulating progesterone softens cartilage and loosens once-stable joints Upper back pain: Increase breast size – Pelvic tilt exercises, core muscle strengthening, balance exercises(theraball) – Decrease walking, girdle – Sleeping postures – Heat/cold – Massage/relaxation Muscles cramp: phosphorus/calcium ratio, pressure on pelvic nerves and blood vessels – R/O DVT, dehydration – Ligament Pain: Stretching of pelvic ligaments • Avoid twisting • Upper Extremity discomfort: May report pain, numbness, tingling due to postural changes and fluid retention. CTS symptoms are frequent – Exercises: balance, core stabilizers, – Wrist splint if necessary – Educate on sleeping postures Constipation: large amounts of progesterone cause dec. contractibility of GI tract & large intestine compressed by uterus. Bulk forming, nonnutritive laxatives, water, exercise, food suggestions, prenatal vitamins( every 2days) Cramping: R/O: ectopic pregnancy, miscarriage, GI problems, UTI Varicose veins: increases vascular congestion in pelvis, stretching of round ligaments, pressure from presenting fetal part. Legs and Vulva- vasodilation from hormones – Support hose, legs up for venous drainage-2x/day, girdle, decrease prolong standing and sitting, crossing legs – R/O: Deep vein thrombosis Third Trimester Braxton-Hicks contractions: Edema: R/O: pregnancy induced hypertension Joint aches/pains: differentiate from labor contractions-grow longer, stronger, closer together at regular intervals Sleeping on left side, Rest 2-3x/day, isometric contractions, do not wear constrictive clothing, TAKE BP EVERY VISIT Hormonal changes increase mobility of all joints – SI, Sacrococcygeal, pubic, increase size of pelvis for delivery – More prone to injury Childbirth Preparation Three philosophies: – Grantly Dick-Read: education and relaxation techniques to reduce fear-tension-pain cycle – Bradley: exercise to prepare muscles, relaxation techniques, inward focusing with deep abdominal breathing to achieve labor and delivery w/o medications – Lamaze: relaxation techniques and breathing, outward focusing, and conditioned response to relax during labor. Postpartum Period from delivery of the placenta and membranes to the return of the woman’s reproductive organs to their non-pregnant state. Approx. 6 weeks Assessment: 4-6 weeks Assessment Ligament stability and joint alignment – Until hormones are stable – Neuro-musculo-skeletal systems are pre-pregnancy state • Behavior • ADL: eating, sleeping, grooming • Interaction with baby • Complications: Gestational diabetes, mastitis, thyroiditis, postpartum eclampsia or hemorrhage Exercise guidelines Regular routine: not sporatically Hydration: 2x normal amount Avoid high impact, excessive spinal curve, stretch adductors Do not lie on back for more than 5 min. Toning and stretching exercises recommended Prohibited sports Snow or water skiing Scuba diving Horseback riding surfing High altitude, oxygen deprivation Exercises: – Stretching: cat/cow, side bow, standing-triangle, cow face, etc. – Core: one arm/leg, tree, theraball – Breathing: belly breathing, alternate nostril, legs up the wall Adjustment options Sleeping options Reflexology Vibrational therapy Heat/ice massage Specific Sport-related Injury Soccer Most frequently added women’s sport among intercollegiate institutions Heading – Avg six times a game – 5250 headers over a 15yr career – This repetitive impact to the skull accounts for 4-22% all soccer injuries – Clinical manifestations range from headache to brain damage Types of Headers Clearing : ball is to be projected high into the air over a long distance Shooting: sufficient speed to elude the goalkeeper Passing: advances the ball over a small distance Jumping: approach by running and great accelerated force into the neck musculature Cervical Spine Musculature Just before impact, the muscles of the neck must stabilize the head to dissipate the effects of the contact with the ball During execution, the head is accelerated forward by the neck musculature to generate momentum that can be transferred to the ball Sternocleidomastoids become active before contact with the ball to generate the forward velocity of the head Trapezius muscles remain active following impact to stabilize the head and neck system Figure Skating 50% traumatic injuries 50% overuse injuries – Women more frequently to the lower extremities – Causes include inflexibility, inadequate or asymmetric strength, inappropriate warmup or cool-down, poor diet, fatigue, overuse Basketball(netball) Women have 25-60% more ankle and knee injuries Lumbar spine injuries are usually causes by contact with another player Achilles tendon injuries due to inappropiate landing techniques Field Hockey One of the most common team sports in the world next to soccer Swimming Shoulder Impingement Syndrome Lumbar Hyperextension Injuires Cervical overuse syndromes Breaststroke: Medial collateral ligament Specific Sport-related Injury Soccer Most frequently added women’s sport among intercollegiate institutions Heading – Avg six times a game – 5250 headers over a 15yr career – This repetitive impact to the skull accounts for 4-22% all soccer injuries – Clinical manifestations range from headache to brain damage Types of Headers Clearing : ball is to be projected high into the air over a long distance Shooting: sufficient speed to elude the goalkeeper Passing: advances the ball over a small distance Jumping: approach by running and great accelerated force into the neck musculature Cervical Spine Musculature Just before impact, the muscles of the neck must stabilize the head to dissipate the effects of the contact with the ball During execution, the head is accelerated forward by the neck musculature to generate momentum that can be transferred to the ball Sternocleidomastoids become active before contact with the ball to generate the forward velocity of the head Trapezius muscles remain active following impact to stabilize the head and neck system Figure Skating 50% traumatic injuries 50% overuse injuries – Women more frequently to the lower extremities – Causes include inflexibility, inadequate or asymmetric strength, inappropriate warmup or cool-down, poor diet, fatigue, overuse Basketball(netball) Women have 25-60% more ankle and knee injuries Lumbar spine injuries are usually causes by contact with another player Achilles tendon injuries due to inappropiate landing techniques Field Hockey One of the most common team sports in the world next to soccer Swimming Shoulder Impingement Syndrome Lumbar Hyperextension Injuries Cervical overuse syndromes Breaststroke: Medial collateral ligament Adolescence and Puberty Adolescence: the time period from puberty to adulthood: physical, psychological, social, cognitive and emotional changes Puberty: phase of physical development of sexual maturation and child is capable Puberty (Pubescence) Physical Transformation – Breast development – Pubic hair growth – Growth spurt – Menarche – Achievement of fertility Phases of Puberty 1. Adrenarche • • • • Begins about 8 y/o and continues until appox. 16 y/o. Increased adrenal activity DHEA/DHEAS Secondary sexual characteristics: responsible for pubic and axillary hair Gonadarche 2. • • • Begins approx. 8 y/o Hypothalamus-Pituitary-Ovarian Axis Primary sexual characteristics: Increased gonadal stimulation 3. Menarche The first menstrual period 17% body fat necessary 22% body fat needed for ovulation 2-21/2 years after breast development HPO Axis: Biphasic feedback system (a positive feedback mechanism) Hypothalamus: synthesis and release of gonadotropin releasing hormone(GnRH); – Aka: luteinizing hormone releasing hormone(LHRH) • Pituitary: GnRH(LHRH) stimulates the Pituitary to synthesize and release gonadotropins, FSH and LH • Ovaries: FSH and LH stimulate the ovary • Results in germ cell maturation and hormone synthesis Normal Pubertal Growth Principal factor: Insulin-like growth factor-I (IGF-I) GH exerts its action through this mediator. Concerted action between GH, IGF-I, Estrogen, progesterone, and other sex hormones ** GH directly stimulates epiphyseal cartilage growth Puberty (Pubescence) Physical Transformation – Breast development – Pubic/Axillary hair growth – Growth spurt – Menarche – Achievement of fertility Breast development Budding occurs with rising levels of estrogen 1st sign of sexual development May be unilateral, often tender < 8 y/o: precocious > 13 y/o: delayed Pubic/Axillary hair growth Lags breast development by about 6 mths Appears late in puberty – If first sign of puberty, may cause Hirsutism and menstrual irregularities Growth spurts Starts with breast development Average growth: 2-5 in/yr Sex steroids and GH contribute Increase weight: 8-20 lbs. Higher percentage of fat Tanner Developmental Scale Sexual maturity rating, Tanner staging Pediatrics A system for objectively determining sexual maturity, which correlates chronologic age with a group of anatomic parameters, determining the degree of adolescent maturation; the most commonly used system was delineated by Tanner; in ♀, 5 stages of maturation are recorded for pubic hair and breast development; in ♂, 5 stages are recorded for pubic hair, growth of penis and testicles. McGraw-Hill Concise Dictionary of Modern Medicine. ゥ 2002 by The McGraw-Hill Companies, Inc. Menarche Single most emblematic event in the transition to womanhood Lack of menses by 16-17 y/o merits evaluation – Primary Amenorrhea – Hypothalamic immaturity (20%) – HPO axis Achievement of fertility Occur approx. 2-21/2 years after menses Anovulatory cycles until HPO axis matures. Secretions of GnRH are pulsatile; every 90 min FSH and LH are augmented in peaks As puberty progresses, the ovaries amplify the message from the gonadotropins and release a greater amount of estrogen. This cycle begins only during sleep. As the HPO axis becomes regulated, adds in the uterus in the communication link, the young adolescent will begin ovulating healthy follicles. Ovarian Follicles Birth: 600,000 Puberty: 300,000 Menopause: 30,000 Full maturation of one dominant follicle depends on development of support follicles, which secrete hormones such as estradiol, inhibin, and androgens, necessary for healthy HPO-U axis Common Female Adolescence Problems Musculoskeletal nutritional Endocrine system • Dysmenorrhea Dysfunctional Uterine Bleeding • Eating Disorders • Psychosocial Issues • • Musculoskeletal Rapid Growth demands – Scoliosis evaluation – “growing pains”: joint instability – Nutritional • • • • 2200 kcal/day(11-14y/o), 2400 kcal/day(15-18) Protein/Calcium/Potassium/Zinc Iron: Increased Blood volume 1:10 overweight Endocrine influence on musculoskeletal system – Thyroxine, insulin, corticosteroid=promote skeletal growth – Parathyroid hormone, calcitonin, Vitamin D • Skeletal mineralization Parasympathetic/Sympathetic Parasympathetic – Uterus via inferior mesenteric plexus: sacral plexus – None to ovaries Sympathetic – Uterus and ovaries via thoraco-lumbar spine – Breasts via Upper - mid thoracic spine Common Referred Pain Patterns Viscerosomatic pain from the May refer to Ovaries T12 and the medial thigh Fallopian Tubes T11-T12 Uterus T10-L1 and the lower abdomen Cervix S2-S4 uterine ligaments Across the lumbosacral area Vagina Low back and buttocks Cervix Sacral base Rectum and trigone of the bladder Sacral apex Green’s gynecology: essentials of Clinical practice, 1990 Dysmenorrhea Severe pain or cramps in the lower abdomen during menstruation – Primary: painful menses that is not related to any definable pelvic lesion. Primary dysmenorrhea begins with the first ovulatory cycles in women under 20 – Secondary: Painful menses that is related to the presence of pelvic lesions or pelvic disease(ie: endometriosis, fibroids, PID) Who Gets it? Most female adolescents and young adults Most common reason for absences from school or work Causes of Primary Dysmenorrhea Increased uterine activity/forceful contractions Excessive production of vaspression Overproduction of prostaglandins(E) Cervical Stenosis Misalignment of pelvic girdle(sacrum and ilium) Ligament imbalance: Broad, Round, Uterosacral T12-L4, S2-S4 nerve intervention Other factors: diabetes, anemia, stress, low pain threshold, increase sensitivity to pain Causes of Secondary Dysmenorrhea Post-surgical adhesions: C-section, episiotomy, or tears with birth Cervical stenosis due to surgery on cervix IUD cause irritation Endometriosis Fibroids PID IBS Signs and Symptoms- Primary Dull, midline, cramping or spasmodic lower abdominal pain Shortly before of at the onset of menses Radiate to the lower back and inner thighs Ancillary symptoms: nausea, diarrhea, vomiting, headache, anxiety, fatigue Risk Factors Earlier age at menarche Long menstrual periods Smoking Obesity Alcohol consumption High simple-sugar diet Treatment/Therapies for Dysmenorrhea Manipulation Massage Exercise: Stretching Rest Acupuncture Herbs: Bromelain, tumeric, cumin TENS/ IST Heat NSAIDS Dietary changes Dietary Omega-3 fatty acids Thiamine (vitamin B1) Calcium: 1200-1800 mg/day – leafy veg, broccoli, sardines Magnesium: 500 mg/day – Leafy veg, molasses, soybeans, nuts, seeds Red Raspberry tea, chamomile Decrease consumption: – Red meat and dairy: precursors to the inflammatory prostaglandins via arachidonic acid – Alcohol: liver stressor and interfere with detoxification pathways – Caffeine: a sympathetic NS stimulator that can intensify smooth muscle contraction – Sugar: depletes body of Ca, K, Mg, Mn Abnormal Uterine Bleeding Menorrhagia- abnormally heavy or prolonged bleeding during menstruation; longer than 7 days Metorrhagia- irregular bleeding or bleeding in between cycles Amenorrhea-absence of menses for at least 6 months Oligomenorrhea- Infrequent menses; > 35 days Polymenorrhea- Menses occurring with abnormal frequency Causes of DUB: Adolescence Immature HPO axis Anemia Eating Disorders Pregnancy Eating Disorders Epidemic proportions in Western Countries 9:10 are women 1.2 million women in America affected by eating disorders The end point of social, biologic, and individual factors Mortality rate of anorexia 8-18% Anorexia Nervosa Refusal to maintain body weight Body weight less than 85% of expected for height and weight Intense fear of gaining weight Self evaluation of one’s body altered Two main clinical forms: – – – – Food restriction: 50% OCD Binge/Purge: worse addictive behaviors BOTH EXERCISE EXCESSIVELY Peak age 14-18: stressful life event Bulimia Nervosa Recurrence of Binge eating – 2x/wk for 3 months = diagnosis Purging/Non-purging Recurring compensatory behavior to prevent weight gain – Laxatives, diuretics, excessive exercise, fasting, vomiting Peak age 18 y/o: after diet Etiology of Eating Disorders Psychological factors that cause addiction to food as source of comfort Family difficulties Irregularity in neurohormonal systems – Serotonin Struggle with body image and sense of identity Anorexia, Bulimia, Obesity and Gynecological Health Nutrition plays a key role in the growth and development of adolescents Growth spurts: achieve 25% of adult height and 50% of adult weight Achievement of fertility Menstrual abnormalities reflect abnormal nutrition Anorexia: hypothalamic suppression and amenorrhea; high risk of osteoporosis Bulimia: 50% hypothalamic dysfunction and irregular menses; less risk of osteoporosis Obesity: Anovulation and hyperandrogenism(Polycystic ovary disease) Pathophysiology of Eating Disorders Anorexia – Severe caloric restriction suppresses the HPO axis – Risk of osteopenia and osteoporosis is high Bulimia – 50% lose their menstrual cycle – Oligomenorrhea does not appear to impact bone density The Adolescent Partnership Communication – – – – Listening skills: open “psychological” ears Repetition and patience Non-judgmental, motivate and inspire Be a good role-model Evaluation – Keep in mind the adolescent’s perspective on her health within the context of her developmental state – At 12 y/o: adult brain is only 5% developed – Cultural issues of race, ethnicity, class, community and past experiences Meet the Parents Balance the needs of the adolescent and needs of the parents Begin Hx with parent and adolescent Find an opportunity for the parents to present concerns away from the adolescent. Do patient education and treatment programs with the parent and child together Find many opportunities to discuss treatment and education with adolescent alone. At the end of every session, ask the adolescent if there are any unanswered questions or concerns Endometriosis Estimate 20 million women Complications: Pelvic Pain Cramps Bladder Disorders Infertility “Retrograde Menstrual Bleeding” John A. Sampson, Albany NY named disease in 1927 explained how, not why HYSTERIA Greek for hystero = uterus Complaints from menstrual cramps were once considered a form of hysteria Seven Early Warning Symptoms of Endometriosis Menstrual cramps that increase in severity over time. Intermenstrual pain, or mittelschmerz. Dyspareunia, or painful intercourse Infertility of unknown origin Bladder infections Pelvic pain History of ovarian cysts Prostaglandins 1935. First discovered by Dr. U.S. von Euler at the Karvlinska Institute in Stockholm originally thought produced solely by prostate gland in males. Hence their name. 1957. Dr. V.R. Pickles, British physiologist at University of Sheffield studied the function of these amino-acid like hormones. He found them in uterine tissue which was a medical milestone in menstrual cramps. F2 or (F2 Alpha) Usually kept in control by the pregnancy hormone, progesterone. If conception occurred progesterone continues to be produced and F2 is not COMPLAINTS Dysmenorrhea: painful menstruation Dyspareunia: Painful intercourse ‘cul de sac’ Rectal bleeding: Urinate frequently, blood in urine during menstruation FOUR BASIC CAUSES OF ENDOMETRIOSIS Hereditary factors Immune system stress Hormone levels The embryonic theory Before prostaglandin inhibitors were developed, it was not unusual to hear of women who became addicted to Laudanum tincture of opium- to relieve their pain. Others tried Sweat baths with massage “Salt glow” rubdown of the abdominal cavity to stimulate blood flow. ‘Galvanism’ less fearsome cousin to shock treatment Liniments, douches, decorations, poultice, brews Hemlock tea “tones uterus” (leaves and inner bark. Now use everything from TENS unit to acupuncture. Alternative Therapies Acupuncture Herbs Chinese Medicine Yoga Magnesium 100:1 with calcium in bone 3x magnesium in muscle Insomnia, nervousness, rapid heartbeat, mm cramping Regulate body temp-last through perspiration Cramping-Ca2+ and Mg 2+ 2:1 Potassium and Iron RBC and muscle tissue contraction of mm, heartbeat, nerve impulse, and body fluids electrolyte minimum daily required 40eg kidney or cardiovascular disorders RBC and hemoglobin RBC lives 100 days women store=250mg men store=830 mg Ferrus gluconate ferrus sulfate Comparison of Diagnostic Techniques for Endometriosis PROCEDURE INDICATION FOR TEST TYPE PROCEDURE REVEALS Laparoscopy Pelvic tumors Pelvic mass Clinical symptoms of endometriosis Invasive surgery Pelvic endometriosis Pelvic adhesions Tubal pregnancy Uterine tumors Pelvic cysts Culdoscopy Pelvic tumors Pelvic mass Clinical symptoms of endometriosis Invasive surgery Pelvic endometriosis Pelvic adhesions Tubal patency Uterine tumors Pelvic cysts Pelvic sonogram Tumors Cysts Noninvasive procedure Pelvic tumors Pelvic cysts Side Effects of Danocrine Weight gain Headaches Fatigue Acne Depression Oily skin Breast tenderness Back pain Hot flashes Rash Bleeding Vaginitis Breast lumps Dizziness Mild Hirsutism Inc. Allergies Pelvic pain Dec. Breast size Neck aches INFERTILITY •After a couple has been trying to conceive over one year. (over 35 years old - 6 months). •$1 billion a year market CAUSES OF FEMALE INFERTILITY Pre-existing endometriosis Underactive thyroid gland Nutritional deficiencies Inappropriate body fat ratio Hormonal Imbalances Use of addictive substances Depression and stress PREEXISTING ENDOMETRIOSIS Alfa - v/beta 3 protein Blocks fallopian tubes or ovaries w/scar tissue Tissue produces prostaglandins , the hormone that interferes with the release of eggs Affects mechanism between fimbriae and the ovary Inadequate luteal phase HYPOTHYROIDISM Excess Estrogen Autoimmune process Increase risk of miscarriage NUTRITIONAL SUPPORT OF THYROID Iodine rich foods: 25 - 1,000 mcg(fish, kelp, seaweed) Zinc: 20-60 mg(beef, oatmeal, nuts, chicken, seafood, liver, dried beans) Copper: 2 -3 mg(liver, eggs, yeast, legumes, nuts, raisins) Tyrosine: 300-1000mg(soy,beef, chicken, fish) B complex: 25-50mg Magnesium: up to 400mg The Big Picture Under weight or obesity chronic anemia Low energy intake low immunity Inappropriate Body Fat Ratio 85% < or equal to ideal weight > to 120% athletes eating disorders amenorrhea Diet & Supplements Women with fertility problems should eat a whole foods diet, avoid highly processed and refined foods, and eliminate excess caffeine which can contribute to infertility. •Vitamin C: 1,000 mg three times daily •Zinc: 20-60 mg three times daily •Magnesium: at least 400 mg daily •Vitamin B complex: 25-50 mg daily •Beta Carotene: 6mg daily •Omega 3 EFA: 3000 mg •Borage oil: 200-300 mg of gamma linolenic acid daily •Vitamin B6: 50 mg daily •Vitamin E: 400 IU daily •Folic Acid: 500mg Hormonal Imbalances Xenoestrogen - laden pesticides “greenhouse gases” Detoxification protocols (liver channel flows through reproductive organs) Birth control pills OTHERS Use of addictive substances Depression & stress Infertility Workup Barnes Basal temp test pelvic exam pap smear laparoscopy (if indicated) hysterosalpingogram progesterone test antisperm antibody test HERBAL REMEDIES Chastetree Berry (vitex angus - castus) Dong quai (Angelica Sinensis) Licorice (Glycyrrhiza glabra) Siberian ginseng (Eleutherococcus senticosus) PREMENSTRUAL SYNDROME (PMS) PREMENSTRUAL DYSPHORIC DISORDER(PMDD) Premenstrual Syndrome(PMS) Umbrella term for a broad range of symptoms that begin after ovulation, peak before menstruation, and diminish after menses. Premenstrual Dysphoric Disorder(PMDD) Classified in the Diagnostic and Statistical Manual of Mental Disorders as a psychiatric disorder. Classification of Symptoms Somatic: water retention, pimples, intestinal disturbance, low back pain, migraines,TMJ, cold sores Cognitive: lack of motor coordination, social impairment, dysphoria Emotional: anxiety, irritability, depression, fatigue, eating habits, mood swings CAUSES OF PMS poor diet estrogen dominance Under active thyroid gland exhausted adrenal glands Food sensitivities or allergies Stress: sleep disorders nutritional deficiencies Altered serotonin and dopamine levels POOR DIET •low levels of magnesium •higher percentage of total dietary calories derived from fat •Imbalance of Blood sugar ESTROGEN DOMINANCE bloating, weight gain, headaches, backache diet high in estrogenic foods chronic stress Peri menopause Under active thyroid UNDERACTIVE THYROID GLAND ‘HYPOTHYROIDISM’ low production of progesterone TRH (Thyrotrophin-releasing hormone) TSH (thyroid-stimulating hormone) produced by pituitary gland EXHAUSTED ADRENAL GLANDS Chronic stress or hypothyroidism Produce adrenaline & noradrenaline Progesterone used to produce adrenal hormones NUTRITIONAL DEFICIENCIES B6 hinders liver’s ability to metabolize Estrogen Magnesium - chronic stress promotes magnesium excretion, which in turn leads to fluid and sodium retention Fiber, protein & fat Food Sensitivities Environmental sensitivities stress sleep disorders caffeine lack of sunlight lack of exercise DIETARY RECOMMENDATIONS Consume a high-complex carbohydrate diet Limit sugar to less than 10% total calories Limit protein to 15% of total calories & limit or avoid protein from animal sources For chocolate cravers, choose moderate amounts of low-fat chocolate foods such as cocoa made with nonfat milk & chocolate cake with no frosting Reduce fat intake to no more than 30% of calories DIETARY RECOMMENDATIONS (CON’T) REDUCE SATURATED FAT TO LESS THAN 10% OF CALORIES INCLUDE ONE TO TWO TBS OF SAFFLOWER OIL IN THE DAILY DIET. LIMIT SALT TO MINIMIZE FLUID RETENTION AND SWELLING CONSUME SEVERAL SERVINGS DAILY OF FIBERRICH FOODS TO ENSURE A FIBER INTAKE RANGING BETWEEN 20 - 40 g. AVOID CAFFEINE, ESPECIALLY WHEN ANXIETY AND BREAST TENDERNESS ARE PROBLEMS DIETARY RECOMMENDATIONS (CON’T) Vitamin B6 supplementation (50-150mg/day) started on day ten of the menstrual cycle and continued through day three of the next cycle has produced positive results in some women. The RDA for Vitamin B6 is 1.6 mg per day. Vitamin B6 in doses greater than 100 mg a day should be taken only with the supervision of a physician. DIETARY RECOMMENDATIONS (CON’T) Consume at least RDA levels of Magnesium, Iron, and the B-Complex Vitamins, and no more than 300 IU of Vitamin E (RDA is 12 IU). Vitamin D (700 IU/day)and Calcium(1200mg/day) L-tryptophan WHAT YOU CAN DO TO GET RELIEF learn stress reduction techniques get natural light antidepressants- st. john’s wort Exercise Vitamin E (400-800 IU) Magnesium “anti stress mineral” ALTERNATIVE MEDICINE THERAPIES FOR PMS acupressure aromatherapy ayurvedic medicine Yoga/stretching detoxification Herbal remedies PMT-Cator Clincial measurements of symptoms The Guy Abrahams PMS classification chart identifies four subgroups of Premenstrual Tension PREMENSTRUAL SYNDROME CLUSTERS CLUSTER SYMPTOMS INCIDENCE (PRECENT) PMT-A Nervous tension, irritability, mood swings, anxiety 66 PMT-H Weight gain, swelling of extremities, breast tenderness abdominal bloating 65 PMT-C Headache, sweets cravings, increased appetite, heart pounding, fainting, fatigue, dizziness 24 PMT-D Depression, forgetfulness, confusion, crying, insomnia 23 PMT-A Anxiety Irritability Insomnia Hormonal Imbalance – Estrogen is CNS stimulant – Progesterone is CNS depressant PMT-A Basic Dietary guidelines B6(pyridoxine):50-100mg Fiber: 20-40G Reduce caffeine Lower dairy and refined sugar PMT - H Hyper hydration Breast tenderness Abdominal bloating Edema of face and hands PMT-H Dietary Guidelines Ginkgo Biloba 40 mg(3 times a day) Vitamin A and B6 Magnesium 200mg/day Vitamin E 150-400IU/day Decrease Sodium PMT - C Cravings for sweets Increased appetite Headaches Fatigue Glucose Intolerance PMT-C Magnesium: 430 mg B6: 100 mg lower salt and simple carbohydrates Decrease salts and simple carbohydrates Vitamin A 200,000 - 300,000 IU PMT - D Depression Forgetfulness Confusion Lethargy Possible excess progesterone PMS-D Amino Acid L - Typtophan: 6g Tyrosine 3 - 6 g B6 Magnesium Treatment Protocol Adjustments Nutrition Exercise Acupuncture Lifestyle Homeopathic Chiropractic Adjustments T11 – S3: sympathetic/parasympathetic L2 produced marked decrease in symptoms(Hubbs 1986) ROM of femur at hip joint. Adductor and psoas major muscle hypertonic SI joints Mosby’s Recommendation Cramps/LBP: L2-L4 Breast tenderness: T5-T7 Fluid Retention and weight gain: T12-L1 Anxiety: T3-T7 Nutrition-Dietary Changes • Reduce hypoglycemia: small, frequent meals • Decrease serotonin synthesis: Eat protein with carbohydrates • Limit Arachidonic acid: precursor to Prostaglandin E Eliminate caffeine • Limit high sugar foods • Screen for excessive yeast • Limit salt • Increase dietary fiber • Increase water consumption • Limit alcohol • Increase fish oils • Supplemental Support B complex Vitamin Vitamin B6 Lecithin Magnesium Zinc Calcium Flaxseed Vitamin E oil C or Fish Exercise Regular Aerobic: Endorphin release Yoga: Especially inversions and sacral region Specific strengthening: Keigel Homeopathic Evening Primrose oil: lessens uterine contractions & pain, 5001000mg/3x day Black Cohosh: regulates hormone production, can delay onset,1-2 capsules/ 3-4hrs Valerian: reduce anxiety, mild sedative, 1-2 capsules/ 3-4 hrs Chaste Tree Berry: helps balance estrogen/progesterone, 40 drops/day for PMS or amenorrhea Cramp bark: eases cramps,useful in cases of excessive bleeding, 1 capsule/3-4 hrs for cramping (dosage recommendations from Women’s Encyclopedia of Natural Health by Tori Hudson) Lifestyle changes Stress reduction: “relaxation response”, yoga, biofeedback Adequate rest Schedule activities with PMS in mind No Smoking Get natural light AYURVEDIC MEDICINE BALANCE THE DOSHAS : bodily humors (energies) Vata - blood flow and the endometrial lining (movement) Pitta - menstruation for hormonal changes (metabolism) Kapha - contents of menstrual flow (structure) •On the first day of menstruation, have a liquid diet (blended soups, juices) to aid digestion. •Avoid eggs and fermented, spicy, or sour foods. •Eat foods that are warm and easy to digest. •Eat less than usual, especially in the evening. •Avoid cheese, yogurt, red meat, fried foods, and chocolate. •Avoid carbonated beverages and cold drinks. •If you crave salt, satisfy the desire minimally, but try to resist the sugar craving or find natural substitutes such as whipped cream with honey rather than ice cream. •Take a hot shower rather than a bath. •Budget time for resting. •Reduce your exercise schedule. •Spend some time turning inward. TRY FISH OILS FOR RELIEF OF CRAMPS Taking as little as 6g of fish oil daily during the time of menstrual cramping can significantly reduce the pain. When 42 young women, 15 to 18 years old, took 6g of fish oil (omega-3 essential fatty acid) daily for two months for relief of menstrual pain, pain reduction was rated at 37%. The women also managed on 53% less conventional pain medication (ibuprofen) for their cramps. Acupuncture Reflexology Pregnancy Important Factors Mechanical stress variations Hormonal Considerations – Relaxin, pregnanediol and estriol Patient comfort Boundary Issues Nutritional Support Musculoskeletal Conditions Low back pain Tension cephalgia Altered gait Chronic neck and back fatigue Intercostal neuralgia Groin Pain Thoracic Outlet Syndrome Symphasis Pubis Pain Sciatic neuralgia Coccygodynia Herniated IVD Carpal tunnel syndrome DeQuervian tenosynovitis Osteonecrosis of femoral head Common Complaints Bleeding Gums Dehydration Breathing Difficulties Diastasis Recti Abdominis Dizziness/Light-headedness Fluid Retention Symptom Heartburn In Utero Constraint (Webster technique) Morning Sickness Tipped Uterus (Buckled Sacrum Maneuver) Snoring Serious Issues Gestational Diabetes Pre-eclampsia/Toxemia Premature Contractions Rhesus Factor Spontaneous Abortion(Miscarriage) Etiologies Sleep disturbances Viral infection Lack of Exercise Chemical Imbalance (GH, Serotonin) Microtrauma Autoimmune(RA) Emotional State Nutrition for the Childbearing Years A women’s nutritional status before and during pregnancy and during lactation helps determine the outcome of her pregnancy and the long term health of herself and her child. Maternal nutrition during pregnancy & lactation influence: development of brain composition and size of the body infant’s metabolic competence to handle nutrients mother’s future health Recommended Weight Gain for Pregnant Women Prepregnancy Weight classification (BMI) Underweight (<19.8) Normal (19.8 to 26) Overweight (26.1 to 29) Obese (>29) Recommended Total Gain lb kg 28-40 12.5 - 18 25-35 11.5 - 16 15-25 7.0 - 11.5 > or = 15 > or = 7 Energy Requirements 1st trimester 96 k cal/day (2115) 2nd trimester 265 k cal/day (2275) 3rd trimester 430 k cal/day (2356) Macronutrients & Micronutrients The quality of the maternal diet is as important as its quantity. Protein Requirements= 60 g/day 20% increase over nonpregnant level Greatest concerns are low levels of: •iron •calcium •zinc •folic acid Iron Iron deficiency anemia is a serious condition during pregnancy. It is associated with preterm delivery and increased maternal mortality. RDA pregnant (30 mg) non pregnant (15 mg) • rapid expansion of maternal blood volume •deposition of iron in fetal tissues Heme Iron •found in food of animal origin •absorbed at a rate of 15 -30% Non-Heme Iron •found in food of plant origin •absorbed at a rate of 5% Vegetarian Avoidance of red meat but consumption of fish and/or chicken lacto - ovo: no meat consumption but intake of dairy products vegans: no consumption of food of animal origin. (Macrobiotic diet included) Foods High in Calcium (Recommended Intake 1, 000 mg/day) Milk & Dairy Products yogurt, plain, nonfat (1 cup) yogurt, fruit flavored, low fat (1 cup) chocolate milkshake (1 cup) skim milk (1 cup) whole milk (1 cup) cheddar cheese (1 oz) American cheese (1 oz) ice cream, soft serve (1 cup) ice cream, hard serve (1 cup) cottage cheese (1 cup) Calcium (mg) 452 345 256 302 285 204 174 206 170 154 Foods High in Calcium (Con’t) (Recommended Intake 1,000 mg/day) Protein tofu w/calcium sulfate (1/2 cup) sardines, canned, w/bones (1/2 cup) tofu w/o calcium sulfate (1/2 cup) almonds (1/2 cup) Fruits & Vegetables spinach, fresh, cooked (1/2 cup) broccoli, cooked (1/2 cup) okra, cooked (1/2 cup) orange (1 medium) calcium (mg) 434 428 130 165 122 85 88 54 ZINC crucial for tissue growth deficiency can cause poor fetal growth deficiency common because Zinc is found in the same foods as Iron & Calcium RDA pregnant 20 mg non pregnant 15 mg Plant Sources of Zinc wheat germ nuts dried beans Folic Acid most important vitamin during pregnancy all cell division DNA synthesis Recommended Daily Allowances adults 230 mg childbearing years 400 mg pregnancy 800 mg Folic Acid 5-10 mg fruits vegetables cheese milk eggs 100-150 mg liver orange juice spinach Deficiency Neural tube defects in the fetus megaloblastic anemia in mother Vitamin A excess is teratogenic retinol Beta Carotene is not Smoking Highest % of Low Birth Weight Babies #1 obese smokers who gained < or = 15 lbs #2 normal weight smokers who gained < or = 25 lbs Hellerstedt, Hines, Caffiene does cross the placenta breast milk half life higher in pregnancy 11 hours infants (100 hrs) Pregnancy Test Urine • HCG: hormone called human chronic Gonadotropin • 26 -36 days after last menstrual period • 8 -10 days after conception A positive result usually indicates pregnancy. Only two-thirds of women with ectopic pregnancies will have positive pregnancy tests. Positive results also occur in : (a) choriocarcinoma (b) hydatidiform mole (c) testicular tumors (d) chorioepithelioma (e) chorioadenoma destruens (f) conditions w/a high ESR such as acute salpingitis (g) cancer of lung, stomach, colon, pancreas, and breast Interfering Factors 1.False-negative tests and falsely low levels of HCG may be due to a dilute urine (low specific gravity) or a specimen obtained too early in pregnancy. 2. False-positive tests are associated with (a) proteinuria (b) hematuria (c ) presence of excess pituitary gonadotropin (HLH) as in menopausal women (d) drugs 1. Anticonvulsants 2. Antiparkinsons 3. Hypnotics 4. Tranquilizers Obstetric Sonogram Confirming pregnancy facilitating amniocentesis determine fetal age multiple pregnancy fetal development is normal fetal viability localizing placenta masses postmature pregnancy Major Uses of Obstetric Sonography First Trimester Second Trimester Third Trimester confirm pregnancy confirm viability rule out ectopic pregnancy confirm gestational age birth control pill use irregular menses no dates postpartum pregnancy previous complicated pregnancy caesarean delivery RH incompatibility diabetes mellitus fetal growth retardation establish/confirm dates if no fetal heart tones clarify dates/size discrepancy large for dates--rule out poor estimate of dates molar pregnancy multiple gestation Leiomyomata Polyhydramnios congenital anomalies small for dates--rule out poor estimate of dates fetal growth retardation congenital anomalies Oligohydramnios if no fetal heart tones clarify dates/size discrepancy large for dates--rule out Macrosomia (Diabetes) multiple gestation Polyhydramnios congenital anomalies poor estimate of dates small for dates-- rule out fetal growth retardation Oligohydramnios congenital anomalies poor estimate of dates Major Uses of Obstetric Sonography (Con’t First Trimester clarity dates/size discrepancy large for dates--rule out Leiomyomata Bicornuate uterus Adnexal mass multiple gestation poor dates molar pregnancy Small for dates--rule out poor dates missed abortion blighted ovum Second Trimester If history of bleeding--rule out total placenta previa If RH incompatibilty--rule out fetal hydrops Third Trimester determine fetal position--rule out breech transverse lie If history of bleeding --rule out placenta previa abruptio placentae Determine fetal lung maturity Amniocentesis for lecithin/sphingomyelin ratio Placental maturity (grade 0-3) If RH incompatibility--rule out fetal hydrops RUBELLA ANTIBODY TEST Induce IgG IgM antibody formation infection in 1st trimester associated with congenital abnormalities, miscarriage or stillbirth Elisa Test (enzyme immunoassay or enzyme linked immunoassay) TESTS DONE TO PREDICT NORMAL FETAL OUTCOME AND IDENTIFY FETUS AT RISK FOR INTRAUTERINE ASPHYXIA Name of Test & Normal Values Reason for Performing Test Breast Stimulation Test (BST) Normal values: reactive; negative Implies that placental support is adequate and that the fetus is probably able to tolerate the stress of labor should it begin within a week. There should be a low risk of intrauterine death due to hypoxia. 1 After 26 weeks’ gestation, the nipples are stimulated to release oxytocin that causes uterine contractions similar to labor contractions. TESTS DONE TO PREDICT NORMAL FETAL OUTCOME AND IDENTIFY FETUS AT RISK FOR INTRAUTERINE ASPHYXIA Name of Test & Normal Values Oxytoxic Challenge Test (OCT) Normal Values: Reactive; negative Implies that placental support is sufficient should labor begin within one week. 2 Reason for performing test Intravenous oxytocin is administered to produce three (3) good quality contractions of at least 45 seconds each in 10 minutes, and the FHR is monitored for reaction to this stress. It is performed when a nonstress test is nonreactive or a BST is either positive or unsatisfactory. TESTS DONE TO PREDICT NORMAL FETAL OUTCOME AND IDENTIFY FETUS AT RISK FOR INTRAUTERINE ASPHYXIA Name of Test & Normal Values Acoustic Stimulation Normal Values: Reactive Nonstress test Normal Values: Reactive; at least two (2) episodes of fetal movement associated with a rise in FHR Provides a baseline status & implies an intact CNS and autonomic N-S that are not being affected by intrauterine hypoxia Reason for performing test Using an electronic fetal monitor and sound source on the maternal abdomen, an evaluation of fetal movement in response to stimulation is done. It determines fetus’ ability to respond to environment by an increase in FHR associated with movement where not under the stress of labor. 3 Amniocentesis hematologic disorders fetal infections inborn errors of metabolism sex linked disorders identification of chromosomal abnormalities neural tube defects such as: -anencephaly -encephalocele -spina bifida -myelomeningocele estimation of fetal age wellbeing of fetus pulmonary maturity HIGH-RISK PARENTS WHO SHOULD BE OFFERED PRENATAL DIAGNOSIS 1. Women of advanced maternal age (35 or over). 90% fall in this category; at risk for children with chromosome abnormality, especially trisomy 21 (at age 35 to 40, the risk for Down’s is 1% to 3%; at age 40 to 45, there is a 4% to 12% risk; and over age 45, the risk is 12% or greater. 2. Women who have previously borne a trisomic child, or clients who previously had a child with any kind of chromosome abnormality. 3. Parents of previous child with spina bifida or anencephaly or family history of neural tube disorders. 4. Couples in which either parent is a known carrier of a balanced translocation chromosome for Down syndrome. HIGH-RISK PARENTS WHO SHOULD BE OFFERED PRENATAL DIAGNOSIS (CON’T) 5. Couples, of which both partners are carriers for a diagnosable metabolic or structural autosomal recessive disorder. Presently, over 70 inherited metabolic disorders can be diagnosed by amniotic fluid analysis. 6. Couples, of which either partner or a previous child is affected with a diagnosable metabolic or structural dominant disorder. 7. Women who are presumed carriers of a serious x-linked disorder. 8. Couples and families whose medical history reveals mental retardation, ambiguous genitalia, parental exposure to environmental agents (drugs, irradiation, infections). 9. Couples and families whose medical history reveals multiple miscarriage or stillbirths, infertility. 10. Anxiety about potential offspring. CLINICAL IMPLICATIONS 1. Elevated level of alpha-fetoprotein is an indicator of possible neural tube defects. 2. Creatinine levels are reduced in prematurity. 3. Increased and decreased total volume of amniotic fluid is associated with certain developmental arrests. 4. Increased bilirubin levels are associated with impending fetal death. 5. Color changes of fluid are associated with fetal distress and other disorders. 6. Sickle cell anemia and thalassemia can be detected by examination of fibroblast DNA obtained by amniocentesis. CLINICAL IMPLICATIONS (Con’t) 7. X-linked disorders are not routinely diagnosable in utero. However, because they affect only males, the sex of the fetus may be determined in a woman who is a carrier of a deleterous x-linked gene, as in hemophilia or Duchenne’s muscular dystrophy. 8. Cystic fibrosis. 9. The presence of some of the over 100 detectable metabolic disorders. 10. For disorders in which an abnormal protein is not expressed in amniotic fluid cells, other test procedures are necessary, such as DNA restriction endonuclease analysis. HERPES Natrum Mutriaticum (Chloride of Sodium) Pica Calcarea Carbonica (Carbonate of lime) Nitricun Acidum (Nitric Acid) LACTATION: The greatest physiological stress of the life cycle Fatty acid composition of human milk is influenced by the maternal diet. Fatty acids are responsible for nerve & brain development in the infant. • Protein Requirements = Pregnancy (60 g/day) • Iron Requirements drop (15 mg/day) • Mineral content of Milk (Ca 2+, Mg 2+, K +2, Na 2+ ) are not affected by maternal diet • Vitamin Content is dependent on maternal dietary intake. (esp. B6, thiamine, folic acid) • Weight loss is experienced by 80% lactating women • Aerobic exercise does not affect breast milk volume or composition BEST-ODDS NURSING DIET Increase the caloric intake to about 500 calories per day over the pregregnancy requirements. Increase calcium requirement to five servings per day. Reduce protein intake to three servings per day Drink at least eight glasses of fluids (milk, water, broths or soups, and juices); take more during hot weather and if perspiring a Lactation Protein requirements: 60g/day Iron: 15 mg/day Mineral content of milk not affected by maternal diet Vitamin content is dependent on maternal dietary intake Weight loss experienced by 80% lactating women Aerobic activity does not affect breast milk volume or composition Benefits of physical fitness Good muscle tone Sense of well-being Sense of body control Best physical shape for labor and delivery Improved sleep Reduced anxiety an dfrustration Weight control Improve chances for easier labor Body fat deposition to a minimum Improved self image Treatment Protocol Manipulation: decrease 2nd tri, inc. 3rd tri Massage(caution in severe edematoxemia) Heat/ice (no modalities) Foot reflexology/cranial sacral Peppermint, ginger, papaya Meridian stimulation Stress Injury to Bone: Interactive model Mechanical factor Hormonal Influence Nutritional environment Genetic Predisposition Definition of Stress Injury Stress injury to a bone occurs on a continuum, ranging from normal bone remodeling/repair to frank cortical fractures. Terms such as bone strain and stress reaction are used to reflect this progression of bone injury toward a frank cortical stress fracture, which is defined as a partial or complete fracture of a bone resulting from its inability to withstand nonviolent stress Bone Biology overview Extrinsic Mechanical Factors Acute change in training regimen – Duration, intensity, frequency) Footwear age Fitness level: early fatigue of muscles Running Surface/terrain – Uneven: hills, roads – Hard/soft Intrinsic Mechanical Factors Tibial Bone width – Large compression and tension forces – The external forces exceed the tibia’s intrinsic resistance strength – Narrow mediolateral tibial width have less resistance to these forces(area moment of inertia) Foot Structure – Pes cavus(high arch) absorbs less stress and transmits greater force to the tibia and femur – Pes Planus(flexible, low arch) absorbs greater metatarsal force Hormonal Factors Delayed Menarche Hypothalamic hypoestrogenic Amenorrhea Ovulatory Disturbances Oral Contraceptive Pills Testosterone Nutritional Factors Low Calcium Intake Vitamin D Genetics Inadequate Calories Anorexia Nervosa Common Sites for Fractures Pubic Ramus Femoral Neck Femoral Shaft Patella Tibia Medial Malleolus Tarsal Navicular Fifth Metatarsal Sacrum Topics in Women’s Health Chiropractors are ‘Port of Entry’ Women account for nearly twice as many outpatient visits as men NIA, office of research on Women’s Health 1990’s NCCAM: National Center for Complementary and Alternative medicine What is Port of Entry Care Provide evaluation of comprehensive health needs and coordinate care Involves integrated, accessible health services that addresses most of an individual’s needs, regardless of problem type or organ system PCP’s are assumed to be competent in initial evaluation of all problems with which patients present. What are the needs? POE’s: internists, general practitioners – – – • Pap smear Preventative tests Evaluation of symptoms, DDX, ROF, Refer Chiropractors: • Preventative tests • Evaluation of symptoms, DDX, ROF, Refer • Port of Entry for non-allopathic therapy Women’s Education Mass media: print, television, radio – One study: 90% women reported the media as main source of information about mammography • How do they report in compared to : • Medical journal articles • Women’s greatest health risks • Most commonly expressed health concerns Resources http://www.nlm.nih.gov/medlineplus/womenshealth.html http://www.cdc.gov/women/index.htm http://womenshealth.gov/topics.cfm www.shirleys-wellness-cafe.com/women.htm http://www.healthy.net/ www.cogme.gov/rpt5_4.htm Paradigm shift Historical, medical research has been based on the 70-kg man. Efforts to acknowledge the biological differences. Women’s participation in the medical profession has risen dramatically. Female Osteopathic physicans increased 36% between 1989-1992. The trend has been on a continuous rise. Demand by consumers and policy makers for increased attention to women’s health issues.