The Underhydration Problem: There is an underlying hidden phenomenon commonly occurring in most of our patients. Identification and modification of underhydration can improve your patient outcomes.
Understanding Scar Tissue: A review of scar tissue physiology will prepare the doctor to revisit and improve how to support injury healing in their patients.
Clinical Applications of Cartilage Physiology: A review of cartilage tissue physiology will prepare the doctor to revisit and improve how to support acute conditions are well as prevention and maintenance of your patients’ joint health.
Solving for Posture: You will review in depth negative effects of chronic postural distortions and learn simple interventions to incorporate into your practice to compliment your chiropractic adjustments.
Osteoporosis: We are going to discuss osteoporosis risk factors, imaging modalities, especially as it relates to vertebral compression fracture, and prevention. Then bring it all together to give the doctor better management options for your patients with low bone density.
The Effects of the Vertebral Subluxation Complex: After this in depth look at the neurophysiology of abnormal movement the chiropractor will appreciate the amazing effects the restoration of movement by chiropractic adjustment has on their patients’ health.
Perspectives on Peripheral Neuropathy: After taking this course the chiropractor will have an understanding of current theories behind peripheral neuropathy and additional options for management of this condition for their patients.
What Did You Do Scenarios: These short clinical case studies give the chiropractor a chance to use their knowledge in decision making in a variety of circumstances.
The Underhydration Problem
I .’Under-Hydration’ defined
II. How this shows up in everyday practice
A. Muscle spasm
B. Constipation
C. Plantar Fasciitis
III. Reasons
A. low water intake
B. Processed foods
C. mineral deficiency
D. caffiene
E. Alcohol
F. Blood sugar imbalance
G. Adrenal fatigue
IV. Solutions
Clinical Applications of Cartilage Physiology
I. 3 types of Cartilage
A. hyalin
B. elastic
C. fibrocartilage
II. Cartilage is hydrophilic: Structure
A. Chondrocytes in an extracellular matrix.
B. Chondrocytes synthesize collagen and proteoglycans.
C. Chondrocytes dependent on long range diffusion of nutrients via synovial fluid.
D. avascular, alymphatic, aneural
III. Joint Anatomy
A.Histologically the three joints in the body are fibrous, cartilaginous, and synovial.
B. Functionally the three types of joints are synarthrosis (immovable), amphiarthrosis (slightly moveable), and diarthrosis (freely moveable).
C. The two classification schemes correlate: synarthroses are fibrous, amphiarthroses are cartilaginous, and diarthroses are synovial.
D. Synovial joints are often further classified by the type of movements they permit, which we will not cover here
1. Synovial joints
a) Joint capsule is a fibrous connective tissue that is attached to each participating bone just beyond its articulating surface.
b) Synovium/Synovial membrane
1) Synovium produces synovial fluid Inner layer has villi like small intestine
2) Joints contain relatively little synovial fluid.
IV. Degradation
A. Trauma
1. Acute
2. Repetitive strain
3. Effects
a) Damage= release of cytokines = inflammation
b) Avascular, aneural, alymphatic
c) Osteoarthritis affects whole joint, but primarily hyaline cartilage.
d) Study: hardening of bone leads to degradation of cartilage = viscious cycle.
V. Osteoarthritis
A. Age related vs Secondary to trauma
1. 20 yo vs 80 yo
2. what is the definition of ‘trauma’
3. Chiropractic vs medical view
VI. Role of Chiropractic in maintaining synovial joint health
A. adjustments = better balanced movement
1. intersegmental
2. global movements
3. ROM both local and regional
B. Other factors
C. Nutrition
1. anti-inflammatory diet
2. nutritional supplementation
3. How to navigate all the options
4. Hydration
VII. Clinical Uses
A. Joints
1. Facet Joints
2. SI joints
3. Knees
4. Shoulders
B. Joint inflammation is a different type of pain and often harder to resolve than muscle ache
Understanding Scar Tissue
I. Causes of Damage
II. Physiology of scar tissue formation
A. Non-dividing cells
B. Role of Collagen
III. Stages of Wound/Injury Healing
A. Inflammatory
B. Proliferative/Regenerative
C. ReModulation/Maturation/Remodeling
IV. Nutritional Supplements to consider:
V. Implications
A. Consider the tissues injured: muscle, ligament, tendon, disc (or all of them)
B. Complex structures= uneven, incomplete tearing (microscopic)
C. Have realistic timeframes for healing
D. Educate: prepare for worst, hope for the best
E. Application:
F. Patient examples:
Solving for Posture
I. We use a tremendous amount of energy fighting the effects of gravity.
II. Posture has a long list of negative affects on our health
III. Tech neck is even worse than what we have seen traditionally
IV. Weight of the head= 10 lbs per inch
V. Effects:
VI. Muscle
A.Upper Cross Syndrome
1. Description
2. Intervention
B. Lower Cross Syndrome
1. Description
2. Intervention
VII. Fascia
A. Connective tissue envelope
B. The fascia’s function
VIII. Good News
A. most people have
B. you can still address this issue effectively with a fairly easy home rehab program
C. Do not have to spend a lot of time on this.
D. Simple, but works really well.
Osteoporosis
I. Definition
A. The big picture first
1. Bone fractures, particularly in the spine or hip, are the most serious complications of osteoporosis.
2. Hip fractures often are caused by a fall and can result in disability and even an increased risk of death within the first year after the injury.
3. Vertebral body fractures
II. Physiology Review
A. Bone is a combination of protein (mainly collagen) and minerals
B. Your bones are in a constant state of renewal
C. How likely you are to develop osteoporosis depends partly on how much bone mass you attained in your youth.
III. Risks
A. A number of factors can increase the likelihood that you’ll develop osteoporosis — including your age, race, lifestyle choices, and medical conditions and treatments.
B. Unchangeable: Some risk factors for osteoporosis are out of your control, including:
1. Your sex. Women are much more likely to develop osteoporosis than are men.
2. Age.
3. Race.
4. Family history.
5. Body frame size.
6. Hormone levels
C. Dietary factors
1. Low calcium intake.
2. Eating disorders
3. Gastrointestinal surgery.
D. Steroids and other medications
E. Osteoporosis has also been associated with medications used to combat or prevent:
1.Seizures
2. Gastric reflux
3. Cancer
F. Medical conditions: The risk of osteoporosis is higher in people who have certain medical problems
G. Lifestyle choices
IV. Based on all of the above it can inform your imaging considerations
A. acute pain may be fracture
B. refer for evaluation of Bone Mineral Density (BMD)
C. adjusting technique of choice
D. diet, exercise, supplementation
V. Diagnosis of OP:
A. Plain film radiography (X-ray)
B. CT Scan
C. DEXA scan: Dual x-ray absorptiometry
VI. Imaging Overview for OP concerns: Vertebral Compression Fracture and Hip fracture
A. Plain Film Radiography (x-ray):
1. pros:
2. cons:
3. Considerations for VCF
4. Hallmark Xray findings of VCF:
5. VCF also needs to be differentiated from other possibilities
6. Hip fracture
a) Types of Hip Fracture
b) Femoral neck (approx 50%)
c) Intertrochanteric (approx 45%)
d) Subtrochanteric (approx 5%)
e) X-ray findings
B. CT scan
1. Spine: detects vacuum sign better than x-ray
2. spine and hip both
C. MRI
1. Spine
2. Hip
D. Bone scan (scintigraphy w/ Technitium99)
E. Chiropractic considerations for OP:
VII. Prevention
The Effects of Vertebral Subluxations: a neurologic perspective
I. Philosophy
The 33 Principles of Chiropractic are chiropractic’s core foundational philosophical tenants
This may not sound very ‘Science-y’ to many modern day scientists, researchers, and physicians, however:
II. Science: Neurology Basics
A. Types of mechanoreceptors (I-IV)
B. Mechanoreceptor stimulation (movement of joints) brain affects
C. These extensive connections means movement positively affects
1. movement, muscle tone, posture, balance, positively affect emotions, coordinates visceral functions, improves immunity, learning, supports endocrine balance, coordinating/organizing thought
D. Afferent input is a basic nutrient that the brain needs for proper function and regulation of the human experience
E. Mechanoreceptor stimulation reduces nociception
F. It is well known and understood, not just in chiropractic…
1. Abnormal joint position and abnormal joint movement causes:
III. Also known: Mechanoreceptors are very dense in suboccipitals muscles, intersegmental spinal muscles, TMJ, and atlanto-occipital joint.
IV. The nervous system has a plasticity to it.
A. Plasticity has been defined
B. PNS sensitization occurs from mechanoreception/nociception imbalance
C. C fibers proliferate
V. These are all well-known hard neurologic, anatomic, physiologic facts
A. Therefore Subluxations are
1. chronic stressor that stimulate many brain areas
2. Deep dive on the Cerebellum
3. Pain is not reliable indicator of need for care (we known this)
B. Regardless of technique DC adjustments work
1. effects
2. reasons
C. If DC adjustments are so beneficial than why are they so hard for many of our patients to hold?
Perspectives on Peripheral Neuropathy
I. Background
II. Need for intervention b/c chronic condition
A. Not well addressed by available traditional methods
B. Prevalance
III. New Perspectives
A. PN= caused by ischemia
1. lack of dilation of arterioles= lack of oxygen and healing/everyday nutrients and removal of normal waste products.
2. Reasons
a) Nitric oxide cycle interruption
1) Diabetes, chemo, toxins
IV. Where do we as DC’s fit in?
V. Case Examples:
A. Chemo
B. B12 def neuropathy post gastric bypass
C. IBS = nutrient deficiency
D. Vegetarian
E. statin drugs, or even high doses of red yeast rice.
VI. Observations
VII. General Considerations
VIII. Neuropathy specific nutritional supplements
“What Would You Do’? Patient Scenarios
I. Roofing Contractor Supervisor: Slipped on ice in someone’s backyard, hit head. Unconscious for 4 hours
II. Guy shows up with a right elbow the size of an orange. It is dripping yellow.
III. You see a large bump on the back of your patient’s neck. It is yellow and oozing. He is diabetic.
IV. Pt shows up with a cast/boot and crutches
V. Patient comes in intoxicated and wants to wrestle…
VI. 19 yo male. Wrestling with friend. Pushed into a cement wall. He has Klienfelter’s.
VII. 75 yo male walks into your office reporting right arm and hand mm spasms and lack of control. BP: 88/66, P: 65; slower communication
VIII. Painless limp in a 5 yo boy
IX. 18 mo old boy won’t bear weight on leg
X. 18 mo old girl has pain and won’t lift arm after fall off of bed
XI. 14 yo female soccer player with heel pain
XII. Teenage swimmer shows up with px in upper traps and numb hands
XIII. 15 yo male hockey player with local LBP
XIV. When you suspect labrum tear
XV. Pregnant patient presents with severe pubic bone pain post MVA:
XVI. Elderly patient falls: need to consider…
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III. Understanding Scar Tissue
1. Grubbs, H. Et al. (21 May, 2022). Wound Physiology. NCBI Bookshelf. 2022.
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3. Salter, R., Textbook of Disorders and Injuries of the Musculoskeletal System, 3rd ed., Williams &Wilkins, 1999.
IV. Neuropathy Perspectives
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V. What Do You Do Scenarios
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2. Yochum, T., Rowe, L., Essentials of Skeletal Radiology, Vol.1, pg.327-372, Williams & Wilkins, 1996.
3. Ferlin, A. Et al. (March 27, 2010). Osteoporosis in Klinefelter’s syndrome. Mol Hum Reprod. 2010 Jun;16(6):402-10.
4. Chan, D. Et all. (2006 Aug). Genetics of disc degeneration. Eur Spine Journal. 15(Suppl 3);317-325.
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VI. The Effects of Subluxation
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VII. Solving for Posture
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VIII. Osteoporosis
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6. Chiodini, I. (June, 2008). Role of cortisol hyper secretion in the pathogenesis of osteoporosis. www.pubmed.com
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8. Konig, D. (December 4, 2017). Specific collagen peptides improve bone mineral density and bone markers in postmenopausal women- a randomized controlled study. www.mdpi.com
9. Schnell, S. Et al. (2010). The 1-year mortality of patients treated in a hip fracture program for elders. Geriatric Orthopaedic Surgery and Rehabilitation I(I)6-14.
Kyle Hagel, DC
Dr. Hagel has over 20 years of practice experience with a diverse practice background that includes Evaluation and Management of Auto Injuries, Functional Muscle Evaluation, Sports Medicine, Postural Reeducation, Structural Correction, Disc Injury Management, Spine and Extremity Bracing, Neuropathy Pain Management, Weight Loss, Functional Medicine, and Acupuncture. He also has benefitted greatly from working cooperatively with Physicians, Physician Assistants, and Nurse Practitioners in an integrated clinic for the last 14 years and continues to do so.
Educating patients has always been very important to Dr. Hagel in his practice. Patients that understand their condition make better decisions about their care. He is excited to now be involved in chiropractic continuing education and helping other doctors to do the same for their patients.