The ice or heat?: A common dilemma

Should I use ice or heat? This is one of the most of the most frequently asked questions in our clinic. Consider this common scenario: a patient enters the emergency department with severe back pain. The emergency doctor examines the patient and may even take some x-rays. He then determines that the severe pain is resulting from severe muscle spasms in the low back. He treats the patient with an injection of pain medication and releases the patient with a prescription for pain medications and instructions to apply a heating pad to the low back to alleviate the muscle spasms. (Yikes!). The patient then presents to our office a few days later because of persistent pain. We tell the patient to apply ice to the low back. Huh? How confusing!

A commonly-used rule of thumb is to apply ice for the first 48 hours after an injury, then apply heat as the inflammation subsides. So why do emergency room doctors tell people with acute back pain to use heat? The reason is because it is a common misconception that the use of heat has a relaxing effect. (Let’s be honest -- a heating pad just sounds better, doesn’t it?) But in fact when an injury occurs, muscles surrounding the site of injury (e.g., an ankle or shoulder or low back) go into “splinting” mode -- they contract or spasm in an effort to stabilize and/or protect the inflamed area. The key word here is INFLAMMATION. Applying heat to an acute strain or sprain -- an area of INFLAMMATION -- will actually INCREASE the inflammation because heat is pro-inflammatory. So, while it feels good while it is being applied, a heating pad can actually take an injury that would normally resolve nicely in 3 days and turn it into a problem that doesn’t resolve for weeks! It is vital to treat the underlying injury and inflammation since that is what is causing the muscles to go into spasm in the first place. When the inflammation subsides, so does the muscle spasm.

Cold slows chemical reactions and slows the transmission of pain signals to the brain. Ice causes blood vessels to constrict, decreasing blood flow and helping to limit the amount of swelling (edema). Swelling impairs the metabolism of the tissue surrounding the injury, decreasing the delivery of nutrients needed for healing as well as the removal of inflammation from the area, which in turns, reduces pain. In addition, ice helps decrease decrease the pain by numbing sore tissues and slow nerve impulses, which interrupts the spasm reaction between nerves.

However, inappropriate icing may make an injury worse rather than better. For some people, spending over 20 - 30 minutes continuously applying ice can be counterproductive. Have you noticed that when you play in the snow throwing snowballs with your bare hands that initially the hands are blanched and chilled by the snow? Then eventually your hands start to turn bright red and warm despite the continued contact with the snow. This redness and warmth indicates that prolonged exposure to the icy snow is actually increasing blood flow to the hands. Basically, when body tissues are cooled, nerve cells in the chilled area initially force adjacent blood vessels to constrict, leading to a marked reduction in blood flow in that portion of the body. However, if the temperature of the affected area continues to drop the blood vessels begin to open up again to prevent freezing of tissue, even though cold is still being applied. This prolonged exposure to cold may actually increase inflammation and pain as the circulation returns to the tissues. So don’t fall asleep on that ice pack!

How to appropriately apply ice:

• Apply ice to the injured area for 15 minutes each once or twice hourly.
• A 15-30 minute minimum interval between each application will allow sufficient time for tissues to “re-set.”
• Before the tissue warms up fully, apply the ice again. Do this more frequently the first 48 hours and then decrease to 3-5 times per day until the injury resolves.
• Icing frequently in the acute stage can speed up the healing process.
• Some individuals with certain circulatory abnormalities should avoid the use of ice.

Re-freezable gel packs are the most common type of application for ice. They’re convenient, easy to use and mold to any body part. To prevent frost bite remove all frost from the gel pack or other source of cold. Consider placing a moist paper towel between the ice pack and your skin. A barrier too thick will not allow for sufficient cooling.

Ice cups are useful for ice massage around smaller areas of the body including hands, feet, ankles, elbows, shoulders and knees. Fill a Styrofoam or a paper cup with water and place it in the freezer. Once frozen, peel away the styrofoam/paper around the top of the cup, exposing a solid 'bulb' of pure ice.

An ice bag with ice cubes or crushed ice also works, but can be messy if it leaks. Use a damp towel under this type of ice bag to prevent damage to the skin, particularly in older persons and those with diabetes.

Heat
Heat is beneficial for use on chronic and non-inflammatory injuries. Moist heat therapy is characterized by the application of warm, moist compresses to the body as a natural remedy for the relief of pain and a renewed sense of health. Just as with ice, there are various modes of application.

Methods of heat application consist of hot water (hot tub/Jacuzzi), a soaking soothing cloth, ultrasound, or a microwaveable moist heating pad. Moist heat is more beneficial. A dry heating pad should be avoided. Using a hot wet towel or a wet towel between your skin and the heating pad is a good way to produce moist heat. (Warning: do not use wet towels or anything that contains water with an electric heating pad or blankets! Do not use a dry heating pad!).

Moist heat therapy stimulates the thermoreceptors in the body. Thermoreceptors work by blocking the body's pain transmitters from making their way to brain-and the end result is a significant decrease in painful sensations. Moist heat can help decrease joint and muscle stiffness, relax sore muscles, and provide soothing comfort, especially in arthritic joints.

Warming therapies are not recommended to be used on acute inflammation or trauma because a boost in circulation and warmer temperature of the limb is like pouring gasoline on a fire. Applying heat too early can worsen the inflammation and make the pain more severe. Do not use heat on open wounds or if you have areas of numbness (cannot feel if it is too hot -- as in diabetes, for example), increased sensitivity to heat, circulatory problems, infections or malignant tumors.

So, the take home message here is if the affected area feels or appears hot, swollen and tender to the touch, ice. If the affected ares is stiff and it takes firm pressure before pain is felt, heat.

Blogging... who has the time?

I was just checking out my blog page and noticed that my last post will be a year old next month.  Everyone's blogging these days...  AND facebooking, my spacing, LinkedIn and those are the ones of which I'm aware.  I'm sure there are hundreds, if not thousands of ways people are keeping in touch and keeping us posted of events in their lives - sometimes too much information.  It's pretty overwhelming for me to say the least.  However, whether I like it or not, I think this is the future and I should jump on the wagon before the wagon distances itself and I'm left in the electronic dust!  I don't think we have choice... we are born into the technology super highway by default.  For example... each year, my family gathers in Southern California to celebrate Christmas.  My sister and brother-in-law usually make the trip out there from South Carolina to join the celebration.  However, this year, they were expecting and the due date was too close to Christmas so they weren't able to make it :-(.  Not to worry though... thanks to Skype, we were able to see the little sprout who came 4 days early on Christmas eve.  So on Christmas day when the family gathered for the celebration, Lillian Riu at one day old had her first teleconference in her hospital room! Everyone got to see her from 3 thousand miles away and didn't have to wait for the announcement.    I wouldn't be surprise if she'll have a blog up in no time!  So I better keep up with this blogging thing so I don't get left behind in the technology haze (although this blog was more self-serving to show off my little niece).   It's a great way to share life's joys.  Good health is essential to enjoying and sharing life's joys so I will make a effort to post useful health information in between sharing my life's joys.  Thanks for reading my blog!

Is the calcium you're taking being absorbed?

Osteoporosis is a disease characterized by loss of bone mass, accompanied by microarchitectural deterioration of bone tissue, which leads to an increase in the risk of skeletal fracture and deformity.  Adequate nutrition plays a major role in the prevention and treatment of osteoporosis.  The nutrients of greatest importance are calcium, vitamin D and magnesium.

Why are we so calcium deficient?  
Modern diet
Low in magnesium
High in dairy/calcium
High in sugars and alcohol 

   (increases excretion rate of magnesium in the urine) 

Grains are refined 

   (decreases the magnesium content)

Fertilizer in soil contains potassium which is a magnesium antagonist

vs. 

Primitive diet

High in magnesium (grains, seeds, nuts & vegetables)

Low in dairy/calcium (allows calcium to be efficiently stored in body)

Numerous studies have shown that higher calcium intake at various ages are associated with higher bone mineral density compared with the bone mass of those with lower calcium intakes. However, taking calcium alone is less beneficial than taking calcium with vitamin D and/or magnesium.  Without vitamin D and/or magnesium, calcium may not be fully utilized, causing under absorption.   

When there is an increase of calcium in the bloodstream, the body secretes calcitonin and decreases parathyroid hormone (PTH).   The role of PTH is that it draws calcium out of the bones and deposits it into the soft tissues.  Calcitonin increases calcium in the bones and keeps it from being absorbed into the soft tissues.   Because vitamin D and magnesium suppress PTH and stimulates calcitonin, it helps put calcium into the bones, preventing osteoporosis.  Less calcium into the soft tissues also helps eliminate some forms of arthritis.  The cumulative effect of higher PTH levels, secondary to poor calcium and vitamin D nutrition (secondary hyperparathyroidism), is an increase in bone remodeling leading to significant loss of bone and an increased fracture risk.

Did your know? Chocolate has high amounts of magnesium so premenstrual craving of chocolate can indicate signs of magnesium deficiency.

In addition to eating a good diet containing grains, seeds, nuts and  vegetables, supplementation with a calcium is helpful in preventing osteoporosis.  To assure that you calcium is mobilized and stored in your bones, make sure that you take a calcium supplement that contains vitamin D, magnesium or both.    The recommended dose for magnesium is 250 mg for every 500 mg of calcium consumed.  Below is the Institute of Medicine's age-appropriate recommended doses for calcium and vitamin D.  

Food and Nutrition Board Dietary Reference Intakes (Recommended
Average Intakes for Calcium and Vitamin D)
Age (y) Calcium (mg) Vitamin D (IU)
3–8: 800 200
9–17: 130o 200
18–50: 1000 400
51–70: 1200 400
70: 1200 600

Institute of Medicine: “Dietary Reference Intakes for calcium, magnesium,
phosphorus, vitamin D and Fluoride.” Food and Nutrition Board,
Institute of Medicine. Washington, DC: National Academy Press, 1997.

Chiropractic care during pregnancy

Low back pain is a common complaint in pregnancy. Low back pain in pregnancy can be the result of mechanical alterations. As the uterus expands with the growth of the baby, the belly shifts your center of gravity forward. In addition the weakening and stretching of the abdominal muscles, the postural change creates a straining force on the low back. When low back pain radiates into the buttocks and thighs, it’s usually resulting from the growing uterus pressing on the piriformis muscle (one of the pelvic floor muscles) and the sciatic nerve that runs beneath it.  The piriformis muscle can also undergo strain due to widening of the pelvis and change in the gait pattern during pregnancy.  Pain arising from the piriformis muscle is often under-diagnosed and under-treated, resulting in ongoing pain. When diagnosed early and with appropriate treatment, symptoms usually resolve successfully allowing normal pain free function. 

The other factor that can contribute to low back pain in pregnancy is hormonal changes. Hormonal changes, particularly the release of the hormone relaxin can result in muscle and ligament relaxation, which can loosen your joints and ligaments that attach your pelvic bones to the spine (the sacroiliac (SI) joints). This can make you feel less stable and cause pain with prolonged standing, walking, rolling over in bed or getting up and down from a chair.

Who's most likely to have low back pain during pregnancy?
Not surprisingly, people who have experienced low back pain previously will likely have low back pain during pregnancy. You're also at higher risk if you've lead a very sedentary lifestyle and have poor flexibility and weak back and abdominal muscles.

What can I do to avoid back pain?
1. Start an exercise program to stretch and strengthen muscles that support the back and legs, including your abdominal muscles. Stretching gently and cautiously will prevent further strain joints which have been made looser by pregnancy.
2. Swimming is a great exercise option for pregnant women because it strengthens your abdominal and lower back muscles, and the buoyancy of the water takes the strain off your joints and ligaments.
3. If you sit all day, be sure to sit up straight and take frequent breaks from sitting. Get up and walk around at least every hour or so.
4. Avoiding prolonged standing is equally important. If you need to stand all day, try to take a midday break and rest lying on your side while supporting your upper leg and abdomen with pillows.
5. Wear comfortable shoes and avoid high heels. As your belly grows and your balance shifts, high heels will throw your posture even more out of whack and increase your chances of stumbling and falling.
6. Avoid lifting. If you do lift, always bend from your knees and lift things from a crouching position to minimize the stress on your back.
7. Listen to your body. If you find that a particular activity or exercise makes your back hurt, then avoid doing it!

What can I do to get relief?
1. Doctors of chiropractic can alleviate the uncomfortable symptoms arising from the muscular, ligamentous, and biomechanical stresses encountered during pregnancy. We accomplish this through the use of spinal manipulative therapy and myofasscial massage therapy.
2. Prenatal massage by a trained therapist may provide great relief.
3. Acupuncture can be extremely effective for acute pain relief.
4. Try heat or cold. If muscles or joints feel tender to the touch and has a sensation of being “hot.” Apply an ice pack to the affected area for 15 minutes every hour. If the muscles feel tense or deep aching sensation, apply a moist heating pad.

A study released in 2006 demonstrated that chiropractic care is safe during pregnancy and support the hypothesis that it may be effective for reducing pain intensity. Lisi, AJ. Chiropractic spinal manipulation for low back pain of pregnancy: a retrospective case series. J Midwifery Womens Health. 2006 Jan-Feb;51(1):e7-10.