Why Am I So Tired All The Time???

By Matthias Wiederholz

Fatigue is a common presenting complaint for so many patients. Frankly, primary care doctors just don’t have the time to properly evaluate people for fatigue. Why you ask? Simple – there simply isn’t enough time. Most primary care doctors have to see a patient about every seven minutes in order to make a profit. That’s possible if the primary complaint is a simple cold, but fatigue requires a much more in-depth assessment. Our Functional Medicine experts can certainly do the comprehensive workup that is necessary to uncover the root cause of your fatigue.

Simple causes of fatigue will likely be discovered with routine blood work done by your primary care doctor. These may include anemia, diabetes, electrolyte imbalances, or obvious thyroid disease. That said, starting with your primary care doctor to rule out these obvious causes is a great idea.

But what about those people who complain of fatigue and have been to the primary care doctor and still don’t have an answer? Some of these patients have been to multiple specialists and still have no answers. This is the perfect case for a Functional Medicine expert.

If the above obvious causes have not been ruled out, we will certainly order tests for these. But we will also look for more subtle causes of fatigue. Probably the most common cause I see in my practice is chronic stress. Most people probably don’t even know that you can measure the effects of chronic stress on the body. We do this with a salivary cortisol test that measures your cortisol levels four times throughout the day. This is your “stress hormone” and chronic stress will often result in adrenal fatigue or hypocortisolism. This takes a long time to correct, but identifying the cause is the first step. People who suffer from stage 3 adrenal fatigue will often have hypofunctioning thyroid glands as well. The dysfunction may not be obvious and you may have been told that your thyroid is normal, but subtle changes can still result in problems. And you may not have obvious diabetes, but this chronic stress may also affect your body’s sensitivity to insulin. This is called insulin resistance and we stage this into three stages as well. We can usually correct these factors with diet changes, stress-reduction techniques, and targeted supplements/herbs.

Another common cause of fatigue is hormonal imbalance. We discussed cortisol, thyroid and insulin, but here we’re talking about sex hormones (estrogen, progesterone, testosterone, etc). When these critical hormones are suboptimal or out of balance, a common complaint is fatigue. Testing for these hormone levels is simple and correcting imbalances often involves diet changes and bioidentical hormone restoration.

Less common causes for fatigue involve toxic exposures (heavy metals, plastics, etc) and chronic infections (Lyme disease and chronic viral infections).

Most causes of fatigue can be uncovered with a detailed history and laboratory assessment. Do not accept a diagnosis of chronic fatigue syndrome without first doing this comprehensive assessment. Ask to see myself or my partner, Joseph Jimenez, when scheduling your appointment. Our Functional Medicine expertise will certainly prove invaluable to you in your endeavor to feel well again.

Preparing For a Marathon

By Heather

Think you can’t run that marathon? Think again. If you’re in good cardiac health, preparing and training your body to go the distance can be achieved in a few months. You can go the distance, with preparation

Pushing through “the wall” when aiming to run over 26 miles requires a healthy head start.

The wall is a common term in running, which refers to the point at which athletes run out of energy because of depleting resources. Aisiling Linehan, doctor of physical therapy at Performance Spine and Sports said some athletes can bust through and run a marathon with as little as three months of training.

“That is for somebody who works out regularly and doesn’t have any cardiac issues or physical limitations,” said Linehan. But she cautions that those just starting their fitness journey should start smaller and set other goals such as a running a 5k first. “A lot of my patients really benefit from couch to 5k programs. You run until you walk, then you run again. Eventually you will find you don’t have to walk. A lot of people say it’s a great way to build up stamina.”

Linehan said one of biggest mistakes people make is to over train and end up with an overuse injury. When asked at what point a runner is ready to go the distance, she said when they are able to run at least 20 miles.

Linehan, who has run two marathons and several shorter races, such as a Tough Mudder, has never had a running injury. She said one of the activities she does to remain injury free is yoga, which she is certified to teach.

She said even before starting endurance training athletes should focus on strength training. “Yoga, balance training and core strengthening are all helpful.”

The most common injury she sees in runners is hip bursitis, which is inflammation of the hip. She said there are two common, and preventable, causes for this hip pain, weak glute muscles and poor frontal plane control.

In order to combat this she recommends certain strength training exercises. One, which can be done at home with no additional equipment, is a side-plank. The steps to a side plank are to lie down on the ground on one side with knees straight. Prop the upper body up using the elbow and forum, directly under the shoulder. Activate core muscles, then raise hips until the body forms a straight line from ankle to shoulders.

The work of getting into marathon shape can be hard but Linehan said it’s worth it.

“I think it’s a great goal and you feel very accomplished afterwards,” she said.

She is gearing up for her next marathon, the Vancouver. She works at Performance Spine and Sports located at 4056 Quakerbridge Road, Suite 111 in Lawrenceville, N.J.

Marathon Training

By Heather

Smart start, safe finish

Training for a marathon, or maybe just a weekend run? Preparation for activity should involve injury prevention.
Learn how to prepare, outfit, stretch and get to the finish line, injury-free.

Crossing the finish line of a race is an exhilarating experience, whether it’s a 5k or a marathon, the work of running a race safely begins months or even years before the start.

The first step is getting into the right shoe. Dr. Maria Trakas, from Performance Spine and Sport Medicine said that the correct shoe can be vital in providing the right support.

“From a biomechanical standpoint people need the right shoe. If you are not pronating at the right point in the running or walking cycle it can be problematic.”

Pronation, or the way a foot turns when it falls to the ground, can be observed by looking at the wear pattern on an old pair of shoes. Different shoes are required for people who hit the outside of the heel first, the middle or the inside. Trakas said this can be explored more thoroughly with gait analysis. She said they offer that for some patients but the service is also available at stores that specialize in athletic footwear.

Once the new shoes are laced up it’s time to get the muscles ready. Trakas recommends a course of dynamic stretching before a workout. “Dynamic stretching involves going through a total body motion that mimics the activity you are going to be doing.”

For runners that can mean skipping or doing lunges, which will increase the heart rate and circulation.

Trakas offered another tip for warming up, foam rollers. Foam roller’s are dense foam cylinders that resemble logs. Placed behind hard to reach spots, it can be used to loosen knots that can limit range of motion and help with circulation. The foam roller can do double duty as Trakas recommends it at the conclusion of a work-out to relieve tension.

With proper shoes and a dynamic warm-up complete its time to put those feet on the ground. There are many online programs available to get first time runners started, such as interval training mixing runs and walks. Trakas said those can be a good template to get a person started, but not every person can start out running. New runners need to listen to their bodies Trakas advised. “Small aches can lead to bigger issues. For somebody who is brand new to working out, pushing your body beyond its comfort zone can be a recipe for disaster.”

To get into running shape without an overuse injury and give the body time to heal between runs Trakas recommends cross training. Some activities that promote healing and working different muscle groups include swimming, cycling, group classes or yoga.

In the end proper preparation all boils down to one thing, “To avoid injury it’s important to balance strength, training, flexibility and biomechanics. It’s making sure that your bones and joints are doing what they should be doing at the appropriate phase of movement.”

Estrogen Metabolism: A Key Factor in Breast Cancer Risk Assessment

By Matthias Wiederholz

October is breast cancer awareness month. One aspect of breast cancer risk that is not discussed frequently is estrogen metabolism. This is not only important in women on bioidentical hormone restoration therapy, but also for young women who are exposed to endogenous estrogen, the estrogen their bodies make every day. This estrogen has to be metabolized just like any other hormone in the body.

The metabolism of estrogen involves two main competing pathways: 2-hydroxy estrone and 10-hydroxy estrone. There is one minor pathyway, 4-hydroxy estrone. Confused yet? It will become much clearer in a moment.

2-hydroxy estrone is considered the “good estrogen” in that it does not stimulate cell growth and is considered “anti-cancer”. The caveat is that phase two detoxification pathways are intact and healthy. This is called methylation and is measured in the 2-hydroxy estrone to 2-methoxy estrone ratio. These are simply urine tests. Factors that promote healthy methylation are SAMe, methionine, Vitamin B2, B6, B12, folic acid (in activated form), trimethylglycine, and reducing stress.

Studies show that 16-hydroxy estrone may increase the risk for breast cancer. High levels are associated with obesity, hypothyroidism, pesticide toxicity (organochlorines), omega-6-fatty acid excess, and inflammatory cytokines. The ratio of 2-hydroxy estrone to 16-hyroxy estrone is an important indicator of the potential cancer risk of a particular individual.

4-hydroxy estrone directly damages DNA and may be associated with an increased risk for breast cancer. Equine estrogens such as Premarin increase metabolism into 4-hydroxy estrone. Women with uterine fibroids often have elevated 4-hydroxy estrone levels. Methylation is important here as well as 4-hydroxy estrone can be methylated to 4-methoxy estrone which renders it inactive.

Basically we want more metabolism down the 2-hydroxy estrone pathway. We can accomplish this through moderate exercise, cruciferous vegetable intake, flax, soy, high protein diet, indole-3-carbinol, di-indolemethane, omega-3 fatty acids, B6, B12, folate, trimethlyglycine, rosemary, turmeric, weight loss (obesity decreases 2-hydroxy estrone). Reducing one’s exposure to xenoestrogens is also critical. Xenoestrogens are found in pesticides, synthetic hormones fed to animals, plastics, and cosmetics. Reducing alcohol intake is also important as alcohol interferes with the body’s ability to detoxify estrogen.

All of these pathways can be easily tested with a simply urine test. Call one of our offices to set up an appointment to discuss your risk and have your pathways tested today.

What is tennis elbow?

By Jason Green

Much of the population knows little about elbow injury.  This article is going to discuss one specific condition local to the elbow known as tennis elbow, or more specifically, “lateral epicondylitis.”  And here’s something that might surprise you, tennis elbow is not restricted only to those of us who play tennis!  Mind-blowing, I know.

So what is tennis elbow and how do I know if I have it?  Well, the condition is an overuse injury that is caused when there is tendon damage that manifests as pain around the outside of the elbow.  This damage leads to difficulty with wrist movements and forearm rotation, limiting day-to-day activities due to pain.  The majority of injury typically occurs during wrist extension (approximating the back of the knuckles to the elbow) and twisting, which we see much of in racquet sports, particularly tennis.  However, we commonly see these types of injuries in those who work at a computer, on industrial machinery, or in various athletes.  Occasionally, tennis elbow can be initiated by an abrupt blow to the elbow.

I think I have lateral epicondylitis, what should I do about it?

It’s important to first decrease the pain and inflammation in the area, which can be achieved through ice, rest and/or pain or anti-inflammatory medication.  Once stabilized, it is important to be evaluated by a qualified provider who can isolate weaknesses, overcompensations, and joint restriction; and can provide a plan to rehab these accordingly.  It’s pivotal to identify movements that have caused the condition in the first place, so that these can be avoided at all costs.  Lastly, make sure that you’re working with a group of rehab providers that have a good-standing relationship with a physical medicine doctor.  If rehab is not enough then pain management, regenerative treatments and cutting edge TENEX procedures have great outcomes.

Hopefully, this has added some insight into what exactly tennis elbow is and what can be done for a speedy recovery.  If you have any questions, feel free to call or email our office to setup a consultation.

Small Swimming Tips that Make a Big Difference

By Jason Green

It goes without saying.  We’ve all waited long enough for this summer to come along.  And if you’re like me, now that summer is here, it won’t take you too long to find the closest pool and jump right in.  However, before you hop on in, take a minute to think about swimming safely.

We all know the benefits to swimming.  From cardiopulmonary fitness for every age group, to consistent calorie burning for weight-loss enthusiasts, to being a low impact form of exercise for those with aches and pains or orthopedic conditions; there’s a health benefit for just about everyone.  But, many of us do not consider the health risks associated with swimming.

For starters, healthy swimming can be divided into three main categories which require attention.  These are hygiene, sun-safety, and what swimmers do and do not bring into the pool with them.  Remind children to break from the pool every hour for hydration, sunscreen application, and bathroom breaks.  Consider UV protective shirts or shorts for the little ones, as 90% of the lifetime sun exposure occurs before the age of 20.  This wear those of us who happen to be parents can have a large impact on our child’s lifetime risk for skin cancer.

Constantly remind the young ones not swallow pool water.  No swimming when the child has diarrhea.  Shower before swimming and wash hands after using the restroom or changing diapers.  These are simple reminders that go a long way!

So remember, even though we are all excited to get in the water, we all must swim safe and be courteous of everyone around us!

Yoga 101

By Gary Fuschini

Yoga has become very popular in the U.S. in recent years.  It is an ancient activity involving exercise, meditation, breathing and philosophy.  Some sources claim its origins date back 5000 years.  Many styles of yoga have developed through the years and we can find a variety of classes within most suburban communities.

While you can benefit from any type of yoga, there is also potential for injury.  It is wise to be cautious when initiating any new form of exercise and to seek clearance from your MD.  If you are new to yoga, it is important to start at the proper level.  Speak to the instructor if in a class and inform them that you are a beginner and of any injuries you may have.  If using a video, be sure it is appropriate for your level and be extra careful not to perform any activities that cause you pain.

There are some basic yoga poses that may be helpful to introduce the beginner who is considering taking a class or to alleviate some aches which are common among those of us who have sedentary jobs or basic posture-related issues.

Child’s pose:    Begin on all fours with hands directly under shoulders and knees under hips.  Keeping your hands on the floor, gently shift your weight back until your butt rests on your feet or as far as you can go comfortably.  Let your head rest on the floor and breathe.  Try to stay in this restorative pose for a minute or more, repeating 2 or 3 times.

Bridge:    Start by lying on your back with knees bent and feet flat on the floor, hip width apart.  Breathe in.  As you exhale, start to curl your tailbone under and lift your buttocks off the floor.  Only go as high as is comfortable.  Do not let your knees fall out to the side.  Hold for a breath, then slowly lower yourself and repeat 10 -20 times.

Bird Dog:    In the hands and knees position, keep your back level.  Do not arch or round your back.  Find your neutral posture then slowly and with control raise your arm and your opposite leg.  Only raise as high as you can without losing your neutral spine posture.  Hold for a breath then gently lower back to starting position.  Repeat with the other side for a total of 10 times.

Cat/Cow:    Begin on all fours with shoulders right over hands and hips right over knees.  Inhale and as you exhale draw your navel in and round your spine from head to tail, trying to curl into the shape of the letter “C”. (Think of an angry cat)  As you start to inhale, slowly uncurl your spine and gently round towards opposite direction.  (Think of a cow’s swayback)  Sync your movements with your breath.  Repeat 10-20 times.

Remember to always be comfortable while practicing theses poses.  There should not be pain.  Always keep breathing and do not judge yourself!

Tips to Help You Get Better Sleep

By Gary Fuschini

Most people do not get enough quality rest.  Without adequate sleep consistently, there are a number of detrimental effects both physically and mentally. Following are a few tips to ensure a better night’s sleep.

Firstly, aim for 8 hours of sleep with 6 being the minimum.  Although we can function on considerably less, we require this amount for optimum health and cognition in addition to strong immune system response.

Use of room darkening curtains or shades will help to create a dark environment which promotes sleep. A sound machine, air filter or fan can add a soothing background noise to drown out distractions.

This last one may be the most difficult but it is worth a try if you feel your sleep is not restful enough or if you have trouble falling asleep.  I recommend the avoidance of viewing electronic screens for 30-60 minutes before bed.  This means no cell phones or computers and no watching TV in bed.

Try to make these tips into habits to reap the benefits of improved rest.

Reshape your body the healthy way: A primer on nutrition and exercise

By Michael Dougherty

It’s summer and that means the mad rush is on to slim down right in time for swimsuit season.  While there are many “diets” out there to choose from, don’t you think it’s time to make some long lasting progress?  Here are a few tips to get you in the right direction:

Make small incremental changes over time for the best results.  You have to be realistic about weight loss.  It doesn’t occur in week or monthly time increments just because bikini season is here.  Healthy habits take 2-3 weeks to form but first you must define where your weakness occurs.  Concentrate on this one habit at a time and make it realistic in the “real world.”  Whether it’s poor food choices, portion sizes, or eating too little, you have to assess and correct the sticking points before moving on.

Implement a plan that is reasonable and can work with everyday life.  Deciding to eliminate food groups or go on a special diet doesn’t work for most people.  In most life situations, this just won’t work.  Think of family dinners, birthday parties, or special occasions.  These overly restrictive diets leave little space for wiggle room.

Stay away from extreme dieting and focus on normalizing eating patterns.  Large calorie deficits can lean to hormonal dysregulation if done for long periods of time.  Fasts, cleanses, and calorie manipulation do work in the short term but, again, offer little long term effects other than potentially detrimental ones.  Focus on a nutritious approach and healthy meal selections when planning your approach.

Don’t count calories excessively.  They are important but don’t tell the whole story.  Our body is a complex system that requires hormones and enzymes to break down the food we eat.  The type of food we eat rather than the amount can influence our energy expenditure and fat loss.  Fat loss and hunger control are influenced by neuro-peptides that arise from the brain as well as the gastrointestinal tract.  Hormones are also released, sometimes in coordination with or because of these neuropeptides.  The signaling your body receives from food, from circulating hormones, and from these neuropeptides can lead to feedback loops that can be negative to long term health if the signaling if flawed.

For more information and a look at the most beneficial exercise, join us for a free seminar at NJAC in Lawrenceville, NJ Thursday, June 26th at 6:30.

Benefits of Laser Therapy

By Christopher Cush

We have been fortunate enough to add laser therapy to the list of rehabilitation modalities that we offer at Performance Spine and Sports Medicine. This is a tool that very few people have access to in the area. The laser that we have is a class IV high intensity laser from light force. The class IV laser allows you to get deep into injured tissue and achieve a thermal effect that the traditional class III cold laser does not. The thermal effect of the laser promotes increased blood flow to the injured tissue which helps to improve healing time. Deep Tissue Laser Therapy accelerates your body’s own natural healing process through photo-bio-stimulation.

Photo-bio-stimulation is the act of changing the condition of damaged tissue by stimulating cell metabolism which in turn improves the speed of tissue healing. This is achieved by photons from the laser head being emitted into deep tissue cells, which causes soothing warmth in the area. The photon molecules are absorbed by mitochondria in the injured cells. Mitochondria are the driving force behind energy production in a cell. Stimulation of mitochondria produces ATP, nitric oxide, and reactive oxygen species.

The production of these signaling molecules in concert has been shown to induce growth factor production and improve cell proliferation (healing).Laser therapy is effective in treating chronic conditions, acute conditions and post-surgical pain. This tool allows us to expedite the healing process which creates quicker recovery times and decreased time in pain and discomfort.