Back Clinic Chiropractic. This is a form of alternative treatment that focuses on the diagnosis and treatment of various musculoskeletal injuries and conditions, especially those associated with the spine. Dr. Alex Jimenez discusses how spinal adjustments and manual manipulations regularly can greatly help both improve and eliminate many symptoms that could be causing discomfort to the individual. Chiropractors believe among the main reasons for pain and disease are the vertebrae’s misalignment in the spinal column (this is known as a chiropractic subluxation).
Through the usage of manual detection (or palpation), carefully applied pressure, massage, and manual manipulation of the vertebrae and joints (called adjustments), chiropractors can alleviate pressure and irritation on the nerves, restore joint mobility, and help return the body’s homeostasis. From subluxations, or spinal misalignments, to sciatica, a set of symptoms along the sciatic nerve caused by nerve impingement, chiropractic care can gradually restore the individual’s natural state of being. Dr. Jimenez compiles a group of concepts on chiropractic to best educate individuals on the variety of injuries and conditions affecting the human body.
Dr. Alex Jimenez, D.C., presents how stress can impact many individuals and correlate with many conditions in the body in this 2-part series. We refer our patients to certified medical providers who provide multiple available treatments for many people suffering from hypertension associated with the cardiovascular, endocrine, and immune systems affecting the body. We encourage each of our patients by mentioning them to associated medical providers based on their analysis appropriately. We understand that education is a delightful way when asking our providers questions at the patient’s request and understanding. Dr. Jimenez, D.C., only uses this information as an educational service. Disclaimer
How Stress Impacts the Body
Dr. Alex Jimenez, D.C., presents: Now everyone responds to changes in the environment differently. When it comes to many individuals doing everyday activities from working at their job, opening on the weekends, traffic jams, taking exams, or preparing for a big speech, the body goes through a constant state of hyperreactive to a stage of emotional, mental exhaustion that leaves the individual to be exhausted and stressed out. And the key is to recognize this before it happens, as we see this impact of stress on our patients and ourselves. And the first thing to realize is what the initiating event is causing this impact.
Whatever the initiating event, the most important part is our perception of the event. What does it mean to us? Is it our perception? When the body goes through this initiating event, it can cause the perception to lead to the response and the effect on our body. So perception is everything as we talk about stress and the stress response. Now, we have over 1400 chemical reactions that occur in the body. So for this talk’s purpose, we’ll discuss the three key ones: adrenaline and neuro-adrenaline, aldosterone, and of course, cortisol.
And why are these important? Because every one of these has a huge impact on cardiovascular disease. Now, in the 1990s, many doctors were starting to understand the effect of stress on the physical body. And what happens to people when their HPA-axis signals that they are under threat and start flooding their bodies with stress hormones? Well, we see enhanced coagulation. We see a shift in the renin and angiotensin system. It revs up. We see weight gain in people and insulin resistance. What a lot of people don’t realize is that lipids become abnormal with stress. Almost every one of our patients knows that tachycardia and arrhythmia occur when our adrenaline is flowing, and our blood pressure increases. Now, think about this through the language of medicine.
Around the 1990s, doctors were giving aspirin and Plavix at the time for coagulation. We continue to provide ACEs and ARBs to our patients. The impact of cortisol causes weight gain and insulin resistance. We give statins; we give metformin. We provide beta blockers for that, tachycardia, and calcium blockers for that high blood pressure. So every single hormone that gets turned on with stress, we have a drug that we’re using to balance that. And quite frankly, for years, we talked about how good beta blockers were for the heart. Well, when you think about that, beta blockers do block adrenaline. So when doctors look at this, they begin to think, “Well, maybe we need to medicate and meditate, right? We’re using all these drugs, but we may need to look at other ways to transform the stress response.”
What is Vasoconstriction?
Dr. Alex Jimenez, D.C., presents: We won’t read every one of these symptoms because there are so many, but it all comes down to the same thing. Stress. We have to think of someone who’s in an auto accident, for example, and that person is bleeding. So the body is beautiful in that it puts together a way to stop the individual from bleeding or vasoconstriction. Vasoconstriction is constructing these blood vessels and making the platelets sticky so they form a clot, and the blood can stop. This increases the cardiac output by raising the heart rate and increases aldosterone, which causes salt and water retention to raise the blood pressure. So for someone in a medical emergency, like an accident, bleeding, or losing volume, this is the beauty of the human body. But unfortunately, we see people living this way, literally 24/7. So we know the vasoconstriction and the platelet stickiness, and we see increases in markers for inflammation, homocysteine, CRP, and fibrinogen, all of which increase cardiovascular risk.
We see the impact of cortisol, not only raising blood pressure, not only causing diabetes and insulin resistance, but also depositing abdominal fat around the midline. And then, as you’ll see in a few minutes, there are links between stressful events and arrhythmias like atrial fibrillation and even ventricular fibrillation. For the first time in medicine, in cardiology, we have a syndrome called takosubo cardiomyopathy, which is affectionately called broken heart syndrome. And this is a syndrome in which the myocardium becomes acutely stunned to the point of causing severe left ventricular function or dysfunction. And usually, this is triggered by bad news and an emotionally stressful event. It looks like someone needs a heart transplant. So when we think about the old Framingham risk factors, we say, which of these are impacted by stress?
Symptoms of Stress
Dr. Alex Jimenez, D.C., presents: People have all sorts of maladaptive behaviors to stress, whether 20 friends in this pack of cigarettes, eating this Cinnabon because it makes me feel good right now, or all the cortisol will make me fat and diabetic. Lipids go up under stress; blood pressure goes up under stress. So every one of these risk factors is impacted by stress hormones. And, of course, we know that with the turning on of the RAS system or the renin-angiotensin system, we always see a worsening in heart failure. And this is very much described in the literature. And, for those of you who may work in the emergency room, ask your patients what they were doing before coming in with their episode of congestive heart failure or chest pain. And you’re going to hear stories like, I was watching a bad movie, or I was watching a war movie, or I got upset over the football game, or something like that.
We’ll talk about heart rate variability, which gets impacted by stress. And, of course, stress affects our ability to resist infections. And we know that people are under stress when they’re vaccinated. For example, Cleco lasers work but don’t produce antibodies to the vaccine when they’re under stress. And, of course, as you’ll see in a minute, severe stress can cause sudden cardiac death, MI, and so on. So it is a bad player that’s overlooked. And for many of our patients, stress drives the train. So when we’re talking about eating brussels sprouts and cauliflower and, you know, lots of green leafy vegetables, and someone is under so much stress that they’re trying to figure out, “How am I going to get through the day?” They’re not hearing any of the other things that we’re recommending.
So, chronic stress and affective disorders, whether depression, anxiety, or panic, put our foot on the accelerator and rev up the sympathetic nervous system. We know that the same things we see with aging, as you’ll see in a minute, are linked to increased levels of stress hormones, especially cortisol. So whether it’s osteoporosis, decreased bone density, endothelial dysfunction, platelet activation, hypertension, central obesity, or insulin resistance, this comes from a stress response. And we have to have a plan for our patients on how to handle this. American Institute of Stress says that 75 to 90% of all healthcare provider visits result from stress-related disorders. And that’s way too high, but by looking at the patients and where they were coming in with, they tell their stories to their doctors. The results are the same; it doesn’t matter whether it was headaches, muscle tension, angina, arrhythmia, or irritable bowel; it almost always had some stress trigger.
Acute & Chronic Stress
Dr. Alex Jimenez, D.C., presents: There’s a difference between acute and chronic stress with our perception and social connection. Even though we gain some strength from a higher power, stress can impact anyone, and most of us might not be able to handle it well. So a great study was done many years ago by Dr. Ray and Holmes that stated, 50 years ago, put together a method for quantifying life-changing events. So let’s look at some areas, such as life-changing events. How do life-changing events and how do they rank? Which are the big ones, and which are the little ones?
And how does that ranking lead to major medical problems like cancer, heart attack, and sudden death in the future? So they looked at 43 life-changing events, ranked them originally, and re-ranked them in the 1990s. And some of them remained the same. They gave an adjustment score to the event, and then they looked at numbers that would be linked to major illness. So, for example, a life-changing event. Number one, 100 life-changing units, is a death of a spouse. Anyone could relate to that. Divorce was number two, separation number three, and the end of a close family member. But also noticed that some things got ranked that are, you might not equate with, being a major life-changing event that can impact a stress response like marriage or retirement.
Conclusion
Dr. Alex Jimenez, D.C., presents: So it wasn’t the actual single event that made the difference. It was the adding up of events. And what they found after looking at 67 physicians was if you had a life-changing unit score of somewhere between zero and one 50, not a big deal, no real major illness, but once you hit that 300 mark, there was a 50% chance of major illness. So this timeline of events in the patient’s life. We want to know what was going on in their life when their symptoms started and then bring it back earlier to understand the environment in which this individual was living. The impact of stress can make many individuals develop chronic conditions and mask other symptoms that can lead to muscle and joint pain. In part 2, we will dive in more about how the impact of stress affects a person’s body and health.
Hamstring syndrome is a condition where the sciatic nerve gets pinched between the hamstring muscles and the pelvic bone or by the tissue bands that connect the hamstring muscles causing compression on and around the nerve. It is seen in individuals that play sports that involve running, kicking, or jumping, in middle-aged individuals engaged in daily activities that have suffered falls, and in individuals that sit for many hours. Chiropractic care, massage, and decompression therapy can relieve the symptoms, release the trapped nerve, relax and stretch the muscles, and restore function.
Hamstring Muscles Trapped Sciatic Nerve
Three muscles make up the hamstrings in the back of the thigh. The sciatic nerve runs from the low back down the leg into the foot. A trapped sciatic nerve can cause various symptoms and sensations in the back of the leg, hip, buttock, and foot. It may hurt to sit down or stretch the legs out, and there is usually tightness in and/or around the buttock and back of the leg. The symptoms typically recede when lying on your back.
Cause
Regular wear and tear on the back muscles and hamstrings can contribute to the condition.
Often the sciatic nerve and/or the sheath surrounding the sciatic nerve gets trapped and irritated as it travels around the ischial tuberosity. The ischial tuberosities are known as the sit bones.
The area where the sciatic nerve runs down the back of the leg can become narrowed, leading to nerve irritation and stinging, numbing, and tingling sensations.
The injury often happens during sudden, quick, forceful movements that overstretch the tendons and/or muscles but can also happen during slow movements.
Movement agitates the pulling and rubbing of the nerve on the muscles.
A non-painful pull or pop of the hamstrings can cause the muscles to spasm and wrap around the nerve.
Symptoms
Symptoms usually include the following:
Leg pain that worsens when sitting.
Intense electrical shooting pain that makes it hard to stand or move.
Difficulties moving the leg or foot.
Numbness and weakness in and around the leg.
Tingling or burning sensations running down the leg.
Persistent pain on one side of the lower back.
Chiropractic Care
Chiropractic treatment can relieve the symptoms and release the trapped nerve. Treatment includes:
Accurate Diagnosis – A chiropractor will examine and review physical activity, work, and medical history.
Ice and Heat therapies will stop the swelling and increase blood flow.
Massage therapy relaxes the muscles and increases circulation.
Decompression therapy incrementally and gently stretches the body.
Chiropractic adjustments realign and reset the body.
Targeted stretches and exercises will keep the muscles loose and increase strength.
Nutritional recommendations will help reduce inflammation and prevent flare-ups.
Hamstrings and Sciatic Nerve Relationship
References
Lohrer, Heinz, et al. “Nerve entrapment after a hamstring injury.” Clinical journal of sports medicine: official journal of the Canadian Academy of Sports Medicine vol. 22,5 (2012): 443-5. doi:10.1097/JSM.0b013e318257d76c
Mattiussi, Gabriele, and Carlos Moreno. “Treatment of proximal hamstring tendinopathy-related sciatic nerve entrapment: presentation of an ultrasound-guided “Intratissue Percutaneous Electrolysis” application.” Muscles, ligaments and tendons journal vol. 6,2 248-252. 17 Sep. 2016, doi:10.11138/mltj/2016.6.2.248
McGregor, Catriona, et al. “Traumatic and overuse injuries of the ischial origin of the hamstrings.” Disability and rehabilitation vol. 30,20-22 (2008): 1597-601. doi:10.1080/09638280701786138
Saikku, Kari, et al. “Entrapment of the proximal sciatic nerve by the hamstring tendons.” Acta orthopaedica Belgica vol. 76,3 (2010): 321-4.
Dr. Alex Jimenez, D.C., presents how hypertension affects the human body and how to find ways to manage the symptoms associated with hypertension affecting many individuals in this 2-part series. Part 1 looked into the various factors that correlate with hypertension, and part 2 looked at the different genes and body levels affected by hypertension. We refer our patients to certified medical providers who provide multiple available treatments for many people suffering from hypertension associated with the cardiovascular, endocrine, and immune systems affecting the body. We encourage each of our patients by mentioning them to associated medical providers based on their analysis appropriately. We understand that education is a delightful way when asking our providers questions at the patient’s request and understanding. Dr. Jimenez, D.C., only makes use of this information as an educational service. Disclaimer
What Are ADMA Levels In Hypertension
Dr. Alex Jimenez, D.C., presents: Okay, so what affects ADMA levels? Upregulation of NRF-2 can decrease ADMA levels. So that’s great. So looking at things high in EGCG, think of green tea, sulforaphane, resveratrol, and exercises that reduce ADMA levels in the body. Improving blood sugar control improves ADMA levels, addressing the homocysteine pathway and looking at acidencial homocysteine. So this asks the question, what is the most common over-the-counter medication in the United States for gastroesophageal reflux or hyperacidity of the stomach that increases ADMA levels? And that is proton pump inhibitors, a poor diet, or elevated homocysteine. These are a couple of touch points on the ADMA that you can consider.
Let’s shift a little bit. Remember we talked about increased oxidative stress? There’s a whole enzyme system orchestra that addresses oxidative stress. And chronic oxidative stress can lead to hypertension. It also leads to fibrosis or gradual fibrosis of end organs. And so when you have elevated, reactive oxygen species, cell proliferation, migration changes, apoptosis changes, there’s increased inflammation. Reactive oxygen species make your tissue at the basal membrane level stiffer; your tissue becomes stiffer when you have increased oxidative stress. You start shifting with increased oxidative stress, extracellular matrix enzymes, and structure, and then you start getting endothelial dysfunction.
Many enzymes are influenced by nutrition and our genetic makeup that shift our balance of oxidative stress. Some of those enzymes are glutathione and glutathione peroxidase. The fifth enzyme down is GPX, which is the enzyme that helps us react to inflammation and toxins by altering the glutathione balance. We mentioned glutathione multiple times. We’ll talk about glutathione as a biomarker that you can check to assess oxidative stress in your patient. So is your oxidative stress because of mitochondrial dysfunction, or is your increased oxidative stress due to inflammation? We’ve seen this as a side effect in many patients, as increased inflammation leads to increased oxidative stress associated with increased mitochondrial dysfunction. This triangle is a matrix of interaction between the energy node, mitochondrial dysfunction, reactive oxygen species, and the defense and repair node inflammatory markers. We have seen this multiple in multiple different conditions.
How Oxidative Stress Is Associated With ADMA Levels?
Dr. Alex Jimenez, D.C., presents: When we see oxidative stress findings in many different organ systems in many other conditions in our medical practices, in many patients, we often see all these chronic conditions associated with oxidative stress as part of their symptoms. When this happens, we have to consider how to modulate them by asking them a few simple questions. We would ask them what kind of spices and herbs they use when they cook. Or what is their diet plan? These questions are important to analyze and assist the patient because culinary spices can affect many aspects of our body’s metabolism that could influence blood pressure.
By looking at the list of various spices, it is important to add them to food preparations or to alter the taste of food to add flavor and improve your health. Another thing to look for when it comes to lowering blood pressure is by adding these various spices into your food as part of your daily routine and being referred to a health coach or a nutritionist, whose main job is to add more spices to a patient’s diet and coming up with numerous recipes that have these spices. Remember, it doesn’t take a lot; a teaspoon to a tablespoon of mixed herbs in your food throughout the day could help normalize your blood pressure.
How To Come Up With A Plan To Lower Hypertension
Dr. Alex Jimenez, D.C., presents: Okay, how will you address oxidative stress, and what biomarkers might you look at? Well, oxidative stress affects many different levels of our cellular and subcellular levels. Oxidative stress can cause damaged DNA and change the fats in the membranes of the mitochondrial cell. It can induce increased lactation and disrupt protein structure in our bodies. So we start looking at total antioxidant capacity. Total antioxidant capacity is influenced by the nutritional adequacy of essential fats of too many simple carbohydrates of enough minerals, vitamins, and phytonutrients. So you can check glutathione levels in the serum, cysteine levels, enzymes, glutathione peroxidase, superoxide dismutase, and lipid peroxide on this list to see what is elevated in the body. You can check these different markers and get a clue of what portion of the cells or organ system is influenced by oxidative stress.
When we see these results, we need to develop a plan to increase the fat-soluble antioxidants, which can be fat and water-soluble, like alpha-lipoic acid. Or, say, for example, somebody has elevated eight-hydroxy-deoxy guanosine. What are the things that help you repair their DNA sequence? Well, it’s the components in one cellular, one-carbon metabolism. It’s your B vitamins. It’s methyl groups from essential fats. But then you have to ask, why is this elevated? Is it elevated because of micronutrient deficiency, mitochondrial toxicity, chronic inflammation, or hyperglycemia? So it’s common for your cardiometabolic patients to frequently see increased DNA oxidation marker eight-hydroxy-deoxy-guanosine.
Okay, those are biomarkers you can check in the urine or the blood. What’s another biomarker that you can check by looking at the nitric oxide angiotensin balance? What are ways that you can check endothelial function? What are ways that you can improve endothelial function even without checking? Well, there are different things that you can do to enhance nitric oxide. We’ve mentioned them before, like improving the bacterial balance, eating more flavonoids, increasing foods rich in nitrates, or even adding yoga to your regimen. There are ways that you can improve endothelial function without medications like sildenafil, as noted, that could potentially correlate with sleep apnea. It may address whether they have sleep apnea, need a mandibular split, and address some of the conditions they carry with them. Or, at the very bottom, it may manage their high-fat meals.
Okay, if you have somebody on a ketogenic diet, you must recognize potential oxidative stress and address it with your patients. So what are some early ways to detect vascular or endothelial dysfunction? One of the outpatient tools you can use is the vascular reactivity index. This detects vascular disease and looks at the pliability of the flexibility of the small capillaries and how well you profuse tissue downstream of an obstruction. So instead of looking at coronary arteries or carotids, it’s looking down at the level of the arterial, and we look at what’s called reactive hyperemia. So, it gives you some prognostic inflammation.
Measuring Blood Pressure
Dr. Alex Jimenez, D.C., presents: And there have been studies that follow people with reactive hyperemia to look at endothelial dysfunction and how that interacts with the Framingham risk score. And we know that when somebody has an abnormal index that predicts cardiovascular events, combining it with the end path lowers the lower endothelial function readings, which is associated with long-term cardiovascular disease. So how does it happen? You put a blood pressure cuff on your arm with a monitor on your finger. You blow the blood pressure cuff up to obstruct blood flow. You then, after five minutes, release it, and your vascular response to that surge of blood after having the blood flow occluded predicts hypertension and coronary heart disease. On the left, you see the normal endothelial function; the blue line on the top graph on the left is the obstruction of blood flow.
And then, after five minutes, you release the cuff, and you see this almost bell-shaped flow of blood down to the capillaries. You know the response, the endothelial function. That is a normal curve on the right. It is poor endothelial function. You can see there are no signs of arterial capillary flexibility. And so this is predictive up to seven years later. So then you ask yourself, is there anything that can improve endothelial function when I expect endothelial function dysfunction, or do I have an abnormal vascular reactivity index? And yes, let’s choose one as an example. Eating blueberries twice a day or taking them in powder form is rich in anthocyanins. To that point, you can add them to a smoothie that you have incorporated into your diet and have antioxidants in your system. The anthocyanins and their metabolites can help improve vascular function while increasing the mediated flow dilation and lowering 24-hour systolic blood pressure.
We use a lot of carotid in medial thickness because if I have somebody with hyperlipidemia, hyperglycemia, or hypertension, I want to use it as a leverage point to see if they have inflammation, their carotid bull or their internal carotid on each side to track to see if we’re getting systemic improvement in inflammation or can we get reversal with plaque. And so we’ve successfully done that through testing our clinic, advanced lipids, and education through group medical visits along with lifestyle interventions with nutraceuticals. And we have had a reduction in plaque and mark modulation and improvement in inflammation. If you don’t do anything helpful, the average increase in carotid intimal medial thickness per year is between 10 and 20% of the abnormal level. You can use this as a tool, as an outpatient, very easily to monitor the reduction in systemic vascular inflammation in plaque.
Looking At The Emerging Markers
Dr. Alex Jimenez, D.C., presents: Some other emerging markers, like HSCRP, uric acid, heavy metals, nutritional deficiencies, and TMAO, correlate with hypertension. And by improving those markers, you get improvement in blood pressure. Here’s the thing to remember. When you look at an HSCRP and see that it’s above one, here’s the connection. Now HSCRP inhibits endothelial nitric oxide synthase. So when you see an elevated HSCRP, you make a connection to lower nitric oxide. If you see an elevated HSCRP that downregulates the angiotensin-two receptors, it can increase blood pressure and is associated with increased cardiovascular risk.
How often do you check uric acid? It’s important to prevent uric acid in hypertensive patients. If it’s above six, you need to address it. How do you manage elevated uric acid levels? Well, by removing purine-rich foods or improving the metabolism of urine through your one carb metabolism, b12, fully b6, limiting their alcohol or avoiding a lot of extra high fructose sugar or improving their body weight, or addressing insulin resistance. All these mediate uric acid. If you have somebody who’s hyperemic, remember these five areas of modifiable physiologic imbalance. So I hope you’ve seen that hypertension is a syndrome. It’s not one thing; it’s not stiffness; it’s a syndrome in that you have three areas that you have to consider inflammation, oxidative stress, and immune response. You can look at a lot of the different imbalances around this dial.
Conclusion
Dr. Alex Jimenez, D.C., presents: You can look at your patient; you can look at what ways you can further evaluate them. And so, when you see a patient with hypertension, consider the treatments outlined in your clinical decision tree. And then, you can apply the modifiable lifestyle factors and the things to lower their blood pressure. Incorporating these lifestyle applications can improve the root cause and help you find the root cause of hypertension through the functional medicine lens.
Dr. Alex Jimenez, D.C., presents how hypertension affects the human body and some causes that can increase hypertension in many individuals in this 2-part series. We refer our patients to certified medical providers who provide multiple available treatments for many individuals suffering from hypertension associated with the cardiovascular and immune systems affecting the body. We encourage each of our patients by mentioning them to associated medical providers based on their analysis appropriately. We understand that education is a delightful way when asking our providers questions at the patient’s request and understanding. Dr. Jimenez, D.C., only makes use of this information as an educational service. Disclaimer
How To Look For Hypertension
Dr. Alex Jimenez, D.C., presents: Let’s go back to the decision tree so you can begin to think about how you will apply the go-to-it model in functional medicine to hypertension and how you will start better assessing somebody with hypertension rather than telling them that their blood pressure is elevated. Is the body influenced by inflammation, oxidative stress, or immune response? Is it affecting endothelial function or vascular smooth muscle from those three categories of reactions, inflammation, oxidative stress, or immune response? Do we choose a diuretic calcium channel blocker or an ACE inhibitor? And so to do that, it’s really important in our gather section. Taking the medical history and the timeline of their hypertension, you get a clue about the organ damage to the questionnaires. You’re looking at their anthropometrics.
This includes the following questions:
What are the inflammatory markers?
What are the biomarkers and clinical indicators?
Those are outlined through the clinical decision tree. And already just doing that, you’re going to expand and fine-tune your lens on what you might see in your hypertensive patient. Let’s add to the timeline when does hypertension begin? The timeframe of hypertension begins actually in prenatally. It’s important to ask your patient if they were early or large educational age. Was their mother stressed? Were they born early or premature? Was there nutritional stress in their pregnancy? If they know that, you can have two people with the same kidney size, but the person who didn’t have enough protein during pregnancy can have up to 40% less glomeruli. Knowing that will change how you adjust the medication decades later if you know they possibly have 40% less glomeruli.
The Timeline For Blood Pressure
Dr. Alex Jimenez, D.C., presents: So it’s important to take the timeline of their blood pressure. Then it’s also important to recognize what is happening when we begin to organize and collect data through the biomarkers; the basic biomarkers will give you clues about whether they have issues with insulin lipids, whether they have problems with vascular reactivity, autonomic nervous system balance, imbalance, coagulation, or immune toxin effects. So this is a reasonable thing to print off because, in your hypertensive patient, this is through just the biomarkers you can begin to get a clue as to what areas of dysfunction affect inflammation, oxidative stress, and immune response and how these biomarkers reflect that information for you. This is very reasonable to have in front of you to help change your thoughts about hypertension and also enables you to refine some of the characteristics of the person on the other side of your stethoscope in a more personalized, precise way.
But let’s start at the very beginning. Does your patient have high blood pressure? We know that depending on the end organ effects of their comorbidities, you may run someone a slightly higher blood pressure if you have a profusion issue in the brain and the kidneys or the heart, but some guidelines are there. Our 2017 American Heart Association guidelines for blood pressure categories are listed here. They’ve waxed and waned back and forth over the last couple of decades, but this is very clear. Having elevated blood pressure, anything above 120, really shifted how many people we start seeing or considering addressing the root causes of their blood pressure. So we will come back to this, especially in the case to help us look at how we categorize people with blood pressure issues.
The Criteria To Mesure Blood Pressure
Dr. Alex Jimenez, D.C., presents: What is the first step? It’s how do you have the blood pressure taken in your patient? Do they monitor it at home? Do they bring those numbers to you? How do you monitor blood pressure in your clinic? How do you get accurate readings in your clinic? Here are the criteria to accurately measure blood pressure and the questions to consider whether you’re doing all these.
Do you ask your patient whether they’ve had caffeine in the last hour?
Whether they’ve smoked in the previous hour?
Were they exposed to smoke in the last hour?
Is the place where you’re taking blood pressure warm and quiet?
Are they sitting with their back supported in a chair with their feet on the ground?
Do you use the roll-around side table to rest your arm at the heart level?
Are they sitting at the exam table with their feet dangling, and a nurse aide elevates their arm and puts in their axillary fold to hold their arm there?
Are their feet on the ground?
Have they sat there for five minutes?
Have they exercised in the previous 30 minutes?
You may have systolic blood pressure if everything is in the criteria. Here’s the challenge. There are 10 to 15 millimeters of mercury higher when it comes to sitting and taking blood pressure. What about the cuff size? We know last century; most adults had an upper arm circumference of fewer than 33 centimeters. Over 61% of people now have an upper arm circumference greater than 33 centimeters. So the size of the cuff is different for around 60% of your adult patients, depending on your population. So you have to use a large cuff. So take a look at how blood pressure is collected in your office. Let’s say the blood pressure is elevated in your patients; then we have to ask, is it normal? Great.
The Different Types Of Hypertension
Dr. Alex Jimenez, D.C., presents: Is it elevated because of white-coat hypertension? Do they have normal blood pressure, elevated outside the clinic, or masked hypertension? Or do they just have sustained hypertension which is a challenge? We’ll talk about that. So when you interpret, it is also important to consider ambulatory blood pressure monitoring. So if you have somebody who’s hypertensive and don’t know whether the blood pressure goes down and you’re trying to figure out whether they have sustained hypertension, you can use 24-hour blood pressure monitoring. The mean daytime blood pressure above 130 over 80 is hypertensive the mean nighttime blood pressure above 110 over 65 is hypertensive. So why is this important? The average blood pressure dips to around 15% at night because of the issue with blood pressure dipping. Failure to have blood pressure drop while you sleep at night could develop problems that can affect a person throughout the day.
If your patient sleeps at night, it should drop about 15% when they sleep. If they have non-dipping blood pressure, it is associated with comorbidities. What are some of those comorbidities in non-dipping blood pressure? Some of the conditions correlated with non-dipping blood pressure include:
Congestive Heart Disease
Cardiovascular Disease
Cerebrovascular Disease
Congestive Heart Failure
Chronic Renal Failure
Silent Cerebral Infractions
Co-morbidities Associated With Non-Blood Pressure
Dr. Alex Jimenez, D.C., presents: These are the comorbidities associated with non-blood pressure. All of us agree that elevated blood pressure is not necessarily good in all those conditions. So when you look at different people groups or other comorbidities, non-dipping blood pressure is most commonly associated with sodium-sensitive folks, people who have renal insufficiency, people who have diabetes, people who have left ventricular hypertrophy, people who have refractory hypertension or autonomic nervous system dysfunction and finally, sleep apnea. So, non-dipping blood pressure increases your association with subclinical cardiac damage. Okay, Reverse dipping means you are more hypertensive at night and is more ascent associated than during the day is more related to hemorrhagic stroke. And if you have somebody with nocturnal hypertension, you have to start thinking about things like the carotid arteries and increased carotid, internal medial thickness. You start thinking about left ventricular hypertrophy and may see it on EKG. Here’s what we know about nocturnal hypertension. Nocturnal hypertension is a nighttime blood pressure greater than 120 over 70. It is associated with greater predictability of cardiovascular morbidity and mortality.
If you have nocturnal hypertension, it increases your risk of mortality from cardiovascular disease by 29 to 38%. We must know what’s happening at night when we sleep, right? Well, what’s another refinement? Another refinement is recognizing that resting blood pressure is controlled by your renin-angiotensin system. Waking blood pressure is controlled by your sympathetic nervous system. So let’s talk about how their renal angiotensin system drives their nighttime hypertension, and you think about what medication they’re taking. You might change the medication dosing to nighttime. Well, studies have shown that if you have nighttime hypertension and are a non-dipper, it’s best to take your ACE inhibitors, ARBs, calcium channel blockers, and certain beta blockers at night before bed. But it makes sense that you wouldn’t move your diuretics to nighttime, or you will have a disruptive sleep.
Addressing Daytime & Nighttime Blood Pressure
Dr. Alex Jimenez, D.C., presents: So if we don’t address daytime and nighttime blood pressure, we have to consider the effect of blood pressure load. What is your average daytime blood pressure and your moderate sleeping blood pressure is. We know that blood pressure load in young adults is hypertensive only about 9% of the time. So meaning the systolic load is about 9% versus in the elderly, about 80% of the blood pressure load is systolic. And so when you have a higher systolic load, you have more complications and end-organ damage. So what we’re talking about is helping identify your patient with hypertension; what is their timeline? What is their phenotype? Are they only hypertensive during the day, or they’re hypertensive at night also? We have to look at what helps balance that.
Here’s the other point, only about 3.5% of people with hypertension do it have a genetic cause. Only 3.5% of people their genes cause hypertension. The power is at the bottom of the matrix and recognizing these patterns, right? So you look at exercise, sleep, diet, stress, and relationships. So we know that these four autonomic balances help determine blood pressure. We will examine the renal angiotensin system, plasma volume where they hold onto too much fluid, secondary salt load, and endothelial dysfunction. Abnormalities in any of these can lead to hypertension. We’ve been talking about another one that can lead to hypertension: the link between insulin resistance and hypertension.
This diagrammatically gives you an idea of the physiologic interactions between insulin resistance and hypertension. It affects increasing sympathetic tone and increasing renal-angiotensin system balance. So let’s spend a few minutes on the renin-angiotensin system pathway angiotensinogen down to angiotensin two. We take advantage of these enzymes by giving inhibitors to angiotensin-converting enzymes in our hypertensives patients. Elevated angiotensin two leads to cardiovascular hypertrophy, leads to sympathetic phase constriction, increased blood volume, sodium fluid, retention, and aldosterone release. Can you inquire about your patient biomarkers? Can you ask whether they have elevated renin levels?
Look For The Signs
Dr. Alex Jimenez, D.C., presents: Well, you can. You can check plasma renin activity and aldosterone levels. It’s important to do this if your patient is hypertensive and has never been on medication because this is where nitrous oxide is so important. This is where your endothelial nitric oxide synthase is present. This is where you have sheer and hemodynamic stress. This is where dietary intake of arginine or the environment that affects nitric oxide plays such a role in the health of this layer of endothelia. If you lay it all together somehow, miraculously, or at least in your mind’s eye, it’ll cover six tennis courts in the average adult. It’s a huge surface area. And the things that cause endothelial dysfunction are not new news to people in functional medicine. Increased oxidative stress and inflammation are two things we mentioned that play an effect.
And then, look at some of these other components, your ADMA being elevated and correlated with insulin resistance. It all begins to form together in a matrix that interacts. So you look at one comorbidity in cardiometabolic syndrome, and it affects another comorbidity. You suddenly see the interrelation between them or hyperhomocysteinemia, which is a one-carbon metabolism marker, meaning you’re looking at the adequacy of folate, b12, b6, riboflavin, and that activity of your one-carbon metabolism. So let’s look at some of these emerging risk markers to improve and track in patients with hypertension. Let’s reanalyze ADMA again. ADMA stands for asymmetric dimethyl arginine. Asymmetric, dimethyl arginine is a biomarker of endothelial dysfunction. That molecule inhibits nitric oxide synthase while impairing endothelial function, and in all of the comorbidities associated with cardiometabolic syndrome, ADMA can be elevated.
Conclusion
So, as a quick review, L-arginine is converted to nitric oxide via nitric oxide synthase, and nitric oxide adequacy leads to vasodilation. ADMA blocks this conversion. And if your ADMA levels are elevated and your nitric oxide levels are low, then you have decreased nitric oxide platelet aggregation increases in LDL oxidation. So many things reduce nitric oxide or are associated with lower nitric oxide levels, sleep apnea, low dietary arginine, protein, zinc insufficiency, and smoking.
Unhealthy posture and slouching incorrectly position the body unnaturally, adding chronic strain on the muscles and ligaments. For example, when sitting or standing at a workstation, individuals start to relax by slumping forward because it feels comfortable; however, they don’t realize that their shoulders are hunching over, and their neck is in an awkward forward position. For every inch the head moves forward, its weight on the neck and upper back muscles increases by 10 pounds. Individuals that stay in this position for a long time often experience neck soreness, tension in the shoulder muscles, and low back discomfort. Chiropractic care, massage, and decompression therapy can realign the spine to its natural position and train individuals to maintain a healthy posture.
Slouching
Posture is the body’s position in space, the relationship of the body’s parts, head, torso, and limbs to each other. Maintaining the natural lumbar curve in the low back is essential to preventing posture-related discomfort symptoms. This natural curve works as a shock absorber, helping to distribute weight along the length of the spine. The most common causes for slouching posture are:
Repetitive motions or tasks can cause physical and mental fatigue, causing individuals to relax their core muscles.
Combined with the repetitiveness, individuals also begin implementing unhealthy movements because it makes the job easier.
Often individuals want to finish their work tasks, and even though they can feel their muscles and body stiffening and tightening up, they continue to work through the discomfort and don’t take a quick break to move around and stretch.
Stressful situations can cause muscle tension.
Carrying heavy bags, purses, backpacks, etc.
Weight fluctuation.
Pregnancy.
Spine
Muscles move the skeletal system and provide resistance against movement.
The musculoskeletal system comprises soft tissue structures that provide active and passive spinal stabilization.
The spine has natural curves to distribute weight/loads evenly.
The cervical and lumbar spine have a lordosis or forward curve.
The thoracic spine and sacrum have a kyphosis or backward curve.
They help to mitigate the forces exerted on passive stabilizing structures like the ligaments, joint capsules, and intervertebral discs.
A prolonged seated or standing position fatigues the muscles that stabilize the spine from the forces of gravity and body weight. When the tired muscles no longer provide stability, the spine must rely on the passive structures of the musculoskeletal system for support. Without the support, the spine gradually loses its natural cervical and lumbar curves and becomes more kyphotic or slouched. Slouching can provide relaxation and relief to the fatigued muscles; however, repetitive or prolonged stress to the passive structures can result in discomfort and injury to those tissues. This is how nerve compression, ligament inflammation, and disc herniations start.
Symptoms of Unhealthy Posture
Head that leans forward or backward.
Headaches.
Jaw pain.
Poor circulation.
Rounded shoulders.
A decline in breathing efficiency.
Muscle fatigue – Certain muscles can change in length, becoming short and tense or long and weak.
The advantages of practicing healthy posture include the following:
Prevents abnormal wear on the joints.
Lessens stress on the ligaments.
Prevents muscle strain and fatigue.
Prevents the spine from becoming misaligned.
Prevents back aches and soreness.
Reduces the risk of chronic diseases or conditions.
Helps maintain fitness and overall health.
Chiropractic Realignment
Our approach starts by correcting the physical problems caused by slouching, which involves chiropractic adjustments, therapeutic massage, and non-surgical decompression therapy. The objective is to fix the root cause to ensure that the treatment lasts and maintains neuromusculoskeletal health.
Examination
The initial assessment looks at an individual’s posture and a physical evaluation to identify the root cause.
When muscles become weak, over or underused, or suffer injury, others tighten or tense up.
A chiropractor looks at how an individual stands from behind and from the sides, noting issues like uneven shoulders, arched back, twisted pelvis, or other symmetry issues.
Treatment
Massage will increase circulation and reduce tension.
Muscle release and relaxation for any overactive muscles.
A chiropractor will perform slow joint movements.
Targeted stretches and strength exercises will correct imbalances, maintain flexibility, and strengthen the core muscles.
Postural training will help individuals learn to use proper body mechanics and to listen to their bodies.
Impact of Stress
References
Defloor, T, and M H Grypdonck. “Sitting posture and prevention of pressure ulcers.” Applied nursing research: ANR vol. 12,3 (1999): 136-42. doi:10.1016/s0897-1897(99)80045-7
Fortner, Miles O et al. “Treating ‘slouchy’ (hyperkyphosis) posture with chiropractic biophysics®: a case report utilizing a multimodal mirror image® rehabilitation program.” Journal of physical therapy science vol. 29,8 (2017): 1475-1480. doi:10.1589/jpts.29.1475
Katzman, Wendy B et al. “Age-related hyperkyphosis: its causes, consequences, and management.” The Journal of orthopedic and sports physical therapy vol. 40,6 (2010): 352-60. doi:10.2519/jospt.2010.3099
Korakakis, Vasileios, et al. “Physiotherapist perceptions of optimal sitting and standing posture.” Musculoskeletal science & practice vol. 39 (2019): 24-31. doi:10.1016/j.msksp.2018.11.004
Snijders, Chris J et al. “Effects of slouching and muscle contraction on the strain of the iliolumbar ligament.” Manual therapy vol. 13,4 (2008): 325-33. doi:10.1016/j.math.2007.03.001
Yoong, Nicole Kah Mun et al. “Commercial Postural Devices: A Review.” Sensors (Basel, Switzerland) vol. 19,23 5128. 23 Nov. 2019, doi:10.3390/s19235128
Dr. Alex Jimenez, D.C., presents how anti-inflammatory phytochemicals can reduce inflammation and treat other chronic conditions that inflammation is correlated with. We dive into what medicines can trigger inflammatory cytokines and some treatments that work together to reduce chronic inflammation. We refer our patients to certified medical providers incorporating multiple therapies for many individuals suffering from chronic inflammation and its correlating symptoms affecting the body. We encourage each of our patients by mentioning them to associated medical providers based on their analysis appropriately. We understand that education is a delightful way when asking our providers questions at the patient’s request and understanding. Dr. Jimenez, D.C., only makes use of this information as an educational service. Disclaimer
How Medications Associate With Inflammation
Dr. Alex Jimenez, D.C., presents: When it comes to a person’s health and wellness, it is important to know that when you are introducing them to potential antigenic medication, that person’s immune system is already imbalanced and much more likely to make abnormal immune responses, which then can lead to inflammatory effects in the body’s system. You see them mostly with chimeric human marine antibodies, which are the ones that make antibodies for the immune system, to that point, will elicit a much higher immune response. When this happens, it becomes a challenge to long-term pharmacotherapy. So when people go to their doctors for a prescription, about 20-30% of medication prescriptions are never filled because, most of the time, the prescription will never fill them in the drugstore, which can cascade into various issues.
And when people follow their prescription, sometimes they’ll take it for a little while, and after six months, they stop taking it. So the drop in prescriptions taken for longer than six months is quite low. In the last article, we discussed NSAIDs, DMARDs, and biologics, and we will touch base with acetaminophen. Acetaminophen is another one that’s just really widely used, and it’s because it’s put into all of these different cold and flu, and pain products. They sneak it into many other medications; you must read the labels. This is because some people metabolize acetaminophen quickly, which can become toxic. This can lead to individuals getting random headaches throughout the day and causes their glutathiones to be used promptly. So when looking for cold and flu medicine, it is best to look at the labels for acetaminophen because it doesn’t have anti-inflammatory responses since it is used for pain control.
How Acetaminophen Affects the Immune System
Dr. Alex Jimenez, D.C., presents: So even though we do not know how exactly how the analgesic effects work when people take cold and flu medicines, however, we do know that when people take a ubiquitous amount of acetaminophen, it could increase the pain threshold by inhibiting nitric oxide pathways in the body through mediation through the receptors for NMDA and substance P. We still don’t have a great handle on that, but that’s how it works. So, these drugs can be quite useful in the short term, but long-term use has serious side effects.
When looking for medications, it is important to read the labels that have a black box warning, which is the highest warning that the FDA issues for any potential overlapping risk profiles that the FDA issues. This can include severe liver injuries or serious possible allergic reactions that can develop into chronic inflammation of the muscles and joints. Now there are ways to reduce inflammation and prevent the body from being in more pain by slowly introducing anti-inflammatory botanicals and phytochemicals to detoxify the medication causing these complications.
Some individuals may not realize that constant medication for various pains and issues affecting the body can mask other problems involving the body’s systems. This can include:
Endocrine system
Cardiovascular system
Gastrointestinal system
Reproductive system
When these systems have been affected by medications, they can develop inflammatory markers in the vital organs and cause lead to visceral-somatic dysfunction in the body. When pain medications target pain localized in one location, but the issue is in a different area, this is known as referred pain. Referred pain is where the pain is in one muscle group location but is felt in another area of the body. When the organs are involved, it can cause inflammatory symptoms in the system. To that point, this causes the immune system to be induced into autoimmunity.
How The Immune System Is Induced Into Autoimmunity
Dr. Alex Jimenez, D.C., presents: When the immune system has been induced with autoimmunity, the corticosteroids can develop side effects that can be long termed and delay the healing process. Some of the physical symptoms that are visible with autoimmunity include:
Muscle weakness
Diabetes
High blood pressure
Thin bones
Delay wound healing
Flare-ups
Rheumatoid arthritis
Mood changes
When dealing with these inflammatory symptoms associated with pain, there are fundamental functional treatment approaches that can reduce the inflammatory cytokines causing joint and muscle pain.
Treatments To Target Inflammation
Dr. Alex Jimenez, D.C., presents: Some of the treatments that target inflammation include the following:
Slowly incorporating healthy lifestyle choices into a person’s daily lifestyle can reduce the effects of inflammatory cytokines affecting the vital organs, muscles, and joints. It is important to know that incorporating antioxidants, phytonutrients, and anti-inflammatory supplements can reduce residual symptoms in the body. All these treatments are some of the foundations that can address these inflammatory triggers and help reduce muscle and joint pain associated with inflammation.
Anti-Inflammatory Vitamins & Supplements
Dr. Alex Jimenez, D.C., presents: Another important note about these treatments is that vitamins and supplements can combine to help treat inflammatory effects that are causing issues in the body. These anti-inflammatory botanicals and phytochemical agents can not only act on the different pathways in the body but also have different mechanisms similar to healthy nutritional foods. Incorporating anti-inflammatory botanicals and phytochemical agents into the body will help modulate the inflammatory cascades and provide multiple synergistic activities to the body.
These agents down-regulate the inflammatory pathways caused by NF-kappaB. They can act as modulators that dissociate the cytokines from causing more issues like oxidative stress or infections triggering inflammation. However, we need inflammation to heal the body from wounds and infections. We mustn’t want the cytokines too high to cause inflammatory effects. So incorporating anti-inflammatory botanicals and phytochemicals provides a much safer option to the body and can be used in many chronic inflammatory conditions.
Conclusion
Since many botanicals and phytochemicals have anti-inflammatory properties, it can be difficult to find a good amount that the body needs to reduce chronic inflammation. Since many cultures and places have used many nutritional plants and herbs for years worldwide, it can be exhausting. Some of the botanical supplements include:
Zinc
Green tea extract
Capsaicin
S-adenosylmethionine
Ginger
To summarize how it is important to know which supplements have anti-inflammatory properties, doing research and incorporating small changes into a daily lifestyle can provide amazing results and allow the individual to be pain-free and have good health when combining botanicals and phytonutrients.
The iliopsoas muscle is a primary hip flexor that assists in the femur’s external rotation and maintains the hip joint’s strength and integrity. It also helps to stabilize the lumbar spine and pelvis. Athletes often overuse these muscles with all the sprinting, jumping, kicking, and changing directions when running, causing strains and/or tears. Repetitive hip flexion can result in chronic degenerative tendon changes. Chiropractic care and physical therapy can assist in the early phases of healing, safely transitioning to rehabilitation, and returning to physical activities.
Iliopsoas Muscle
The hip flexors are the group of muscles, including the iliac and psoas major muscles/iliopsoas and the rectus femoris/quadriceps. One of the largest and thickest muscles in the body, the psoas, extends from the lumbar vertebrae, crosses in front of each hip, and attaches to the inside top of the thigh bone. The muscle works by flexing the hip joint and lifting the upper leg towards the body. These fibers can tear if tension is more than the muscle can bear. An iliopsoas strain occurs when one or more of these hip flexor muscles become overly stretched or begin to tear.
Injury
The injury can occur from sports or everyday physical activities. This leads to inflammation, pain, and scar tissue formation. An iliopsoas injury is commonly caused by sudden movements, including sprinting, kicking, and changing direction fast while running. Individuals participating in any sports, especially cycling, running, dance, tennis, martial arts, and soccer, are more likely to experience this injury. Other contributing factors include:
Muscle tightness
Joint stiffness
Muscle weakness
Inadequate core stability
Not warming up correctly
Improper biomechanics
Decreased fitness and conditioning
Individuals will feel a sudden stinging pain or pulling sensation, usually on the front of the hip, groin, or abdominal area. Other symptoms include:
Healing and recovery depend on the severity of the injury. A minor iliopsoas muscle injury can take around three weeks to recover fully. More serious strains and tears take six to eight weeks before returning to activity, as the tissue needs time to repair before starting rehabilitation.
Chiropractic Rehabilitation and Recovery
The first steps when dealing with this injury should be P.R.I.C.E. protection, rest, ice, compression, and elevation. It is important to rest and seek treatment immediately; if left untreated, the condition could worsen, lead to a chronic condition, and require surgery. A chiropractic treatment and rehabilitation plan will consist of the following:
Soft tissue massage
Joint mobilization
A chiropractor may recommend crutches to keep the weight off the hip.
A brace can help compress and stabilize the hip flexor to expedite healing.
A flexibility and strengthening program will be implemented to target the muscles around the hip.
Core strengthening exercises will improve the stability of the pelvis area to prevent any further overuse problems.
Wearing compression clothing could also be recommended, as the clothing helps maintain muscle temperature.
Labral Tear
References
Dydyk AM, Sapra A. Psoas Syndrome. [Updated 2022 Oct 24]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: www.ncbi.nlm.nih.gov/books/NBK551701/
Lifshitz, Liran BPt, MSc, PT; Bar Sela, Shlomo BPt MPE; Gal, Noga BPt, MSc; Martin, RobRoy PhD, PT; Fleitman Klar, Michal BPt. Iliopsoas the Hidden Muscle: Anatomy, Diagnosis, and Treatment. Current Sports Medicine Reports 19(6):p 235-243, June 2020. | DOI: 10.1249/JSR.0000000000000723
Rauseo, Carla. “THE REHABILITATION OF A RUNNER WITH ILIOPSOAS TENDINOPATHY USING AN ECCENTRIC-BIASED EXERCISE-A CASE REPORT.” International journal of sports physical therapy vol. 12,7 (2017): 1150-1162. doi:10.26603/ijspt20171150
Rubio, Manolo, et al. “Spontaneous Iliopsoas Tendon Tear: A Rare Cause of Hip Pain in the Elderly.” Geriatric orthopedic surgery & rehabilitation vol. 7,1 (2016): 30-2. doi:10.1177/2151458515627309
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