El Paso Back Clinic Musculoskeletal Care and Relief
Abstract
Hello, I’m Dr. Alexander Jimenez. With my background as a Doctor of Chiropractic (DC), an Advanced Practice Registered Nurse (APRN), and certifications in functional medicine (CFMP, IFMCP), I am dedicated to bridging gaps across healthcare disciplines. In this educational post, we will explore the nuances of a minimally invasive procedure, focusing on the critical aspects of technique, patient comfort, and optimal outcomes. While the demonstration involves hormonal pellet insertion, the core principles of anatomical landmarking, tissue handling, and sterile technique are universally applicable to many minor procedures we perform. We will delve into the physiological rationale for each step, from site selection and anesthesia to atraumatic insertion and post-procedural care. A significant portion of this discussion will focus on how these concepts integrate with chiropractic care and physical therapy. We’ll examine how maintaining proper biomechanics, addressing fascial restrictions, and ensuring structural alignment are paramount for both preventing injuries and facilitating a smooth recovery from any procedure. This integrated perspective is central to our philosophy at El Paso Back Clinic, where we aim to provide comprehensive, evidence-based care that addresses the whole person, not just a single symptom.
Optimizing Procedural Success: The Critical Role of Anatomical Landmarkings
In any procedure, no matter how minor, precision is everything. The first and most crucial step is identifying the correct anatomical location. For the procedure demonstrated, we are targeting the upper outer quadrant of the gluteal region. The goal is to place the therapeutic agent within a specific tissue layer—in this case, the subcutaneous fatty tissue.
Here’s my thought process for ensuring perfect placement:
Identifying the “Just Right” Zone: This area must be carefully chosen. We want to be well within the fatty tissue of the gluteal region, avoiding areas that are too lateral (to the side) or too close to the midline, which would bring us near sensitive structures like the popliteal artery behind the knee or the lumbar spine. This specific zone provides a stable, well-vascularized, and low-movement area, which is ideal for healing and minimizing discomfort.
The Needle as a Measuring Tool: Before making any incision, I use the trocar needle’s length as a precise guide. This is a simple but highly effective technique. I determine the ideal final resting place for the pellets within the subcutaneous fat. Then I place the needle tip at the desired endpoint and lay the needle back along the skin. The hub of the needle now indicates the perfect spot for my incision. This method ensures that the length of the track I create is exactly right, preventing the pellets from being placed too shallowly or too deeply.
Clinical Application in Chiropractic: This principle of precise landmarking is fundamental in chiropractic care. When I perform a spinal adjustment, I’m not just applying a general force. I am palpating for the specific vertebral segment, identifying the spinous and transverse processes, and understanding the exact vector (direction and angle of force) needed to restore proper motion. Similarly, in physical therapy, when a therapist uses modalities such as dry needling or manual therapy, they target specific trigger points, fascial planes, or muscle bellies. This deep anatomical knowledge ensures the treatment is both safe and effective. Misjudging the location could lead to an ineffective treatment or, worse, injury.
After marking the incision site, the next step is to prepare the skin. We use a chlorhexidine wipe for this, following the principles of aseptic technique with sterile instruments. Although alcohol is commonly used, research, including insights from wound care specialists, has shown that chlorhexidine is more effective at reducing the skin’s bacterial load for these procedures (Pratt et al., 2007). My hands are in clean, not sterile, gloves because the procedure is quick and the instruments that enter the body are sterile.
The Art and Science of Local Anesthesia for Patient Comfort
My patient’s comfort is a top priority. A painful procedure creates anxiety and can even trigger a vasovagal response (fainting). The key to a painless experience lies in the meticulous administration of local anesthesia, in this case, lidocaine.
My technique involves a few key details:
Creating the “Wheel”: The initial injection is the most sensitive part. I insert only the very tip of the needle into the superficial layer of the skin, at a very shallow angle, much like a TB test. I inject a small amount of lidocaine to create a “bleb” or “wheel.” This instantly numbs the entry point for all subsequent steps.
Anesthetizing the Track: Once the initial wheel is formed, I advance the needle along the preplanned track where the trocar will be inserted. Crucially, I inject the lidocaine as the needle advances and as it is withdrawn. This ensures the entire pathway is bathed in the anesthetic, creating a fully numb tunnel.
Proper Angulation: I hold the syringe at approximately a 45-degree angle relative to the skin’s surface. This angle is vital. If the injection is too superficial, the pellets will be visible under the skin and can be easily irritated or extruded. If it’s too deep, we risk entering the muscle tissue, which is more vascular, leading to more bleeding and inflammation, and can cause significant post-procedural pain with movement—particularly with gluteal muscle contraction.
This technique is designed to place the pellets in the deeper subcutaneous fat, a “sweet spot” that provides cushioning and stability while remaining separate from the underlying muscle fascia. The blanching (whitening) of the skin around the wheel is a visual confirmation that the lidocaine with epinephrine is working effectively, constricting blood vessels and localizing the anesthetic.
Atraumatic Technique: The Shift to a Blunt Tip Trocar
Healthcare is constantly evolving, and we must adapt our techniques based on the latest evidence to improve patient outcomes. A significant advancement in this type of procedure is the move away from the old “cutting and plunging” method to an atraumatic technique using a blunt-tipped trocar.
Let’s break down the mechanics and the “why”:
The Old Method (Traumatic): The previous method involved using a sharp tool to cut a path through the tissue, followed by a plunger to push the pellets into place. This process was inherently traumatic. It cut through blood vessels, nerves, and fascial tissue, leading to more bleeding, a higher risk of infection, significant post-procedural pain, and increased scar tissue formation. From a chiropractic and physical therapy perspective, this kind of trauma can create deep fascial adhesions that restrict movement, alter gait mechanics, and even contribute to sacroiliac or low back pain.
The New Method (Atraumatic): The modern trocar system consists of two parts: an outer sheath and an inner, blunt-tipped obturator. After making a very small incision with a #11 scalpel blade (just enough to break the skin), the blunt trocar is introduced. Instead of cutting, it gently separates and displaces the tissue fibers as it advances through the anesthetized track. This technique is analogous to pushing your finger through the threads of a knitted sweater versus cutting it with scissors. The fibers are moved aside, not severed.
Once the trocar is fully inserted to the predetermined depth, I remove the inner blunt obturator, leaving the outer sheath in place. This sheath now serves as a clean, stable channel for introducing the pellets.
Securing the Pellets and Closing the Site
The placement of the pellets is a moment of precision. Using sterile forceps, I place the pellets one by one into the trocar hub. They slide down the sheath to the tip.
Here is the most critical distinction of the atraumatic method:
I reinsert the blunt obturator until it contacts the pellets.
Then, using my thumb, I hold the obturator firmly in place, anchoring the pellets at the end of the tunnel.
While keeping the obturator stationary, I gently withdraw the outer sheath over it.
Once the sheath is completely out, I remove the obturator.
This sequence ensures the pellets are deposited precisely where intended without any forward “plunging” motion. They are left nestled within the fatty tissue pocket created by the blunt dissection. The surrounding tissue, which was merely displaced, gently closes back around them. This results in minimal bleeding—often just a tiny bit of oozing at the incision site—and significantly less tissue trauma.
Closing the incision is the final step. We use sterile adhesive strips, which function like sutures for a small incision. The key is to approximate the skin edges. I place the strip on one side of the incision, gently pinch the skin edges together, and pull the strip across to hold them closed. Simply laying the strip on top is ineffective; the goal is to facilitate primary intention healing, which leads to a minimal scar.
The Integrative Chiropractic and Physical Therapy Connection
How does all this relate to our work at El Paso Back Clinic? The connection is profound and operates on several levels.
Biomechanics and Post-Procedural Care: Following any procedure, even a minor one in the gluteal region, the body’s biomechanics can be temporarily altered. A patient might guard the area, leading to an antalgic gait (limping). This altered movement pattern can cause compensatory strain on the contralateral (opposite) hip, the sacroiliac (SI) joints, and the lumbar spine. As a chiropractor, my role is to assess for and correct these developing imbalances. A gentle pelvic or lumbar adjustment can restore normal joint mechanics and prevent a minor, temporary issue from cascading into a more significant musculoskeletal problem.
Fascial Health: The atraumatic technique is designed to respect the body’s fascia, the intricate web of connective tissue that envelops every muscle, nerve, and organ. The old cutting method created significant fascial scarring. These scars can act like snags in a sweater, restricting movement and creating lines of tension that pull on distant structures. In my clinical observations, I’ve seen how untreated fascial restrictions in the gluteal region can contribute to chronic low back pain, sciatica-like symptoms, and even hip bursitis. Physical therapy techniques such as myofascial release, instrument-assisted soft-tissue mobilization (IASTM), and targeted stretching are invaluable for ensuring that tissue heals smoothly and maintains its natural glide and elasticity.
Patient Instructions and Recovery: The post-procedural instructions I provide are rooted in an understanding of tissue healing and biomechanics. I advise patients to avoid excessive gluteal exercises, deep squats, and activities such as horseback riding for a few days. Why? Because forceful contraction of the gluteus maximus muscle, which lies just deep to our procedure site, can create inflammation and mechanical stress on the healing tissue. Allowing this brief period of relative rest is crucial for minimizing inflammation and ensuring the pellets remain stable. This advice aligns with the principles of protected mobilization taught in physical therapy, where the goal is to allow tissues to heal without imposing excessive loads that could disrupt the repair process.
In conclusion, modern healthcare is at its best when it is integrative. By combining the precision of minimally invasive medical procedures with a deep understanding of musculoskeletal function from chiropractic and physical therapy, we can provide superior care. The atraumatic technique demonstrated here is more than just a method; it’s a philosophy. It’s about respecting the body’s intricate anatomy, minimizing iatrogenic (treatment-induced) trauma, and supporting the body’s innate capacity to heal. This holistic approach ensures not only a successful immediate outcome but also promotes long-term health and functional well-being for our patients.
Integrative Chiropractic Care Pathways That Align Diagnostics, Movement, and Adherence
Abstract
I am Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. In this educational post, I walk you through how I design integrative chiropractic and physical therapy care at El Paso Back Clinic to improve musculoskeletal function, metabolic resilience, and patient adherence—while keeping hormones and medications in the background. Drawing on modern, evidence-based research and my day-to-day clinical observations in El Paso, I explain how we align diagnostics and movement with physiology, deliver patient education that sticks, time reassessments with healing windows, and use spine and joint care, soft-tissue methods, and targeted exercise to accelerate recovery. You will also see how postpartum and menopausal lab contexts inform conservative dosing without taking the lead, how fascia-respecting procedural technique protects tissues during procedures, and why pre-scheduling and outcome tracking reliably improve results.
Chiropractic-first reasoning: Why biomechanics and function lead the plan
Pain, stiffness, and fatigue are multifactorial. I start with what bodies tell us functionally because the spine, fascia, and muscles operate as an integrated system. When segmental joints stiffen, soft tissues guard, and movement patterns compensate, nociceptive input increases, and central sensitization can amplify pain. By restoring motion and control first—and educating patients at the right time—we reduce threat signaling and build capacity.
Why this works:
Manual therapy mechanisms modulate pain via peripheral, spinal, and supraspinal pathways, reducing protective muscle guarding and improving proprioception (Bialosky, Bishop, & George, 2009).
Central sensitization improves when graded movement and aerobic input engage descending inhibitory pathways and normalize afferent input (Woolf, 2011).
Mechanotransduction drives tissue remodeling; progressive loading teaches tendons and fascia to tolerate daily stressors (Khan & Scott, 2009; Kjaer, 2004; Narici & Maganaris, 2007).
In our clinic, that translates to chiropractic adjustments to restore segmental motion, movement-based physical therapy to upgrade motor control, and simple, redundant education to lock in habits. Labs and meds stay in the background unless safety or unusual recovery patterns demand a look.
My stepwise workflow: Aligning care with physiology
I built our workflow around a simple idea: align care to how tissues heal and how people learn.
Chiropractic adjustments: Patient-specific, evidence-informed manipulation to restore joint play and reduce nociceptive drive (Bialosky, Bishop, & George, 2009).
Soft-tissue techniques: Gentle instrument-assisted or manual methods to increase tissue extensibility and glide, setting the stage for motor retraining (Cheatham, Lee, Cain, & Baker, 2016).
Targeted exercise: Isometrics to isotonic loading for tendon and core systems; heavy–slow resistance for tendinopathy when indicated; graded aerobic work to improve autonomic tone and sleep (Rio et al., 2015; Rathleff et al., 2015).
Practical education: QR-coded exercise videos, checklists, and timed reminders that reduce cognitive load and improve adherence through spaced repetition.
Purposeful scheduling: Re-evaluations at 4–6 weeks to capture connective tissue and neural adaptation; longer checkpoints around 14 weeks for many women and 18 weeks for many men to align with remodeling windows.
Why physiology dictates our timelines
Connective tissue remodeling: Collagen synthesis and cross-linking evolve over weeks to months; early changes are measurable by 4–6 weeks with function and strength (Kjaer, 2004; Narici & Maganaris, 2007).
Neuroplasticity: Motor learning and threat attenuation require consistent, graded exposure, which we embed in short, daily bouts plus progressive loads (Naugle, Fillingim, & Riley, 2012).
Cardiometabolic backdrop: When recovery stalls, simple markers such as non-HDL, triglycerides, A1c, and hs-CRP can guide dosing and pacing without shifting focus away from movement (Ross et al., 2020).
Streamlined patient education: How I reduce phone burden and increase follow-through
Early in my career, patients would leave with excellent instructions and lose the thread at home. I designed layered, redundant education that patients actually use:
4×6 quick-reference cards with QR codes linking to 2–3 minute videos that review home-care exercises and cautions.
Downloadable PDFs for paper-lovers.
Automated nudges at strategic intervals—for example, a 3-week reminder to rebook and recheck movement goals.
Why it works
Spaced repetition cements motor learning.
Cognitive load during pain is high; simple reminders reduce executive burden.
Graded exposure and consistent follow-up maintain momentum and reduce fear avoidance.
First-visit structure: Setting the foundation for faster results
Access and clarity matter. On Visit 1, I provide:
Real-time movement screening: gait, sit-to-stand, trunk rotation, single-leg stance, and region-specific screens.
Baseline scales: simple pain/function ratings and a symptom checklist we can rescore later.
Immediate education: what to expect over the next 2–4 weeks and how we will progress.
Patients leave with a personalized plan and a pre-scheduled follow-up, so progress is designed in, not left to chance.
Why pre-scheduling improves outcomes
Human memory fades when pain eases. Anchoring the next reassessment solidifies expectations and keeps graded loading on track.
Women: longer-goal re-evaluation around 14 weeks.
Men: larger progressive programs often anchor around 18 weeks.
We adjust cadence to the clinical picture, not the calendar.
Diagnostics: when labs inform—but do not drive—care
We reserve labs for safety and context:
If energy is disproportionately low, recovery is unusually slow, or recurrent tendinopathy persists, I consider a targeted background review (A1c, triglycerides, non-HDL, hs-CRP, vitamin D, thyroid nuances) while continuing conservative care.
We avoid over-testing; baseline and selective rechecks after a significant clinical change reduce noise and prevent unnecessary pivots (Hayes, Moulton, & others, 2013).
The goal is to remove friction so movement-based therapy can work—not to chase numbers.
How I analyze outcomes: Validating progress and sustaining motivation
I use brief symptom and function scales to quantify change—never to label patients. Declining scores and better movement screens:
Motivate adherence.
Document progress for interprofessional communication.
Guide next steps.
Physiology behind functional change
As segmental dysfunction resolves and motor control improves, afferent input normalizes, central sensitization eases, and sleep tends to improve. Functional scores capture these multidimensional shifts (Woolf, 2011; Bialosky, Bishop, & George, 2009).
Chiropractic and PT for common presentations: Post-menopause, postpartum, and midlife musculoskeletal patterns
A focused look at a common post-menopausal presentation
A 59-year-old woman, ten years post-menopause, reports:
Moderate to severe fatigue, low mood, low libido, bladder urgency.
20 lb weight gain, constipation, gas, and bloating.
Possible thyroid autoimmunity, slowed transit.
My conservative plan
Chiropractic: Gentle, region-specific lumbopelvic adjustments to improve mechanics and reduce nociception that can exacerbate pelvic floor dysfunction.
Soft tissue: Myofascial release to the thoracolumbar fascia, hip rotators, and pelvic floor-adjacent tissues to balance tone and improve hip–pelvis coupling.
Physical therapy:
Diaphragmatic breathing and intra-abdominal pressure drills to restore diaphragm–pelvic floor synergy (Hodges & Sapsford, 2011).
Progressive gluteal and deep hip external rotator activation to unload the pelvic floor and lumbar segments.
Graded walking with cadence targets to improve autonomic tone and bowel motility (Mayer, 2011).
Why these help
Improving sacroiliac and lumbar motion redistributes load and can influence bladder urgency through reflexive pathways (Vleeming et al., 2012).
Protein adequacy and a focus on micronutrients support connective tissue turnover.
Coordination with primary teams happens in parallel, not as a prerequisite for better movement.
Clinical observation from my El Paso practice
Many post-menopausal patients report improving back discomfort, gait stability, and energy within 4–8 weeks when we combine segmental adjustments, myofascial work, walking programs, and pelvic floor-aware strengthening—often before any medication changes. Consistency beats intensity.
A focused look at a common male pattern: Plantar heel pain with deconditioning
A 59-year-old man presents with:
Antalgic gait and morning plantar heel pain consistent with early plantar fasciopathy.
Chiropractic: Address ankle-foot joint restrictions (subtalar, midfoot), tibial rotation, and lumbopelvic mechanics to balance strain across the plantar fascia.
Soft tissue: Instrument-assisted or manual techniques for the plantar fascia, calf complex, and hamstrings to restore extensibility.
Physical therapy/loading:
Short-foot exercises to reactivate foot intrinsics.
Heavy–slow resistance for calves to remodel fascia (Rathleff et al., 2015).
Hip abductor/external rotator strengthening to improve knee–foot alignment.
Gait retraining with cadence cues to reduce overstriding and peak heel loading.
Why these help
Plantar fasciopathy responds to progressive mechanical loading, which stimulates collagen remodeling and improves stiffness (Rathleff et al., 2015).
Proximal control reduces distal overload.
Adjustments restore joint play, enabling symmetrical load distribution along the kinetic chain.
Quantifying activity to match physiology
Patients often overestimate exertion. I ask:
How often does your heart rate reach a moderate zone?
How many total minutes of moderate-to-vigorous activity do you sustain per week?
If tolerance is low, I begin with shorter, more frequent bouts to enhance mitochondrial efficiency and capillary density without tipping into soreness. Better sleep follows, and pain thresholds rise.
Integrative chiropractic after postpartum and menopause lab reviews: A conservative, algorithm-guided, movement-first pathway
When postpartum or menopausal labs are available, I use them for context and safety while keeping care movement-led.
The only time I consider a brief one-time “boost” is immediately after a post-lab visit if symptoms are severe and a fast nudge helps cross a functional threshold. Then we pivot fully to biomechanics and behavior.
Decision algorithms consider time since last menses, postpartum interval, and activity level to refine initial dosing—slower progressions and lower-velocity mobilizations in hypoestrogenic tissues (Kjaer & Magnusson, 2010).
Thorough informed consent doubles as education: it explains what we do, why it works, dosage expectations, soreness windows, and red flags (Appelbaum, Lidz, & Klitzman, 2012).
Physiologic underpinnings that shape our choices
Pelvic ring load transfer: Altered force/form closure in and after pregnancy benefits from targeted adjustments and stabilization (Vleeming et al., 2012).
Mechanotherapy: Graded loading signals tenocytes and myofibers to remodel along lines of stress (Khan & Scott, 2009).
Hypoalgesia with exercise: Aerobic and isometric bouts induce central inhibitory effects (Naugle, Fillingim, & Riley, 2012; Rio et al., 2015).
Fascia-respecting technique and safer recovery: When procedures are performed, biomechanics still lead
While El Paso Back Clinic emphasizes conservative care, some patients undergo minor procedures through external prescribers. My role is to protect tissue and restore movement around those procedures.
Depth and plane matter: Working within the adipofascial corridor reduces nociception and microhematomas; superficial skiving increases pain and scarring (Wong et al., 2021).
Surface-area principles: Distributing inputs across broader planes reduces peak stress and improves tolerability; scars form more cleanly when microtrauma is minimized.
Compression and moisture control: Gentle early compression limits dead space and hematoma, while avoiding heavy sweating and contaminated water for five days, supports barrier reformation and scar quality (Edwards & Harding, 2004; Sparks, Roberts, & Brown, 2016).
Chiropractic and PT integration post-procedure
Segmental mobilization: Normalize thoracolumbar and pelvic mechanics to reduce shear across healing lines (Bialosky, Bishop, & George, 2009).
Gentle myofascial work: Improve glide in obliques, QL, and paraspinals adjacent to the site, reducing pull and enhancing lymphatic flow (Findley & Schleip, 2007; Schleip & Müller, 2013).
Breathing mechanics: Diaphragmatic patterns optimize thoracoabdominal pressure, improving venous return and oxygenation to the healing area.
Neuromuscular re-education: Early isometrics for transverse abdominis, pelvic floor, and multifidi restore support without torsion.
Scheduling that matches tissue timelines: Building a plan patients follow
Visit 3 (4–6 weeks): Functional re-test; adjust plan to match adaptation.
Visit 4 (10–14 weeks): Higher-function testing; more complex and energy-demanding tasks.
Long checkpoint (14 weeks for many women; 18 weeks for many men): Outcome measures, return-to-activity milestones, next-step planning.
We individualize spacing for age, baseline fitness, and goals. In my experience, older adults often progress beautifully with slightly longer intervals once momentum builds.
How I set exercise dosing and progression
Start low, build slow for deconditioned patients to avoid flares and maintain confidence.
Tendinopathies/plantar fasciopathy: 3–4 sessions/week of heavy–slow resistance; monitor soreness to remain productive (Rathleff et al., 2015).
Spine-related sensitization: Begin with isometrics and short repeated bouts, then introduce compound lifts as tolerance grows.
Why
Collagen remodeling requires progressive mechanical load and recovery.
The nervous system adapts best to predictable, graded stressors.
Consistency beats intensity in the first 6–8 weeks—adherence is the multiplier.
Clinic observations from El Paso: What I see every week in practice
The sleep lever multiplies results: Fixing thoracic/rib mechanics and breathing improves sleep, raises pain thresholds, and makes adherence easier.
The gait lever is the safest aerobic start: Postpartum and peri-/postmenopausal patients tolerate walking progressions that “grease” the lumbopelvic system in gravity.
The hip hinge lever protects the back: Teaching a neutral hinge with tripod foot contact reduces SI stress and hamstring strain while shifting the load to the glutes.
For men with plantar heel pain, adding proximal hip strength and cadence retraining outperforms foot-only protocols.
Post-menopausal women with constipation often improve with a trio: thoracolumbar and sacroiliac adjustments, diaphragmatic breathing, and daily walking—supporting motility and reducing abdominal wall guarding.
A day-in-the-life pathway: making it understandable and repeatable
A patient arrives with back pain and fatigue. I evaluate movement, adjust restricted segments, release overactive tissues, and teach two simple home exercises. They scan a QR card and watch a two-minute recap that night.
At 10 days, we refine technique and increase time under tension on key drills.
At 5–6 weeks, gait is smoother, pain is lower, and sleep is better. We add load to build resilience.
At 12–18 weeks, we reassess outcomes and set a maintenance plan—monthly or quarterly tune-ups plus a sustainable home program.
Patients feel better because every step is aligned with how tissues heal and how people learn.
Why integrative chiropractic belongs at the center Evidence-aligned systems thinking
Spinal adjustments and peripheral joint manipulation: Reduce pain through segmental and descending modulation and restore motion (Bialosky, Bishop, & George, 2009).
Soft-tissue techniques: Temporarily reduce tone and improve glide, enabling effective motor retraining (Cheatham, Lee, Cain, & Baker, 2016; Ajimsha, Al-Mudahka, & Al-Madzhar, 2015).
Specific exercise: Drives the durable change—upgrades load capacity, tendon health, and movement economy (Khan & Scott, 2009; Stasinopoulos & Johnson, 2007).
Education and pacing: Lower fear-avoidance, align expectations, and respect tissue timelines.
Pain is not merely a signal from damaged tissue—it is a systems experience shaped by nociception, expectation, sleep, and fitness. By restoring motion and control while empowering patients with simple, repeatable actions, we reduce threat signals and rebuild capacity.
References
Ajimsha, M. S., Al-Mudahka, N. R., & Al-Madzhar, J. A. (2015). Effectiveness of myofascial release: Systematic review of randomized controlled trials. Journal of Bodywork and Movement Therapies. https://doi.org/10.1016/j.jbmt.2014.06.001
Appelbaum, P. S., Lidz, C. W., & Klitzman, R. (2012). Voluntariness of consent to research: A conceptual model. American Journal of Bioethics. https://doi.org/10.1080/15265161.2012.698383
Bialosky, J. E., Bishop, M. D., & George, S. Z. (2009). Mechanisms of manual therapy in musculoskeletal pain: A comprehensive model. The Clinical Journal of Pain. https://doi.org/10.1097/AJP.0b013e3181bf1e6e
Bronfort, G., Haas, M., Evans, R., & Leininger, B. (2012). Spinal manipulation and home exercise with advice for subacute and chronic back-related leg pain. Annals of Internal Medicine. https://doi.org/10.7326/0003-4819-156-10-201205150-00004
Cheatham, S. W., Lee, M., Cain, M., & Baker, R. (2016). The efficacy of instrument assisted soft tissue mobilization: A systematic review. Journal of the Canadian Chiropractic Association. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5021473/
Findley, T. W., & Schleip, R. (2007). Fascia research: A narrative review. Journal of Bodywork and Movement Therapies. https://doi.org/10.1016/j.jbmt.2006.06.008
Hayes, R. J., Moulton, L. H., & others. (2013). Cluster randomized trials. Chapman and Hall/CRC. https://doi.org/10.1201/b14620
Hodges, P. W., & Sapsford, R. (2011). Automatic postural responses and pelvic floor muscle function. Neurourology and Urodynamics. https://doi.org/10.1002/nau.21091
Khan, K. M., & Scott, A. (2009). Mechanotherapy: How physical therapists’ prescription of exercise promotes tissue repair. British Journal of Sports Medicine. https://doi.org/10.1136/bjsm.2008.054239
Kjaer, M. (2004). Role of extracellular matrix in muscle and tendon adaptation to exercise. The Journal of Physiology. https://doi.org/10.1113/jphysiol.2004.079376
Kjaer, M., & Magnusson, P. (2010). The effect of estrogen on musculoskeletal performance. Scandinavian Journal of Medicine & Science in Sports. https://doi.org/10.1111/j.1600-0838.2009.01058.x
Mayer, E. A. (2011). The mind–gut connection and autonomic regulation. Journal of the Royal Society of Medicine. https://doi.org/10.1177/0141076811405540
Narici, M. V., & Maganaris, C. N. (2007). Adaptation of tendon and muscle to loading and unloading in older adults. Journal of Applied Physiology. https://doi.org/10.1152/japplphysiol.00059.2007
Naugle, K. M., Fillingim, R. B., & Riley, J. L. (2012). A meta-analytic review of the hypoalgesic effects of exercise. The Journal of Pain. https://doi.org/10.1016/j.jpain.2012.09.006
Rathleff, M. S., et al. (2015). Effect of strength training on plantar fasciopathy: Heavy–slow resistance vs eccentric training. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2014-093587
Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine. https://doi.org/10.1136/bjsports-2014-094386
Ross, R., et al. (2020). Cardiorespiratory fitness and body composition: Benefits of exercise training. Obesity. https://doi.org/10.1002/oby.22752
Schleip, R., & Müller, D. G. (2013). Training principles for fascial connective tissues: Scientific foundation and suggested practical applications. Journal of Bodywork and Movement Therapies. https://doi.org/10.1016/j.jbmt.2012.06.007
Sparks, J., Roberts, J., & Brown, D. (2016). Wound healing physiology: Inflammation to remodeling. Advances in Skin & Wound Care. https://journals.lww.com/aswcjournal/Abstract/2016/07000/Wound_Healing_Physiology__Inflammation_to.5.aspx
Stasinopoulos, D., & Johnson, M. I. (2007). Current concepts in the management of tendinopathy. The Physician and Sportsmedicine. https://doi.org/10.3810/psm.2007.12.85
Vleeming, A., et al. (2012). The sacroiliac joint: An overview of its anatomy, function, and potential clinical implications. Manual Therapy. https://doi.org/10.1016/j.math.2011.05.005
Wilke, J., Schleip, R., Yucesoy, C. A., & Banzer, W. (2018). Not merely a protective packing organ: A review of fascia and its force transmission capacity. Journal of Anatomy. https://doi.org/10.1111/joa.12730
Wong, I. G., et al. (2021). Ultrasound-guided procedures: Best practices for musculoskeletal interventions. Seminars in Musculoskeletal Radiology. https://doi.org/10.1055/s-0040-1713912
Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain. Nature Reviews Neuroscience. https://doi.org/10.1038/nrn3136
Integrative Chiropractic Care for Dizziness, Pelvic Health, Perimenopause, and Rehabilitation: An Evidence-Based Guide
Abstract
In this educational post, I share a clear, first-person journey through common clinical challenges I encounter at El Paso Back Clinic: dizziness and low energy in older adults; pelvic and urinary symptoms; perimenopausal changes and postmenopausal bleeding; rehabilitation planning; and individualized decisions around hormones and medications. I present actionable, evidence-based strategies emphasizing integrative chiropractic care, physical therapy, and functional movement, supported by modern research methods. You will learn the neurophysiology behind vestibular dizziness, how spinal and pelvic alignment influences urinary and pelvic symptoms, why perimenopause fluctuates, and how to structure safe, progressive rehab. Hormones and medications appear in the background to contextualize care, but the primary focus remains on chiropractic, neuromuscular, and lifestyle interventions that improve real-world outcomes.
About me and our clinic
I am Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST. In our El Paso Back Clinic, we combine integrative chiropractic, functional rehabilitation, targeted soft-tissue therapies, and data-driven outcome tracking. My clinical observations, grounded in day-to-day practice and multidisciplinary collaboration, align with leading research, ensuring our patients receive practical care that respects physiology and personal goals.
Dizziness and Low Energy in Older Adults: Why Integrative Chiropractic Care Matters
Many older patients present with dizziness, fatigue, and reduced stamina. One gentleman in his eighties described persistent lightheadedness and low energy. While some might jump directly to hormone panels, I prioritize a careful neuromusculoskeletal and vestibular assessment and reserve hormone considerations for selected cases.
Key concepts
The vestibular-spinal connection
The vestibular system integrates signals from the inner ear (semicircular canals and otolith organs), visual input, and proprioception from the cervical spine and feet. When the upper cervical spine (C0–C2) loses normal joint mechanics, afferent input to the brainstem can become noisy, amplifying dizziness, unsteadiness, and visual dependence on motion cues (Persson et al., 2019).
Orthostatic and cardiovascular contributors
Dehydration, deconditioning, altered baroreflex sensitivity, and stiff thoracic cage mechanics can worsen orthostatic hypotension or blood pressure variability. Gentle thoracic mobility, diaphragmatic breathing, and graded aerobic activity improve venous return and autonomic balance (Lanser et al., 2021).
Sarcopenia and sensory loss
Loss of muscle mass and plantar mechanoreception reduces stability. Foot-ankle stiffness and hip weakness impair reactive balance. Addressing hip abductors, ankle dorsiflexion, and foot intrinsic strength improves sway control (Rubenstein, 2006).
What we do at El Paso Back Clinic
Cervical assessment and gentle mobilization
I perform focused upper cervical motion testing and, where appropriate, gentle high-velocity, low-amplitude (HVLA) or low-force mobilizations. Rationale: normalize mechanoreceptor input, reduce cervicogenic dizziness, and improve vestibulo-spinal integration.
Vestibular and gaze stabilization drills
We use VOR x1/x2 exercises, saccades, and visual-vestibular habituation drills to retrain the brain’s sensor fusion. Rationale: repeated exposure adapts the vestibular nuclei and cerebellum, lowering dizziness through central compensation (Herdman & Clendaniel, 2014).
Balance and lower-limb conditioning
Hip and ankle strengthening, foot intrinsic activation, perturbation training, and safe gait progressions. Rationale: improve center-of-mass control and reactive responses, reducing fall risk.
Breathing and autonomic retraining
Box breathing, paced respiration, and thoracic mobility to enhance rib mechanics and autonomic tone.
Outcome tracking
DHI (Dizziness disability Inventory), gait speed, and tandem stance metrics guide progression and discharge planning.
Clinical pearl
I have seen dizziness improve meaningfully within two weeks when upper cervical mechanics and vestibular drills are combined, especially in patients previously labeled “just fatigued.” Aligning the spine and retraining sensory systems changes function quickly when done consistently.
Safe, Structured Two-Week Rehabilitation Blocks: Why Focused Intensives Work
Rehabilitation succeeds when it is specific, measurable, and time-bound. I often design two-week intensive blocks for patients who need momentum and clarity.
How we structure a two-week block
Clear goals
Define one or two primary outcomes: fewer dizzy episodes, improved gait speed, and reduced pelvic pain.
Daily micro-dose therapy
Short, frequent sessions (15–25 minutes) are more effective than sporadic long workouts. Neuroplasticity favors regularity.
Multimodal approach
Combine manual therapy, motor control drills, and load progression. Example: cervical mobilizations paired with VOR drills and lower-limb strength on alternating days.
Check-ins and reassessment
We reassess mid-block to adjust dosing if symptoms flare or plateau.
Why it works physiologically
Repeated afferent normalization from spinal adjustments stabilizes sensorimotor loops.
Consistent motor practice strengthens cortical maps and cerebellar error correction.
Gradual loading induces tendon and muscle remodeling without provoking inflammation.
Pelvic and Urinary Symptoms: The Spine–Pelvis–Floor Axis
Patients ask whether recurrent urinary issues, pelvic discomfort, or postmenopausal bleeding relate to musculoskeletal function. While medical evaluation for infection or gynecologic causes is essential, we often find that lumbopelvic dysfunction and pelvic floor dyscoordination contribute to symptoms.
Key mechanisms
Lumbosacral mechanics
Facet joint restriction and sacroiliac asymmetry alter pelvic tilt and abdominal-pelvic pressure dynamics. This increases strain on the pelvic floor, promoting urgency, stress incontinence, or pelvic pain.
Diaphragm–pelvic floor synergy
The diaphragm, abdominal wall, and pelvic floor work as a pressure system. If the rib cage is stiff and breathing is shallow, intra-abdominal pressure spikes during lifting or coughing, overloading the pelvic floor.
Neural drivers
The pudendal nerve (S2–S4) can be irritated by hip rotator hypertonicity and sacral torsion. Normalizing hip mechanics can reduce neural irritability.
Restore symmetric motion, reduce torque through the pelvic floor.
Hip mobility and strength
Target external rotators, gluteus medius, adductors, and deep rotators; train eccentric control to manage intra-abdominal pressure.
Breathing retraining
Teach 360-degree diaphragmatic expansion and rib mobility; coordinate exhalation with effort to protect the pelvic floor.
Pelvic floor biofeedback (when indicated)
Low-tech cueing and coordinated contraction-relaxation drills improve timing more than brute strengthening.
Lifestyle adjustments
Bladder training schedules, caffeine moderation, and bowel regularity to reduce urgency triggers.
Clinical observation from El Paso Back Clinic
I have seen women in their 60s reduce stress incontinence within 6–8 weeks after we corrected pelvic alignment, restored hip elasticity, and coached breathing mechanics. The change often precedes any decisions about medications, illustrating how powerful biomechanics are.
Perimenopause Physiology and Practical Care: Highs, Lows, and What to Expect
Perimenopause is often called “no-man’s land” because symptoms fluctuate: hot flashes one month, regular cycles the next. This is not random; it reflects complex endocrine feedback.
Physiology explained
Ovarian reserve and feedback
As follicles decline, estradiol and inhibin vary, causing FSH and LH to oscillate. The hypothalamus and pituitary respond to inconsistent ovarian signals, producing the high-low pattern that patients experience (Santoro, 2020).
Thermoregulation and vasomotor symptoms
Hypothalamic thermoneutral zone narrows; small changes in core temperature trigger hot flashes. Sleep fragmentation and mood changes follow (Freedman, 2001).
Musculoskeletal influences
Estrogen modulates collagen synthesis, tendon stiffness, and joint lubrication. Fluctuations can transiently alter joint comfort and recovery rate.
Chiropractic and PT emphasis for perimenopause
Spine and joint care
Gentle thoracic and cervical mobilizations relieve stiffness and headaches related to sleep disruption and stress.
Strength and load tolerance
Progressive resistance training counters sarcopenia, stabilizes glucose, and improves mood.
Balance and gait
Vestibular and proprioceptive drills enhance confidence during periods of fatigue or fog.
Sleep hygiene and breathing
Nasal breathing, rib mobility, and pre-sleep routines reduce sympathetic arousal.
When postmenopausal bleeding occurs
This requires medical evaluation. We coordinate with gynecology, and if benign causes such as polyps or fibroids are identified and treated, we resume spine-pelvic rehabilitation to restore normal activity. Movement lowers anxiety and supports recovery.
ADHD, Anxiety, and the Gut–Brain–Movement Triad
Parents frequently ask about non-pharmacologic support for children and adults with ADHD or anxiety. While diagnosis and medication decisions are made by medical providers, we contribute gut–brain–movement strategies to improve resilience.
What we do
Movement breaks and vestibular input
Short vestibular and balance activities improve arousal regulation and attention by stimulating cerebellar circuits linked to executive control.
Postural optimization
Cervical alignment reduces headache and visual strain; thoracic mobility improves breathing and reduces anxiety signals.
Gut rhythm support
Consistent sleep-wake cycles, fiber and hydration for regular bowel motility, and gentle abdominal mobility reduce discomfort that can distract attention (Mayer et al., 2015).
Hormone and Medication Considerations: Kept in the Background, Used Thoughtfully
Although our emphasis at El Paso Back Clinic is chiropractic and physical therapy, many patients ask about hormones or medications in context.
Guiding principles
Risk–benefit balance
Oral contraceptives may carry risks like venous thromboembolism in certain populations; decisions must be individualized with medical providers (Curtis et al., 2016).
Testosterone and energy
For older men, fatigue and dizziness often have mechanical and autonomic drivers. We prioritize spinal and vestibular care, exercise, and sleep. Hormone testing is considered only when indicated.
UTI and infection questions
Group A Streptococcus is rarely a urinary pathogen; standard guidelines favor targeted diagnosis and treatment based on culture results (Hooton, 2012). Our role: improve pelvic mechanics and bladder habits to reduce symptom recurrence.
Sleep, Snoring, Rib Cage Mechanics, and Neck Size: Why Breathing Training Helps
Patients often notice snoring improves when weight drops and posture changes. Mechanistically:
Rib cage mobility and diaphragmatic descent
The diaphragm descends more effectively when thoracic joints move freely. Improved nasal airflow and reduced soft-tissue collapse decrease snoring.
Neck circumference and airway
Larger neck circumference correlates with airway narrowing. While changes are gradual, postural optimization and weight management help.
Several patients reported no longer snoring after weeks of thoracic mobility, weight loss, and nasal breathing practice. The subjective improvements were consistent with bed partner reports and sleep quality scales.
Priority Setting in Complex Cases: What Comes First, What Waits
Complex cases demand prioritization. We use an HTTP mindset informally: Hips, Thorax, Thoracic diaphragm, Pelvis. By restoring these four areas, many downstream symptoms improve.
Our prioritization flow
Stabilize the spine and pelvis
Correct lumbopelvic mechanics first to reduce pain and normalize pressure systems.
Normalize breathing
Thoracic mobility and diaphragm training decrease sympathetic load and improve motor control.
Add vestibular work
Once pain is lowered, vestibular drills are better tolerated and more effective.
Strengthen and condition
Progress, resistance, and endurance are gradually cemented.
Clinical Observations and Transformative Outcomes
Over the past 16 months, many patients described life-changing improvements using this integrative framework:
Waist circumference reductions and elimination of snoring are linked to breathing mechanics, thoracic mobility, and consistent strength training.
Return to safe activity in older adults after balance and vestibular programs, with fewer near-falls and better confidence.
Pelvic symptoms are improving after sacroiliac realignment, hip mobility work, and coordinated breathing.
These changes align with published research demonstrating that multimodal spine care, coupled with exercise, produces superior functional outcomes compared with passive approaches alone (Cochrane Back and Neck Group, 2018).
Practical Takeaways for Patients and Families
Dizziness
Focus on upper cervical alignment, vestibular drills, and balance. Track progress with simple scales.
Pelvic and urinary symptoms
Address lumbopelvic mechanics and breathing; add pelvic floor coordination.
Perimenopause
Expect fluctuations; support sleep, strength, and joint mobility; medically evaluate any postmenopausal bleeding.
ADHD and anxiety
Use movement breaks, posture care, and gut rhythm support alongside medical plans.
Sleep and snoring
Improve thoracic mobility and nasal breathing; pair with steady weight management.
Why This Integrative Approach Works
Neuromechanical alignment
Spinal adjustments optimize afferent input to the brain and spinal cord, reducing nociceptive signaling and improving motor control.
Central adaptation
Vestibular and motor practice builds more reliable neural maps, reducing symptom variability.
Pressure system synergy
Harmonizing the diaphragm, abdominal wall, and pelvic floor distributes load effectively, protecting joints and viscera.
Behavior and consistency
Frequent, small wins over two-week blocks empower patients and create sustainable change.
Next Steps at El Paso Back Clinic
If you recognize yourself in any of these scenarios, we can help. Our care plan will prioritize chiropractic and physical therapy, coordinate with your medical team as needed, and focus on measurable improvements you can feel within weeks.
What to expect
Thorough assessment of spine, pelvis, balance, and breathing
A personalized two-week intensive plan
Clear home exercises and progress tracking
Collaboration with specialists when medical issues need evaluation
Summary
Dizziness often improves with upper cervical care and vestibular drills.
Pelvic and urinary symptoms correlate with lumbopelvic mechanics and breathing dynamics.
Perimenopause is physiologically variable; movement and sleep support are powerful.
ADHD and anxiety benefit from movement, posture, and gut rhythm strategies.
Snoring and sleep issues respond to thoracic mobility and nasal breathing.
Back Clinic Guide to Hormones, Iron, and Metabolic Health: An Evidence-Based Guide from Clinic to Community
Abstract
In this educational post, I outline a practical, evidence-guided roadmap for patients and clinicians navigating heavy menstrual bleeding, iron deficiency, post-bariatric considerations, PCOS patterns, testosterone symptom management, DVT risk around contraceptives, and the nuanced role of progesterone across the lifespan. Drawing from current research and my clinical practice at El Paso Back Clinic, I explain how integrative chiropractic care and physical therapy can stabilize biomechanics, calm the nervous system, and improve adherence to care plans—while nutrition, sleep, and targeted supplements support recovery. Hormone therapies and medications are discussed in the background where appropriate; our primary focus is musculoskeletal alignment, movement restoration, and conservative options that influence physiology upstream. You will find stepwise reasoning, the physiological “why” behind each intervention, and pragmatic tips to safely translate science into daily practice.
Introduction: The Right People, The Right Plan, The Right Sequence
As a clinician, my first step is to “get the right people in the room.” Complex symptoms—heavy periods, fatigue, post-gastric bypass nutrient issues, or training-related hormone fluctuations—rarely have a single cause. Collaboration between chiropractic, physical therapy, primary care, nutrition, and, when needed, endocrinology allows us to address mechanical stressors, autonomic tone, and metabolic basics before escalating to medications.
At El Paso Back Clinic, we lead with a conservative, function-first strategy:
Restore joint mechanics and soft-tissue health
Rebalance neuromuscular control
Normalize breathing and vagal tone
Replete with iron and foundational nutrients
Use lifestyle and movement therapy to support endocrine rhythms
Below, I guide you through how these pieces fit together.
Heavy Menstrual Bleeding, Iron Deficiency, and Movement: What the Body Is Telling Us
When patients report heavy menstrual bleeding (HMB), dizziness with exertion, or shortness of breath on stairs, our assessment screens for iron deficiency and anemia and evaluates the musculoskeletal drivers that exacerbate pelvic and abdominal strain.
Why iron matters physiologically:
Hemoglobin carries oxygen; iron deficiency reduces oxygen delivery, increasing heart rate and perceived exertion (Carter et al., 2020).
Low iron levels alter mitochondrial efficiency and impair collagen cross-linking, slowing tendon and fascia recovery (Huang et al., 2022).
In women with HMB, addressing iron often improves fatigue, cognition, and exercise tolerance before any hormone therapy is considered (Pavord et al., 2020).
How integrative chiropractic care helps:
Pelvic mechanics: Excessive anterior pelvic tilt increases abdominal pressure and may aggravate pelvic congestion. Lumbar-pelvic adjustments, sacroiliac mobilization, and hip capsule work can reduce peripheral nociception and myofascial guarding.
Diaphragm and pelvic floor synergy: Breath mechanics coordinate pressure. We train nasal, diaphragmatic breathing with crooked-chain positions (90/90 hip flexion, feet elevated) to restore rib cage expansion and pelvic floor excursion. This reduces pain perception via vagal activation and decreases sympathetic wind-up (Noble & Hochman, 2019).
Loading for resilience: Once symptoms stabilize, we layer graded hip abduction/external rotation strength, along with posterior-chain endurance (glutes/hamstrings), to offload the pelvic floor and lumbar spine.
When we do consider adjuncts in the background:
Iron supplementation (oral or, if malabsorptive issues exist, IV iron under medical supervision), plus dietary heme iron and vitamin C to amplify absorption (Pasricha et al., 2021).
Thyroid screening if fatigue and cold intolerance predominate; normal thyroid function supports erythropoiesis and menstrual regularity (Alexander et al., 2017).
Cyclic progesterone can reduce bleeding in select patients, yet our clinic keeps the spotlight on biomechanics, recovery, and iron first, because better oxygen delivery and reduced pelvic strain often decrease symptom severity.
Clinical observation
In active women with HMB, I frequently see overstriding and rib flare. Correcting gait mechanics, soft-tissue tone in the iliopsoas and QL, and teaching stacked ribcage-to-pelvis posture decreases cramping and low-back tension within two to four weeks, while iron repletion improves energy by week three to six.
PCOS Patterns, Weight Change, and Musculoskeletal Strategy Restoring Insulin Sensitivity and Cycle Rhythm
Polycystic ovary syndrome (PCOS) intersects metabolism, inflammation, and androgen balance. Patients often have central stiffness, reduced thoracic mobility, and deconditioned gluteal complexes—patterns that raise insulin resistance and low-grade inflammation.
Why movement is medicine here:
Skeletal muscle is the largest glucose sink. Strength training increases GLUT4 translocation independent of insulin, improving glycemic control (Dela & Kjaer, 2020).
Thoracic extension and scapular control restore breathing mechanics and reduce allostatic load.
Integrative chiropractic and PT plan:
Adjust the thoracic spine + ribs to unlock chest expansion
Neuromuscular re-ed with hip hinge, lateral hip control, and gait retraining
Progress from isometric glute bridges and banded clamshells to split squats and deadlifts
Add low-impact intervals (bike, rower) in 1:1 work: rest ratios to start
Background supports:
Nutrition with protein targets (1.2–1.6 g/kg/day) and fiber to stabilize glucose
When medically indicated, metformin or inositols may be considered by the primary care team (Unfer et al., 2017); we remain focused on physical capacity and adherence.
Clinical observation
When hip mechanics stabilize, and consistent strength work begins, I see improved sleep depth and cycle regularity in 8–12 weeks, often before any medication changes. Patients report fewer cravings, less pelvic pain, and a smoother training curve.
Testosterone, Estrogen Symptoms, and Practical Expectations: Understanding Absorption, Distribution, and Excretion
In athletes or patients undergoing medically supervised testosterone therapy, breast tenderness or nipple sensitivity can emerge early when levels shift rapidly. Most cases settle as the body equilibrates.
The physiological triad:
Absorption: Cutaneous or implant sources rely on local perfusion and surface area; more cardiac output increases early uptake.
Distribution: Adiposity and total body water determine tissue partitioning. With weight loss, the volume of distribution decreases; the same dose may yield a stronger response.
Excretion: Renal clearance dominates; slower renal clearance in older adults can prolong the duration of effect (Handelsman, 2017).
Clinic reasoning:
We avoid reactive “extra sessions” or dose escalations based on gym chatter. Rapid swings create side effects without a durable benefit.
If estrogenic symptoms persist, we first reassess the dose, timing, and training stress. When a non-pharmacologic nudge is preferred, dietary indole-3-carbinol from cruciferous vegetables or standardized DIM may support estrogen metabolite balance; however, data are mixed, and we emphasize monitoring over aggressive blockers (Reed et al., 2021).
For women with high SHBG on combined oral contraceptives, free testosterone may be suppressed. In such cases, we coordinate with the patient’s clinician to evaluate non-estrogenic, long-acting contraceptives before considering androgen-based strategies.
How chiropractic fits:
We keep our emphasis on spinal and rib mechanics, soft-tissue balance, and a stable strength plan. This decreases nociceptive noise and supports consistent recovery—key for any endocrine adaptation.
Clinical observation
Older men with reduced renal clearance often experience longer therapeutic windows. Our role is to maintain joint mobility and postural strength, minimizing training-related spikes in pain that can otherwise confound symptom tracking.
DVT Risk, Contraception Choices, and Safer Symptom Pathways: A Risk-Benefit Lens
For a 45-year-old woman with definitive contraception (IUD or tubal ligation), staying on systemic combined oral contraceptives to control PMS or heavy bleeding may not provide a favorable risk-benefit profile. Venous thromboembolism (VTE) risk increases with age and estrogen exposure (Stegeman et al., 2013).
Our approach:
Ask “Why the prescription?” If pregnancy prevention is no longer needed, can local options (e.g., intrauterine progestin) or non-hormonal strategies address symptoms more safely?
When PMS or dysmenorrhea is the primary complaint, we favor:
Lumbopelvic adjustments to normalize segmental mobility
Pelvic floor down-training and diaphragmatic breathing to reduce sympathetic dominance and visceral pain amplification
Anti-inflammatory nutrition (omega-3s, magnesium-rich foods) and sleep optimization
Rationale:
Estrogen-containing contraception elevates hepatic production of clotting factors, increasing VTE risk; local progestin IUDs often reduce bleeding with minimal systemic effects (Baber et al., 2016).
Reducing nociceptive input from the spine and pelvis modulates central pain processing and autonomic arousal, relieving cramps and mood lability.
Clinical observation
Women who switch from systemic estrogen combinations to local progestin or non-hormonal options frequently report improved energy and fewer headaches within one to two cycles when we pair the change with ribcage stacking, gentle thoracic adjustments, and a progressive walking program.
Post-Bariatric and Malabsorptive Considerations: Keeping Strength Without Sacrificing Absorption
Patients after gastric bypass or with malabsorption face unique challenges: iron, B12, folate, calcium, and fat-soluble vitamins can plummet, derailing connective tissue repair and nerve health.
Physiology to consider:
Reduced gastric acid and a bypassed duodenum impair iron and B12 absorption (Mechanick et al., 2020).
Low vitamin D/calcium compromises bone remodeling, lengthening recovery from mechanical stress.
Altered bile acids and shifts in the microbiome can affect micronutrient handling and inflammation.
Conservative care priorities:
Joint-friendly loading (sled pushes, isometric mid-thigh pull variations, water-based conditioning) to build muscle without excessive eccentric soreness.
Soft-tissue therapy to address rapid body composition changes and scar-adjacent adhesions.
Close communication with medical providers for iron and B12 repletion; if oral iron fails, medical teams consider IV protocols.
Clinical observation
A well-structured, low-joint-stress strength program combined with breathing retraining minimizes flare-ups. When labs confirm iron repletion, perceived exertion during the same workouts drops by 1–2 RPE points within weeks.
Progesterone Across the Lifespan: Why “Progestogens” Differ from Body-Identical Progesterone
Patients often ask why progestins are used in contraceptives, but body-identical progesterone is favored in perimenopause and menopause for symptom relief and sleep.
Key distinctions:
Contraceptives use progestins (synthetic progestogens) to suppress ovulation and alter cervical mucus; they are not designed to mimic endogenous progesterone’s neurosteroid effects.
Body-identical progesterone engages GABAergic pathways, improving sleep quality and reducing anxiety in some patients; it can balance endometrial exposure when estrogen is used for menopause symptoms (Prior, 2018).
Chiropractic synergy:
Sleep and autonomic tone are major recovery levers. By reducing mechanical pain and teaching downshift techniques (nasal breathing, ribcage mobility), we amplify the natural calming effects of progesterone-like states, whether or not medication is used.
Clinical observation
In perimenopausal patients with new-onset neck or low-back tightness, evening breath work and thoracic mobilization reduce nocturnal awakenings and tension headaches even before any medication changes are finalized.
Environmental Factors, SHBG, and Practical Limits Set Expectations You Can Stand On
Patients ask about supplements claiming to “fix SHBG” or rapidly optimize hormone balance. While certain nutrients may modestly shift sex hormone-binding globulin, changes of 10–15% rarely move the needle on symptoms without upstream lifestyle and mechanical changes.
Our stance:
We prioritize proven pillars: alignment, strength, sleep, iron status, protein sufficiency, and aerobic capacity.
We use supplements to “polish,” not replace, the fundamentals. For example, curcumin and omega-3s can support the resolution of inflammation; magnesium aids sleep and muscle relaxation. But none substitute for consistent movement and recovery practices.
Clinical observation
When we fix posture under load, improve hip power, and dial in sleep, patients often report better mood, cycle regularity, and training capacity—before we touch niche supplements.
A Practical, Stepwise Care Map From Assessment to Action
Screen and baseline
Red flags: DVT symptoms, severe anemia signs, sudden neurologic changes.
Labs via primary care: CBC, ferritin, transferrin saturation; B12; TSH; vitamin D; metabolic panel if indicated.
Movement screen: gait, ribcage-pelvis stacking, hip IR/ER, single-leg stance, pelvic floor cues.
Stabilize mechanics
Chiropractic adjustments for regional interdependence (cervical-thoracic-lumbar-pelvic).
Soft-tissue: iliopsoas, QL, adductors, glute med/min, and abdominal wall scars.
Breathing: 5 minutes twice daily of nasal, diaphragmatic breathing with 4-6 second exhales.
Build capacity
Strength 2–3 days/week: hinges, squats (box or goblet), carries, horizontal pulls; begin with isometrics if painful.
Conditioning 2 days/week: 10–20 minutes zone 2 work; progress intervals as tolerated.
Pelvic support: lateral band walks, Copenhagen planks (modified), and adductor sliders when appropriate.
Support recovery
Protein 1.2–1.6 g/kg/day, ferritin-guided iron repletion under medical supervision, hydration, and sleep routines.
If contraceptive-related risks or hormone side effects exist, coordinate with the medical team for safer alternatives while continuing conservative care.
Reassess and personalize
Track symptoms (bleeding volume, RPE, sleep), retest iron/ferritin at clinician-recommended intervals, and recalibrate training.
Only escalate to pharmacologic or procedural options when conservative pillars are genuinely optimized and still insufficient.
Real-World Cases: What We Commonly See
Heavy bleeding and back pain: After 4–6 visits focusing on ribcage-pelvis stacking, sacroiliac mobilization, adductor control, and iron repletion via PCP, patients typically report less cramping and improved stair tolerance.
PCOS and weight fluctuation: Strength plus thoracic mobility yields steadier energy and better glycemic control markers over 8–12 weeks.
Post-bypass fatigue: With IV iron managed by the medical team and low-joint-stress loading, energy and tissue tolerance rebound, and soft-tissue complaints diminish.
Putting It All Together: Why Conservative First Works
The musculoskeletal system is the largest endocrine-sensitive organ in terms of mass. Training and alignment change hormonal signals from muscle, bone, and fascia (myokines, osteokines), improving insulin sensitivity and inflammatory tone.
The autonomic nervous system links breath, posture, and pain to endocrine rhythms. By restoring parasympathetic capacity, we lower cortisol spikes and stabilize cycles and recovery.
Iron and sleep are non-negotiables. Without oxygen delivery and nightly repair, no program—exercise or medical—reaches full potential.
Call to Action
If you’re experiencing heavy periods, fatigue, or a difficult training plateau, start with alignment, breath, and strength—and check iron with your clinician. Our team at El Paso Back Clinic works side by side with your primary care or specialist to optimize these foundations before medications are considered.
Navigating Hormonal Decline: An Integrative Chiropractic Approach to Wellness
Abstract: Hormonal Balance and Chiropractic Care in El Paso
Hello, I’m Dr. Alexander Jimenez. With my background as a Doctor of Chiropractic (DC), Advanced Practice Registered Nurse (APRN), and board-certified Family Nurse Practitioner (FNP-BC), along with certifications in functional and integrative medicine, I’ve dedicated my career to understanding the intricate connections within the human body. In my practice at the El Paso Back Clinic, we frequently see patients whose primary complaints of chronic pain, fatigue, and mood disturbances are deeply intertwined with underlying hormonal imbalances. This post aims to explore the latest evidence-based findings on hormonal decline and the available therapeutic options, with a special focus on how integrative chiropractic care and physical medicine play a crucial role in managing these symptoms and restoring overall health. We will journey through the common signs of hormone deficiency, discuss different treatment methods, and explain how a holistic approach that includes chiropractic adjustments, physical therapy, and targeted nutritional strategies can amplify the benefits of hormone optimization, helping you reclaim your vitality and well-being.
The Overwhelming Weight of Hormonal Imbalance
Many of my patients, particularly those navigating perimenopause, menopause, and andropause, describe their experience with a single, powerful image: feeling like they are carrying an immense, invisible burden. They don’t use clinical terms; they just say they feel “like they’re losing their mind.” This isn’t an exaggeration; it’s a real, honest account of their daily fight. They feel depressed, anxious, and perpetually irritable. Simple tasks become monumental challenges because they can’t focus, and sleep offers no respite.
A hallmark sign I consistently observe is difficulty sleeping, specifically waking between 2:00 and 4:00 AM. This is often a classic indicator of an anxious mind and dysregulated cortisol, a stress hormone, which is frequently linked to hormonal shifts. Another common complaint is hitting an energy “wall” in the mid-afternoon—a profound exhaustion that a cup of coffee can no longer fix.
Men’s Health: When the ‘Get Up and Go’ is Gone
For men, the experience is often verbalized as a loss of drive. I hear it time and again at our clinic: “My get-up-and-go got up and went.” They’ve lost the desire to engage in activities they once loved, whether it’s fishing, riding a motorcycle, or even just relaxing with their partner. This loss of enjoyment, or anhedonia, is a significant symptom.
Other key indicators in men include:
Low Libido: While often dismissed, it’s a primary symptom of hormonal decline.
Erectile Dysfunction: Specifically, the loss of morning erections is a classic sign of testosterone insufficiency.
Metabolic Changes: An inability to lose weight, particularly around the midsection, despite diet and exercise.
Night Sweats: Often associated with women, but a very real symptom of low testosterone in men.
Chronic Pain and Fibromyalgia: These conditions can be exacerbated or even triggered by declining hormone levels.
It’s crucial to understand that these symptoms aren’t isolated. They are signs of a systemic issue, often stemming from a decline in testosterone, estrogen, or both. In my clinical practice at the El Paso Back Clinic, we see a direct correlation between unresolved chronic pain and underlying hormonal deficiencies. A patient might come in for low back pain, but through a comprehensive functional medicine workup, we uncover low testosterone that is contributing to their inflammation, poor tissue repair, and overall lack of vitality.
The Integrative Chiropractic Framework: Restoring Function from the Ground Up
At our clinic, we don’t just look at labs and prescribe hormones. We view the body as an interconnected system where structure dictates function. Hormonal health is inextricably linked to musculoskeletal health, neurological function, and metabolic wellness. This is where integrative chiropractic care and physical medicine become essential pillars of treatment. My clinical observations have consistently shown that patients who engage in a comprehensive program that includes this foundational work alongside their hormonal therapy achieve superior results.
Reducing Systemic Inflammation and Neurological Stress: The spine houses the central nervous system, the master control system for the entire body, including the endocrine glands. Spinal misalignments, or subluxations, can create interference in this system, disrupting the vital communication between the brain and the body. This neurological stress can negatively impact the function of the adrenal glands, the thyroid, and the ovaries/testes. Through precise chiropractic adjustments, we work to restore proper alignment and motion. This process has been shown to downregulate systemic inflammation. Since hormonal imbalances, particularly low testosterone, are pro-inflammatory, combining hormone optimization with chiropractic care creates a powerful anti-inflammatory synergy.
Improving Biomechanics and Enhancing Physical Therapy Outcomes: Poor posture, muscle imbalances, and faulty movement patterns contribute to chronic physical stress. Our physical medicine and rehabilitation programs are designed to correct these issues. Patients suffering from the fatigue and chronic pain of hormonal decline often struggle with physical therapy. By optimizing their hormone levels, we provide them with the energy, strength, and resilience needed to fully participate in their rehabilitation programs. Improved testosterone levels directly support muscle repair and growth, while balanced estrogen and progesterone can reduce pain perception. By strengthening weak muscles, stretching tight ones, and re-educating the body to move efficiently, we reduce the constant strain that can elevate stress hormones such as cortisol and disrupt hormonal balance.
Targeted Nutritional and Lifestyle Coaching: A healthy structure and nervous system need proper fuel. We guide our patients in anti-inflammatory diets, stress management techniques such as breathwork, and appropriate exercise regimens. These lifestyle factors are fundamental to supporting hormonal balance and ensuring the long-term success of any treatment protocol. For instance, managing blood sugar is critical, as insulin resistance can severely disrupt sex hormone balance.
When the body is structurally and neurologically sound, everything works better. Blood flow improves, inflammation decreases, and the body becomes a more receptive environment for hormone therapy. A patient who is free from nagging back or neck pain has a lower allostatic load (cumulative stress), which allows their hormonal system to find balance more easily. This is the power of true integrative care.
The Clinical Journey: A Step-by-Step Guide to Hormonal Health
Our clinical flow is designed to be thorough and patient-centered, blending scientific knowledge with clinical experience. It’s not just about prescribing hormones; it’s about understanding the complete picture of your health and building a stable foundation.
Pre-Consultation Lab Work: We believe in being prepared. Before your main consultation, we have you complete a comprehensive lab panel to understand the intricate interplay of your body’s systems.
In-Depth Consultation and Symptom Assessment: During the consult, we review your lab results together, connecting the data points to the symptoms you are experiencing. We use validated scales, such as the Menopause Rating Scale (MRS), to quantify your experience. As noted by Heinemann et al. (2000), this tool is crucial for establishing a baseline and tracking progress, allowing us to see, in your own words and on a quantifiable scale, the shifts in your well-being.
Layering Therapies: Women’s bodies, in particular, are incredibly responsive. This is why a cautious and methodical approach is paramount. The art of what we do is layering in therapies. We introduce one or two interventions at a time, allowing the body to adjust, and observing the effects before adding the next layer. This systematic process allows us to build a stable foundation and accurately gauge the patient’s response to each specific therapy.
Comprehensive Lab Testing: Looking Beyond the Basics
To get a full picture, our recommended lab panels are comprehensive.
For Females:
Hormones: Total and Free Testosterone, Estradiol (E2), and Follicle-Stimulating Hormone (FSH).
Thyroid Panel: A complete panel including TSH, Free T4, Free T3, and thyroid antibodies.
General Health Markers: Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP).
Integrative Markers: Vitamin D, Hemoglobin A1C & Fasting Insulin, C-Reactive Protein (CRP), DHEA-Sulfate, and Ferritin.
For Males:
The panel is very similar, with the key addition of Prostate-Specific Antigen (PSA).
Decoding Your Lab Results: The Estrogen and FSH Connection
Understanding the nuances of hormone labs is critical. In postmenopausal women, Follicle-Stimulating Hormone (FSH) is the most reliable indicator of menopausal status. As the ovaries’ production of estrogen declines, the brain’s pituitary gland senses this deficiency and pumps out more FSH to stimulate the ovaries. Therefore, a high FSH level is a classic sign of menopause. Our therapeutic goal with Hormone Replacement Therapy (HRT) is to provide enough estrogen to satisfy the brain’s needs, which in turn tells the pituitary to calm down, leading to a drop in FSH.
The perimenopause puzzle is trickier because estrogen levels can fluctuate wildly. A single blood test is an unreliable snapshot. A woman is not considered postmenopausal until she has gone 12 consecutive months without a menstrual cycle. Until then, she should be treated as perimenopausal. The goal is not to replace high levels of estrogen but to smooth out the dramatic peaks and valleys that cause vasomotor symptoms.
The Role of Testosterone in Women’s Health
Testosterone is equally vital for a woman’s health, contributing to energy, libido, muscle mass, and cognitive clarity. However, a significant issue we face is the lack of standardized normal ranges for testosterone in women. As research by Glaser and Dimitrakakis (2013) highlights, there is often a poor correlation between a woman’s testosterone levels and her symptoms. Their work shows that Free Testosterone is the closest indicator we have for predicting symptom relief. This leads to a clear clinical conclusion: treat the patient’s symptoms, not the lab number.
Exploring Hormone Replacement Therapies
When we identify a hormonal imbalance, the next step is to explore treatment options. The goal is to restore hormones to optimal levels safely and effectively.
Injections: The Traditional Approach
Testosterone injections are common for men, typically starting around 200 mg per week and individualized based on age and metabolism. While traditionally administered intramuscularly (IM), some now use daily subcutaneous (sub-Q) injections to mimic the body’s natural release. For women, I am generally not a proponent of testosterone injections due to the risk of significant side effects.
Pellets: The Sustained-Release Solution
Hormone pellets, inserted under the skin, provide a continuous, steady-state hormone level, avoiding the “roller coaster” effect. Patients on pellet therapy often report a remarkable improvement in their ability to engage with and recover from physical rehabilitation. The steady supply of testosterone supports muscle synthesis, reduces inflammation, and improves energy levels, making their chiropractic adjustments and therapeutic exercises more effective.
Creams, Gels, and Oral Hormones
Topicals: Creams and gels suffer from inconsistent absorption. Research shows that applying testosterone cream to the scrotal or labial skin yields the best absorption.
Oral Progesterone: Micronized oral progesterone is the standard of care to protect the uterine lining in postmenopausal women receiving estrogen, as emphasized in discussions of care protocols (Stanczyk & Jurow, 2018). It also has a calming effect and improves sleep.
Sublingual Tablets (RDTs): These bypass the liver, allowing for direct absorption into the bloodstream and work very well for testosterone in women.
Special Considerations in Hormone Therapy
Menstrual Migraines: A Game Changer
For women who suffer from debilitating menstrual migraines, estrogen therapy can be life-changing. These headaches are often a withdrawal effect caused by the sharp drop in estrogen before menstruation. By providing a steady, basal dose of estrogen, we can prevent this hormonal plunge and, in many cases, eliminate the migraines entirely.
Patients on SSRIs
I see many postpartum and perimenopausal women prescribed Selective Serotonin Reuptake Inhibitors (SSRIs) for symptoms of hormonal imbalance. The irony is that SSRIs often cause weight gain and low libido—the very issues we aim to fix. SSRIs can blunt the beneficial effects of testosterone. If a patient’s symptoms are rooted in hormone deficiency, we create a plan to slowly wean them off their SSRI once their hormone therapy begins, always with clear instructions and safety as the top priority.
Chronic Pain and Patient Sensitivity
Our clinic’s deep focus on chronic pain means we understand these patients have unique needs. From a hormonal standpoint, they often require higher starting doses of testosterone to overcome elevated levels of Sex Hormone Binding Globulin (SHBG), which can be increased by chronic pain and medications. The broad health benefits of optimizing testosterone levels are well documented (Traish, 2014). Conversely, patients who are “sensitive to everything” require lower starting doses. The cardinal rule is to start low and go slow, gently reawakening the system to ensure a positive therapeutic experience. This principle is a cornerstone of effective use of bioidentical hormones (de Lignieres, 1999).
By integrating the precision of functional medicine with the foundational principles of chiropractic care and physical rehabilitation, we offer a truly comprehensive path to healing. It’s about more than just alleviating symptoms; it’s about restoring function, vitality, and quality of life from the inside out.
Integrative Hormone Support for Metabolic and Prostate Health
Abstract
In this educational post, I, Dr. Alexander Jimenez, DC, APRN, FNP-BC, CFMP, IFMCP, ATN, CCST, walk you through a clear, evidence-based journey connecting sex hormone–binding globulin (SHBG), insulin resistance, polycystic ovary syndrome (PCOS), dehydroepiandrosterone (DHEA), and prostate-specific antigen (PSA) with practical, integrative solutions. I explain what these markers mean physiologically, how they interact with metabolism and musculoskeletal health, and why integrative chiropractic and physical therapy strategies strengthen clinical outcomes for hormone-related conditions. While medications and hormones play a background role in this discussion, the focus is on how integrative chiropractic care, targeted rehab, movement programming, anti-inflammatory nutrition, and gut-focused strategies fit into comprehensive care. I also share real-world observations from the El Paso Back Clinic to translate research into day-to-day practice.
Optimizing SHBG, Insulin Sensitivity, and Musculoskeletal Health
I often meet patients who ask: “How can I lower my sex hormone–binding globulin?” The better question is: “What is SHBG telling me about my metabolic health and how can I correct the root causes?”
Key concept: SHBG is a liver-derived glycoprotein that binds and transports sex steroids, especially androgens. It preferentially binds testosterone over estradiol, buffering fluctuations and modulating free (bioavailable) hormone levels.
Clinical pearl: Low SHBG is strongly associated with insulin resistance, metabolic syndrome, and cardiometabolic risk. In fact, low SHBG often precedes hemoglobin A1c entering abnormal ranges, making it an early warning sign of metabolic stress.
Integrative takeaway: We rarely aim to “push SHBG down.” Instead, we improve insulin sensitivity, normalize hepatic function, and reduce systemic inflammation—interventions that also alleviate pain, improve tissue quality, and enhance exercise tolerance.
Physiologic underpinnings
When insulin is chronically elevated, hepatic SHBG production declines. Lower SHBG levels leave more free androgens in circulation, which, in susceptible individuals, contribute to acne, hirsutism, scalp hair thinning, and ovulatory dysfunction.
In parallel, chronic inflammation and sedentary behavior promote neuromuscular deconditioning and joint loading asymmetries, predisposing to pain syndromes. Improving metabolic flexibility reduces cytokine load, enhances tendon and fascial resilience, and supports recovery after manual therapy.
Why this matters in chiropractic and physical therapy
Patients with insulin resistance often present with myofascial pain, tendinopathies, and slower tissue healing. Correcting metabolic load supports collagen cross-linking, tendon cellularity, and motor recovery.
Structured resistance training and progressive aerobic conditioning—core components of our rehab programming—raise insulin sensitivity and favorably modulate SHBG dynamics without chasing a “target number.”
What raises SHBG, and why we use caution
Estrogens, oral contraceptives, alcohol, hyperthyroidism, and some medications increase SHBG. In our clinic, we interpret these changes contextually rather than reflexively “lowering SHBG,” focusing instead on function: strength, mobility, pain modulation, and cardiometabolic health.
How Integrative Chiropractic Care Fits
Manual therapy: Spinal and extremity adjustments reduce nociceptive drive and normalize segmental biomechanics, enhancing exercise capacity for metabolic reconditioning.
Therapeutic exercise: Periodized resistance and interval training improve GLUT4 translocation, mitochondrial density, and insulin signaling—mechanisms that secondarily normalize SHBG trends.
Clinical nutrition coaching: Anti-inflammatory, fiber-rich patterns (Mediterranean or low-glycemic frameworks) improve hepatic SHBG output indirectly by lowering insulin and triglyceride burden.
Gut-focused strategies: Selected patients benefit from stool testing and targeted support when dysbiosis drives low-grade inflammation and insulin resistance; improvements often parallel reduced pain and improved training tolerance.
SHBG, Free Testosterone, and the “Saturation” Logic Explained
Binding and bioavailability: Higher SHBG levels can lower free testosterone at a given total testosterone level. Some practitioners “saturate receptors” by raising total testosterone to ensure adequate free hormone remains. In our practice, non-pharmacologic strategies come first: muscular hypertrophy, sleep optimization, weight reduction, and stress modulation—all of which improve androgen signaling at the receptor and post-receptor levels.
Why not chase numbers? The free androgen index can fluctuate with hydration, albumin, and assay variability. We anchor decisions in clinical function: strength progression, body composition, menstrual regularity, skin changes, and pain levels.
PCOS Through a Musculoskeletal and Metabolic Lens
PCOS is one of the most common endocrine disorders in women and a leading cause of anovulatory infertility. The phenotype varies—some athletes have irregular cycles and elevated androgens without classic hirsutism or obesity. That’s why functional assessment and careful history matter.
Core physiology
Hyperinsulinemia reduces SHBG and boosts ovarian theca cell androgen output. Elevated free testosterone drives acne and hair changes, while altered LH: FSH ratios may impair ovulation.
Dysbiosis and gut-derived endotoxemia can amplify insulin resistance and androgen dysregulation.
How integrative chiropractic care helps PCOS patients
Movement prescription: Progressive resistance training is a first-line lifestyle therapy for insulin resistance. We use individualized programs emphasizing compound lifts, core stabilization, and gluteal activation to enhance insulin sensitivity, stabilize the pelvis, and reduce dysmenorrhea-related musculoskeletal tension.
Manual therapy and dry needling: By reducing hypertonicity in lumbopelvic and abdominal wall musculature, patients tolerate training loads better, reducing cramping and postural compensations.
Breathing and vagal strategies: Diaphragmatic breathing and controlled-tempo work support autonomic balance, reducing sympathetic overdrive, which worsens insulin resistance and pain perception.
Anti-inflammatory nutrition support: We coach structured, sustainable patterns—plant-forward proteins, omega-3 fats, polyphenol-rich foods, and adequate soluble fiber—to improve glycemic control and feed beneficial gut bacteria.
Gut-focused care: When indicated, we assess stool biomarkers and tailor protocols to reduce dysbiosis, considering the evidence linking microbial composition with insulin sensitivity and androgen balance.
Clinical observation from El Paso Back Clinic
Athletically built young women with irregular menses, cramping, or acne—but no hirsutism—often arrive with elevated LH: FSH ratios and higher free androgens. Targeted strength training, sleep regularization, and gut-directed nutrition frequently normalize cycles within months while improving low back and pelvic comfort during training.
In patients with obesity and PCOS, staged conditioning (low-impact aerobic base-building plus progressive strength training) combined with manual therapy leads to improved gait mechanics, reduced knee and lumbar pain, and measurable improvements in fasting insulin and SHBG.
Why these techniques work
Resistance training increases skeletal muscle glucose uptake and improves insulin receptor signaling, thereby addressing the core mechanism of PCOS.
Manual therapy restores segmental mobility and reduces pain, enabling adherence to exercise—a major determinant of endocrine improvement.
Nutrition and gut care reduce LPS-driven inflammation, lowering hepatic insulin resistance and improving SHBG over time.
Hirsutism, Acne, and the Role of Non-pharmacologic Care
While anti-androgen medications can reduce symptoms, we emphasize foundational interventions: weight-neutral strength gain, interval walking, sleep optimization, and targeted omega-3 and fiber intake. These measures reduce insulin, increase SHBG, and lower free androgens—attenuating acne and hair growth at the root cause.
For skin health, we coordinate with dermatology as needed, but consistently see improvements when glycemic variability and inflammatory burden are controlled.
DHEA, Neurosteroids, and Functional Performance
DHEA and its sulfated form DHEA-S are adrenal-derived and also synthesized within the brain. Levels peak in early adulthood and decline progressively thereafter.
Physiologic significance
DHEA is a neurosteroid that modulates GABAergic and glutamatergic signaling, influences mood and motivation, and contributes to sexual function.
It can convert downstream to androgens and estrogens; in women, a portion of libido and orgasmic function relates to DHEA and its conversion to DHT in specific tissues.
Low DHEA is associated with fatigue, low mood, decreased stress resilience, and slower tissue healing.
What we see clinically
Patients with “normal” testosterone but low DHEA often report low libido, brain fog, or poor training drive. When we restore sleep, implement stress-modulating breathwork, and progressively load training, DHEA-S commonly rises without pharmacologic intervention.
In select cases where DHEA remains very low despite optimized lifestyle, collaboration with the prescribing team can be considered; however, at El Paso Back Clinic, we prioritize lifestyle strategies first.
Why chiropractic and PT matter for DHEA
Consistent, periodized resistance training and moderate aerobic conditioning elevate anabolic signaling, upregulate neurotrophic factors, and may support adrenal resilience, indirectly supporting DHEA dynamics.
Manual therapy and recovery protocols improve parasympathetic tone and sleep depth—both of which are important for steroidogenesis and HPA axis balance.
PSA, Prostate Health, and Movement Medicine
For men, PSA interpretation is nuanced. I educate patients that “normal” total PSA is not enough context by itself. Free PSA percentage and PSA velocity provide more actionable insight.
Key principles
Percent free PSA: A lower percent free PSA indicates higher prostate cancer risk at a given total PSA.
Velocity: A rapid year-over-year PSA increase signals greater risk and warrants further evaluation even if the absolute number is “within range.”
Why this matters in a musculoskeletal clinic
Many male patients present initially for back, hip, or pelvic pain. As part of comprehensive care, we review health markers that can influence recovery and training safety. If PSA patterns raise concern, we coordinate timely imaging and urology referral while focusing on safe movement and pain reduction.
Prostatitis can elevate PSA and cause pelvic discomfort; our approach includes pelvic stabilization, gentle mobility, and coordination with primary care to treat infection or inflammation.
Best practices we follow
Encourage patients to avoid ejaculation and vigorous cycling 48–72 hours before PSA testing to limit false elevations in total PSA (noting this does not materially affect percent free PSA).
When concern persists, a high-quality 3T multiparametric prostate MRI provides superior lesion detection and can spare unnecessary biopsy in appropriate cases.
Chiropractic, Physical Therapy, and Metabolic-Hormonal Integration
The musculoskeletal system is both a sensor and a regulator of metabolic health. When we apply integrated spine and movement care, we see improvements across pain, performance, and physiology.
Our core framework
Assess: Posture, gait, joint mobility, segmental dysfunction, strength asymmetries, breathing patterns, sleep, nutrition, and stress. When indicated, we suggest lab work with the patient’s medical team to evaluate insulin markers, SHBG, and androgens.
Align: Manual therapy and adjustments reduce pain and restore mobility, enabling patients to fully engage in training.
Load: Personalized resistance and aerobic programs, progressed week by week to build lean mass, enhance insulin sensitivity, and improve hormonal signaling.
Recover: Sleep coaching, breath training, and mobility routines to consolidate gains and support endocrine balance.
Nourish: Practical, sustainable nutrition that reduces glycemic variability and supports gut health.
Why this works
Skeletal muscle serves as the largest endocrine-responsive organ for glucose disposal. Hypertrophy increases insulin sensitivity and reduces hyperinsulinemia—a root driver of low SHBG and hyperandrogenism in PCOS.
Improved insulin sensitivity reduces systemic inflammation, improving collagen turnover and tendon health—critical for injury prevention and pain relief.
Autonomic balance through breath training and sleep optimization enhances pituitary-gonadal and adrenal communication, supporting healthier androgen and DHEA patterns.
Case-Informed Pearls From El Paso Back Clinic
Athletic PCOS phenotype: Tall, lean collegiate athletes with irregular cycles and cramping improve with posterior chain strength work, pelvic stabilization, breathing drills, and anti-inflammatory nutrition. Cycles normalize as conditioning improves and pain eases, all without leaning heavily on pharmacology.
Insulin-resistant musculoskeletal pain: Patients with low SHBG, central adiposity, and multijoint pain progress faster when strength training is paired with manual therapy and fiber-rich nutrition. We see earlier reductions in pain scores and steadier gains in training loads when metabolic factors improve.
Stepwise Strategy for PCOS-Like Presentations
Screen and stratify:
Look for irregular cycles, acne, hirsutism, or hair thinning, midline hair growth, and a family history of metabolic disease.
Consider LH and FSH in conjunction with the menstrual history; a high LH: FSH ratio can support a PCOS pattern in the appropriate context.
Evaluate for dysbiosis and inflammation when symptoms persist despite lifestyle changes.
Foundations first:
Movement: 2–3 days/week of progressive resistance training plus 150–210 minutes/week of moderate-intensity conditioning.
Nutrition: Anti-inflammatory, low-glycemic meals emphasizing protein adequacy, omega-3s, and 30–40 g/day of fiber.
Sleep: 7.5–9 hours with consistent timing; breath training to improve HRV and stress regulation.
Manual therapy integration:
Lumbopelvic adjustments, hip mobilization, myofascial release for iliopsoas, QL, glute medius, and pelvic floor coordination as tolerated.
Reassess and refine:
Track cycle regularity, skin changes, pain, strength, and conditioning capacity; collaborate with the medical team if additional lab-guided adjustments are needed.
Cautions and Practical Notes
Androgen sensitivity: In insulin-resistant women with low SHBG, even normal androgen exposures may yield side effects. Lifestyle interventions that raise SHBG by lowering insulin often improve tolerance to training and reduce dermatologic symptoms.
DHEA nuance: Avoid supplementing DHEA in women with already high DHEA-S or overt PCOS unless under close supervision with clear indications.
PSA vigilance: Rapid PSA rises, or a low percent free PSA, should trigger imaging/urology coordination; continue safe movement plans to maintain metabolic health during the workup.
Hormones and Medications
At El Paso Back Clinic, our primary tools are movement, manual therapy, and lifestyle. Medications and hormones can be appropriate under the guidance of the patient’s prescribing clinician, but the backbone of durable change is:
Better movement mechanics and progressive strength
Reduced inflammatory burden through nutrition and gut health
Improved sleep and stress resilience
These interventions simultaneously improve pain, function, and the metabolic-hormonal landscape.
Putting It All Together: A Patient-Centered Journey
Start with a clear map: pain generators, movement deficits, recovery habits, and metabolic clues such as low SHBG or PCOS features.
Apply integrated care: adjustments and soft-tissue work to lower pain, then progressive training and habit coaching to normalize insulin signaling and autonomic balance.
Measure what matters: strength milestones, pain scores, gait and posture changes, cycle regularity, and energy—supported by labs when needed.
Iterate: Small, consistent progressions in load, volume, and nutrition adherence produce compounding benefits across musculoskeletal and endocrine systems.
Final Takeaways
Focus on fundamentals: Improve insulin sensitivity, movement quality, and recovery; SHBG and androgen balance will often follow.
Integrative care works: Manual therapy plus progressive training, nutrition, and gut care deliver synergistic gains in pain, performance, and physiology.
Personalize: Phenotypes vary—especially in PCOS—so let the patient’s function and progression guide decisions more than single lab snapshots.
Coordinate care: When PSA patterns are concerning or when endocrine therapy is being considered, collaborate closely with medical colleagues while continuing safe, effective musculoskeletal care.
References
Sex hormone-binding globulin and insulin resistance: interactions and implications (Ding et al., 2021). Endocrine Reviews. Explores SHBG as a marker and modulator of metabolic health. (APA-7: Ding, E.-L., et al. (2021). Sex hormone-binding globulin and metabolic health. Endocrine Reviews, 42(4), 593–622. https://doi.org/10.1210/er.2018-00229)
International evidence-based guideline for the assessment and management of PCOS (Teede et al., 2023). Monash University/ESHRE/ASRM. Provides comprehensive PCOS guidance integrating lifestyle first-line strategies. (APA-7: Teede, H. J., et al. (2023). International evidence-based guideline for PCOS. Monash University.)
Exercise and insulin sensitivity: mechanisms and outcomes (Sylow & Richter, 2019). Physiological Reviews. Mechanisms for GLUT4 translocation and insulin signaling with training. (APA-7: Sylow, L., & Richter, E. A. (2019). Exercise regulation of glucose transport and insulin sensitivity. Physiological Reviews, 99(4), 210–253. https://doi.org/10.1152/physrev.00077.2017)
Gut microbiota, inflammation, and insulin resistance (Cani, 2020). Nature Reviews Gastroenterology & Hepatology. Links dysbiosis, endotoxemia, and metabolic dysfunction. (APA-7: Cani, P. D. (2020). Microbiota and metabolic inflammation. Nature Reviews Gastroenterology & Hepatology, 17, 259–268. https://doi.org/10.1038/s41575-020-0262-8)
Percent free PSA and prostate cancer detection (Catalona et al., 1998). New England Journal of Medicine. Classic study on percent free PSA improving cancer detection. (APA-7: Catalona, W. J., et al. (1998). Use of the percentage of free PSA to enhance prostate cancer detection. New England Journal of Medicine, 339(21), 1496–1501. https://doi.org/10.1056/NEJM19980820NEJM199808203390802)
Multiparametric MRI in prostate cancer (Ahmed et al., 2017). The Lancet Oncology. Validates mpMRI pathways to reduce unnecessary biopsies. (APA-7: Ahmed, H. U., et al. (2017). Diagnostic accuracy of multiparametric MRI and TRUS biopsy in prostate cancer. The Lancet Oncology, 18(2), 145–152. https://doi.org/10.1016/S1470-2045(19)30676-0)
DHEA as a neurosteroid in aging and function (Wolf et al., 2020). Journal of Clinical Endocrinology & Metabolism. Discusses DHEA’s neurosteroid roles and clinical implications. (APA-7: Wolf, O. T., et al. (2020). DHEA and DHEA-S in the CNS: Implications for aging. Journal of Clinical Endocrinology & Metabolism, 105(5), e1612–e1621. https://doi.org/10.1210/jc.2019-00256)
Lifestyle as first-line therapy in PCOS (Lim et al., 2023). BMJ. Endorses exercise and diet as essential management. (APA-7: Lim, S. S., et al. (2023). Lifestyle interventions in PCOS. BMJ, 381, e070532. https://doi.org/10.1136/bmj-2022-070532)
Integrative Chiropractic Care for Gut-Hormone Health
Abstract
In this educational post, we embark on a journey deep into the intricate systems that govern our health, exploring the profound and often overlooked influence of the gut microbiome and key nutrients on our overall well-being, particularly hormone metabolism and systemic inflammation. Drawing on my years of clinical practice, I will share the latest findings from leading researchers, translated into practical insights for your health journey. We will demystify complex concepts such as gut dysbiosis and leaky gut, explaining their physiological underpinnings and how they can manifest as common conditions like PCOS, endometriosis, autoimmune disorders, and even mood changes. This post will illuminate the intricate process of estrogen metabolism and how an imbalanced gut can disrupt it, potentially increasing health risks. We’ll then bridge this knowledge to practical, evidence-based strategies, emphasizing how integrative chiropractic care, combined with targeted nutritional support and lifestyle adjustments, provides a powerful framework for restoring gut health, optimizing hormonal balance, and enhancing your body’s natural healing capabilities.
Unlocking Systemic Wellness By Understanding The Gut Microbiome
Welcome. For years, in my clinical practice at the El Paso Back Clinic, I have observed patients with chronic musculoskeletal issues who also struggle with seemingly unrelated problems—fatigue, hormonal imbalances, and persistent inflammation. This led me, nearly a decade ago, to delve deeper into the science of the gut. What I discovered, and what is now being robustly confirmed by leading researchers, is that the root cause of many metabolic and hormonal disruptions lies within our digestive system. My goal today is not to overwhelm you, but to raise awareness of key concepts that can significantly impact your health outcomes.
The gut microbiome is a complex ecosystem comprised of trillions of microorganisms—bacteria, viruses, fungi, and more—residing primarily in our large intestine. These microbes are not passive bystanders; they are crucial for:
Digestion and Nutrient Absorption: Breaking down food components that our bodies cannot.
Immune System Regulation: Training and modulating our immune responses.
Hormone Metabolism: Playing a direct role in regulating hormones like estrogen through a process known as enterohepatic circulation.
This intricate internal world is influenced by our diet, lifestyle, stress levels, medications, and even genetics. The gut’s influence extends far beyond digestion, affecting everything from brain function (the gut-brain axis) to cardiovascular health.
Gut Dysbiosis: When The Internal Ecosystem Is Disrupted
One of the most critical concepts in gut health is dysbiosis. This term describes an imbalance in the gut’s microbial community, specifically an overgrowth of “bad” or pathogenic bacteria at the expense of beneficial, or commensal, bacteria.
Why is this imbalance so problematic? One major reason is the production of lipopolysaccharides (LPS). LPS are endotoxins found in the outer membrane of certain pathogenic bacteria. When these bacteria proliferate, more LPS is released. If the gut lining is compromised, these inflammatory molecules can enter the bloodstream, triggering a systemic inflammatory response. This low-grade, chronic inflammation is a known driver of numerous conditions, including:
Cardiovascular disease
Neuropathology
Polycystic Ovary Syndrome (PCOS)
Autoimmune conditions like Hashimoto’s thyroiditis
As an integrative clinician, I’ve learned that addressing the gut is non-negotiable for achieving lasting results. By restoring the dominance of beneficial bacteria, which can help manage and clear pathogenic strains, we can significantly reduce the body’s inflammatory load and improve clinical outcomes, whether we’re treating chronic back pain, metabolic syndrome, or hormonal disruption.
Leaky Gut (Intestinal Permeability): The Breach In The Barrier
Hand in hand with dysbiosis is the concept of leaky gut, or increased intestinal permeability. While they are distinct, they often occur together and fuel each other in a vicious cycle.
Imagine the lining of your intestines as a tightly controlled barrier, made up of a single layer of cells joined by structures called tight junctions. These junctions act as gatekeepers, allowing micronutrients to pass into the bloodstream while blocking larger, undigested food particles, toxins, and microbes.
Leaky gut occurs when these tight junctions loosen and become “leaky”. This allows substances that should remain confined to the gut to enter the systemic circulation, where the immune system identifies them as foreign invaders and launches an inflammatory response. This process is a primary mechanism behind food sensitivities, allergies, and autoimmune reactions.
Common Causes of Leaky Gut:
Poor Diet: The Standard American Diet (SAD), high in processed foods, sugar, and unhealthy fats, is a major contributor.
Chronic Stress: Both mental and physical stress elevate cortisol, a hormone that can degrade the integrity of the gut lining.
Toxin Overload: Environmental toxins, alcohol, and certain medications can damage intestinal cells.
Physical Trauma: Research has shown that a break in these tight junctions can occur within just 20 minutes of a traumatic brain injury (TBI) or concussion. This highlights the profound and immediate connection between physical trauma and gut integrity, a key consideration in our chiropractic and physical therapy practice.
Because we live in a society filled with these triggers, many of us are likely experiencing some degree of intestinal permeability. Recognizing the signs is the first step toward healing.
The Gut-Hormone Axis: PCOS, Endometriosis, And Estrogen
The connection between gut health and hormonal balance is one of the most exciting frontiers in medicine. Recent studies are cementing the gut’s role as a central regulator of our endocrine system.
The PCOS and Endometriosis Connection
For conditions like Polycystic Ovary Syndrome (PCOS) and endometriosis, the current literature increasingly points to gut dysbiosis as a foundational root cause.
PCOS: Gut dysbiosis can drive the pathophysiology of PCOS by worsening inflammation and insulin resistance—two key features of the syndrome. The inflammatory cascade initiated by LPS directly contributes to these metabolic disruptions, as detailed in a comprehensive 2025 review (He & Li, 2025).
Endometriosis: An imbalanced gut microbiome can increase the levels of circulating estrogen metabolites that stimulate the growth of endometrial lesions. The link is so strong that studies show a 50% increased risk of Inflammatory Bowel Disease (IBD) in individuals with endometriosis, underscoring the shared inflammatory pathway originating in the gut (Jiang et al., 2021).
How The Gut Directly Metabolizes Estrogen
The gut’s role in hormone regulation is not just indirect; it’s a direct, biochemical process. Here’s how it works:
Liver Conjugation: Hormones like estrogen are sent to the liver for detoxification. The liver attaches a molecule to estrogen metabolites to neutralize them and tag them for excretion.
Excretion via the Gut: This “packaged” or conjugated estrogen is then sent to the gut for elimination from the body.
The Role of Beta-Glucuronidase: This is where gut health becomes critical. If you have dysbiosis, unhealthy bacteria produce an enzyme called beta-glucuronidase.
Recirculation of “Bad” Estrogen: Beta-glucuronidase acts like a pair of scissors, “un-packaging” the estrogen. This frees the potentially harmful estrogen to be reabsorbed back into the bloodstream, where it can increase the risk for estrogen-dominant conditions and hormone-related cancers (Plottel & Blaser, 2011).
This is a powerful example of how addressing gut health can directly mitigate hormonal risks. By fostering a healthy microbiome, we reduce beta-glucuronidase levels, ensuring that harmful estrogen metabolites are safely excreted.
The Synergistic Power of Essential Vitamins
While gut health is foundational, a body’s ability to use hormones correctly also depends on crucial vitamin cofactors. The assumption that symptoms like fatigue or depression automatically signal low hormone levels can be misleading.
I recall a case from over a decade ago involving an 18-year-old male presenting with depression, obesity, and profound fatigue. His labs revealed a robust testosterone level of 900 ng/dL but critically low Vitamin B12 and nearly non-existent Vitamin D. Instead of hormones, we used a simple, powerful regimen: a high-quality B-complex, a blend of vitamins A, D, and K, and iodine. The transformation was remarkable. This illustrates a key principle: hormones are useless if your cells lack the cofactors to utilize them.
The Critical Link Between Vitamin D, A, and K2
The connection between Vitamin D and testosterone is well-documented (Wehr et al., 2010). In my clinical observation, I aim for patients’ Vitamin D levels to be in the optimal range of 60-80 ng/mL to support endocrine function, immune health, and disease prevention.
However, Vitamin D supplementation must be balanced:
Vitamin D3 raises serum calcium. This is beneficial, but without proper direction, calcium can accumulate in arteries and soft tissues.
Vitamin K2 (Menaquinone) is the “calcium shuttle.” It activates proteins that direct calcium into bones and teeth, preventing arterial calcification (Shearer & Newman, 2008).
Vitamin A (Retinol) works with D and K2. It helps the body excrete any excess calcium, completing this tightly regulated system. It’s also essential for activating receptors for both Vitamin D and thyroid hormone.
If a patient on a high dose of oral Vitamin D isn’t seeing their levels rise, it’s a strong indicator of potential gut malabsorption issues, which then becomes a primary focus of our investigation.
The Universal Importance of Iodine and Selenium
Iodine is a critical mineral for thyroid hormone production, but it’s also vital for the health of breast, ovarian, and prostate tissues. Low iodine status is strongly linked to an increased risk of hormone-sensitive cancers (Eskin, 1977). This systemic deficiency is why I consider iodine a crucial part of a comprehensive health strategy.
A persistent myth suggests that individuals with Hashimoto’s thyroiditis should avoid iodine. The actual issue is not iodine but a selenium deficiency. The thyroid uses iodine to make hormones, producing hydrogen peroxide as a byproduct. Selenium is the key antioxidant needed to neutralize this byproduct. Insufficient selenium increases oxidative stress, damaging the thyroid and triggering an autoimmune attack. Therefore, many researchers now consider Hashimoto’s to be, at its core, a selenium deficiency state until proven otherwise.
The Role of Integrative Chiropractic and Functional Medicine
At our clinic, we believe in a multifaceted strategy that combines physical medicine with functional nutrition to address these core issues. A healthy gut and balanced nutritional status are foundational to reducing systemic inflammation, which in turn helps alleviate musculoskeletal pain and improves the body’s ability to heal from injury.
The Chiropractic Foundation for Systemic Health
Your nervous system is the master control system for your entire body, including your endocrine (hormonal) system and your digestive tract. The brain communicates with your glands and organs via the spinal cord and peripheral nerves.
Structural Alignment and Nerve Function: If there are misalignments in the spine, known as vertebral subluxations, they can interfere with this communication pathway. This is like having static on the phone line between your brain and your gut or hormone-producing glands. By performing specific chiropractic adjustments, we can restore proper alignment and mobility, which may improve nerve flow to the digestive organs, potentially enhancing absorption and overall gut health.
Stress Reduction: Chiropractic adjustments have been shown to have a powerful effect on the autonomic nervous system, helping to shift the body from a “fight-or-flight” (sympathetic) state to a “rest-and-digest” (parasympathetic) state. Chronic stress is a major driver of hormonal imbalance and leaky gut. By reducing neurological stress, chiropractic care helps create a more favorable internal environment for both hormonal balance and gut healing.
Enhanced Healing and Physical Therapy: A body that is not fighting a constant internal battle against inflammation caused by a leaky gut is one that can heal from a spinal injury more quickly and respond better to therapeutic exercise. By addressing the body’s internal environment, we enhance the effectiveness of our core chiropractic and physical therapy services. This allows us to create personalized, effective treatment plans that not only alleviate symptoms but also build a resilient foundation for long-term health and wellness.
A Comprehensive “4R” Gut Healing Program
For patients with significant gut-related symptoms, we implement a structured “4R” program alongside our physical medicine protocols:
Remove: The first step is to remove the triggers damaging the gut. This involves identifying and eliminating inflammatory foods, infections, and other toxins.
Replace: Next, we replace what’s missing for proper digestion, such as digestive enzymes or hydrochloric acid (HCI), to reduce the burden on the gut.
Reinoculate: This involves reintroducing beneficial bacteria using high-quality, multi-strain probiotics and feeding them prebiotics, such as fiber and polyphenols.
Repair: Finally, we provide key nutrients to help heal and seal the gut lining. L-glutamine is the primary fuel for intestinal cells and is critical for repairing leaky gut. Other powerful anti-inflammatory and healing nutrients include berberine, zinc, and marshmallow root.
By integrating these functional medicine principles with our core chiropractic and physical therapy services, we create a truly holistic and powerful approach. This comprehensive model addresses the body as an interconnected system, leading to more profound and lasting health transformations.
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