September/October 2021

cndoctor.ca Serving Canada’s Chiropractic and Naturopathic Professions

Building
connections
Neurotrophic factors
in dementia
 September/October 2021 Cndoctor.ca

8
14

Contents 6 COVER STORY: Building connections Columnists

Neurotrophic factors in dementia
BY DR. ROMI FUNG, ND 12 Being bigger
than institutions
8 Helping the aging move better BY DR. ANTHONY LOMBARDI, DC
Life and longevity, part 8
BY DR. DON FITZ-RITSON, DC 22 Get ready for
the economic boom
14 Navigating scoliosis BY DR. ELIAS MARKOU, ND
Your 13-year-old son has a 53 degree thoracolumbar
scoliosis and is about to enter his growth spurt.
What would you do?
Cover photo: © vegefox.com / Adobe Stock, Icons: Freepik / Flaticon.com

BY DR. DEREK LEE, DC

16 Keep it simple, silly

Our CMCC externship experience
BY DR. ERIK KLEIN, DC, AND DR. M. JACOB HAYES, DC

18 Platelet rich plasma

What it is, and how it fits into multidisciplinary
treatment plans
BY DR. CHRIS SPOONER, ND

www.Cndoctor.ca September/October 2021 Chiropractic and Naturopathic Doctor 3

UPFRONT | From the editor

September/October 2021

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COVER STORY

BRAIN HEALTH

Building
connections
Neurotrophic factors
in dementia
by dr. romi fung, nd

D
ementia is an umbrella term that encompasses
multiple neurodegenerative diseases resulting
in cognitive symptoms. Characteristic to the
symptom picture of dementia is not only clas-
sic memory impairments, but also includes
language, problem-solving, executive func-
tions, arithmetic and other cognitive and
thinking capabilities. Therefore, dementia has a large impact
on the individuals activities of daily living.
Alzheimer’s Disease, or Alzheimer’s Dementia (AD), is the
most common cause of dementia, accounting for approxi-
mately 80% of dementia cases (Alzheimer’s Association,
2020).The other 20% of cases consists of Lewy Body Demen-
tia, Vascular Dementia, Parkinson’s Dementia, Crutzfeldt-
Jakob disease,Wernicke-Korsakoff syndrome, Frontotemporal
Dementia and Mixed Dementia. These dementias all have
differing etiologies that this article will not explore in depth.
The hallmark of the pathology of AD is the accumulation
of beta-amyloid protein fragments that have aggregated out-
side neurons in the brain. Also of importance are tau tangles
that are twisted in neurons and eventually lead to the death Longitudinal studies and meta-analysis have exhibited an association
of neurons thereby affecting brain tissue. This pathological of low vitamin D with cognitive impairment and Alzheimer’s disease.
development occurs progressively over many years before
symptoms emerge. form synapses throughout the life span.This process is initiated
One of the concerns regarding the development of demen- by neuronal depolarization, however the numbers of synapses
tia is the ability to create new neural connections. Synapto- formed is dependent on the level of three key nutrients—uri-
genesis is the creation of new synapses resulting in new con- dine, the omega-3 fatty acid DHA, and choline (Wurtman,
nections between preexisting brain neurons. Brain neurons 2014).

DR. ROMI FUNG is a Naturopathic Physician practicing in Richmond, Trophic factors for Alzheimer’s dementia
Photo: © javy / Adobe Stock

British Columbia, Canada. A recent graduate from the Canadian College of
Naturopathic Medicine, Romi helps patients living with dementia improve
their quality of life by taking an integrative and functional approach. On top of
his practice, Romi is currently pursuing doctoral studies in Aging and Health
at Queen’s University and is an Adjunct Clinical Faculty at the Boucher Institute
of Naturopathic Medicine. www.DrRomiFungND.com.
6 Chiropractic and Naturopathic Doctor September/October 2021
Trophic, as defined in the dictionary, is ‘of relating to nutrition;
concerned in nutritive processes’ (Dictionary.com, 2021).
Another definition by Merriam-Webster (2021) states that
trophic factors “promot[e] cellular growth, differentiation, and
survival.” In other words, nerve growth factor is a trophic agent.
This part will explore some nutraceuticals as trophic factors.
www.Cndoctor.ca

Vitamin D
One of the nutraceutical interventions to provide factors in
building neural connections is vitamin D. Cross-sectional
studies have consistently found that vitamin D levels are sig-
nificantly low in individuals with AD and cognitive impairment
compared to healthy adults. Longitudinal studies and me-
ta-analysis have also exhibited an association of low vitamin
D with cognitive impairment and Alzheimer’s disease (Sultan
et al., 2020; Chai et al., 2019; Llewellyn et al., 2011)
In another study done by Chai et al. (2019), there are sig-
nificant positive associations between deficient vitamin D
(defined as <20 ng/mL) and risk of developing AD. By divid-
ing subgroups in the deficient vitamin D to moderate defi-
ciency (10-20 ng/mL) and severe deficiency (<10 ng/mL),
there was a greater association with AD in the severe deficiency
group in comparison to the moderate deficiency group (Chai
www.Cndoctor.ca
et al., 2019). This indicates that the risk of AD was reduced
with increased vitamin D levels.
It is observed that low vitamin D levels is associated with
increased risk of AD. Vitamin D is suspected to be a potential
modulator of neurogenesis. Vitamin D has been shown to
regulate neurotrophic factors and influencing neuronal pro-
liferation, differentiation, survival and growth (Groves &
Burne, 2017). Low vitamin D levels, or hypovitaminosis D, in
AD rat models increased the number of amyloid plaques
(Morello et al., 2018).
Vitamin D is highly recommended to be tested before
considering supplementation. At this time, there is no concrete
evidence on an ideal level of serum vitamin D. However, a
study done by Oudshoorn et al. (2008) suggests that there is
a positive association between serum vitamin D levels and
MMSE scores, with participants with serum vitamin D higher
than 50nmol/L generally scoring the highest. In regards to
dosing, in a double-blind randomized controlled trial of post-
menopausal women with levels than 30ng/mL by Castle et al.
(2020), women who took 2000IU daily found to perform
better in learning and memory tests compared to the 600IU
and 4000IU groups.
Magnesium
Another intervention in supporting neurogenesis is magne-
sium. Magnesium affects many biochemical mechanisms vital
for neuronal properties and synaptic plasticity, including the
response of N-methyl D-aspartate (NMDA) receptors to
excitatory amino acids, stability and viscosity of the cell mem-
brane, and antagonism of calcium (Li et al., 2014).
Magnesium is arguably often overlooked however it is cor-
nerstone to our health. Magnesium levels were found to be
decreased in various tissues of AD patients and negatively
correlated with clinical deterioration (Li et al., 2014). More-
over, Magnesium was demonstrated to modulate the traffick-
ing and processing of amyloid-ß precursor protein in trans-
genic mice (Li et al., 2014).
Magnesium supplementation comes in many forms. One
form that is more appropriate in managing cognitive decline
is magnesium threonate. Magnesium threonate treatment
was shown to reduce Aß-plaque, prevented synapse loss and
memory decline in the transgenic mice (Li et al., 2014).
Strikingly, magnesium threonate treatment was effective even
when the treatment was given to the mice at the end-stage of
their Alzheimer’s disease-like pathological progression (Li et
al., 2014).
Magnesium itself has a poor penetration across the blood
brain barrier (Vink, 2016). However, magnesium threonate is
a more permeable magnesium salt and is a preferred option
in neurological conditions (Vink, 2016).
Phosphatidylcholine and Citocholine
Choline is a major constituent of all biological membranes
including neurons and glial cells (Blusztain et al., 1990). Brain
sample studies dating to the 1980s and 1990s showed reduced
levels of phosphatidylcholine and phosphatidylethanolamine
and increased levels of their metabolites, glycerophosphocho-
line and glycerophosphoethanolamine, respectively, in the
cerebral cortex of AD patients as compared to age-matched
CONTINUED ON PAGE 21
September/October 2021 Chiropractic and Naturopathic Doctor 7
FEATURE
PAITENT CARE
Helping
the aging
move
better
Life and longevity, part 8
by dr. don fitz-ritson, dc
Y
ou know that normal physiology
changes as you age. Gait and mo-
bility are altered with aging and
changes in gait speed is contributed
by impaired balance and stability,
lower limb strength, fear of falling
and are related to functional de-
cline and impaired quality of life(1). Multisen-
sory aging is an important concept, as other
systems ie., vision, hearing, can contribute to
cognitive load and decline(2,3). In a study of gait
speeds with women >75 years old, decreased What would be
cognitive function is associated with changes in the outcome if
gait speed(4). we added
The Canadian Longitudinal Study on Aging nutrition to
showed that all cognitive measures were related to aerobic exercise?
indices of mobility and the relationship often in-
creased with age and brain health(5,6). Mobility
limitations are heavily influenced by musculoskel-
etal mechanisms and higher brain centers espe-
cially the motor control circuit of the dorsal basal
ganglia are all involved(7). Since the musculoskel-
etal and brain systems are involved in mobility and
DR. DON FITZ-RITSON is a chiropractor and a rehab specialist.
He was an Assistant Professor at CMCC. He published 17 papers
and 3 chapters on chiropractic.He co-invented a laser and it
received 7 Health Canada Approvals. He is focused on helping the
aging population live better lives.
8 Chiropractic and Naturopathic Doctor September/October 2021
they change with aging, then we should be looking
at dual tasking, ie., combines walking with say
mental tracking tasks to get a better appreciation
of their interactions. In a study comparing young
vs old adults dual tasking, it showed that the older
group exhibited shorter times during single–leg
stance and single-leg stance + cognitive task com-
pared to younger group(8). Another study looked
at cognitive function and postural control showed
that postural control during visuospatial tasks and
dementia may share neural substrates, specifically
in memory-related regions(9). Also sex differences
such as the effect of aging on the recruitment of
muscles may explain overall increased instability
and fall risk in older adults(10).
Both gait impairment and cognitive decline
have been shown to constitute major fall risk
factors. Those are two big domains and it would
be beneficial for doctors/therapists working with
the aging population to have more specific areas
to access. Some results are beginning to show that
in the cognitive domain, specifically the cortical
Photo: © Africa Studio / Adobe Stock, Icon: monkik / Flaticon.com
executive system and its sub-domains – attention
control, is linked with gait performance in the
aging with high risks of falls(11). Attention, sen-
sory integration, and motor planning are the
sub-domains of executive function associated with
risk of falls through gait dysfunction(12). This
information will begin to guide us as we begin the
task or improving gait/mobility.
The feet are significant for gait/mobility. Their
range of motion, flexibility, co-ordination and
strength are all critical for the normal gait cycle.
By assessing all the evidence based studies, con-
clusions can be drawn regarding which maybe
the best approach to rehabilitate the gait/
www.Cndoctor.ca

Attention, sensory integration,
and motor planning are the
sub-domains of executive
function associated with risk of
falls through gait dysfunction.
mobility cycle. Here are a few pertinent ones.
This study evaluated the effects of resistive exer-
cise (RE) with head rotation exercise (RE+HRE)
on postural balance, lower limb muscle strength,
and gait in older women. This is a dual task study.
They are including head rotation exercises which
is a powerful means of stimulating the vestibular
system and restoring proper proprioceptive sense
to the cervical muscles, brain stem and brain(cog-
nitive/motor).Their findings suggest that
RE+HRE can improve dynamic postural balance,
lower limb strength, gait speed, and cadence in
older women(13).
Another study looking at the effectiveness of
exercise intervention to control dynamic postural
stability under unstable conditions in old
www.Cndoctor.ca
adults(65-80), found that a training program focus-
ing on exercising mechanisms of dynamic stability
in unstable conditions ie., dual task, enhanced
muscle strength as well as sensory information
processing within the motor system during balance
tasks, reducing the risk of falls in old adults(14).
Lack of stability with gait/mobility is caused also
by age-related neuromuscular changes in the hip
abductor-adductor muscles leading to reduced
performance, causing more medio-lateral sway
contributing to balance issues and falls. When
power training was introduced into the program,
ie. strengthening the hip muscles, it was found to
be more effective than strength training at eliciting
improvements in maximal neuromuscular perfor-
mance and enhanced medio-lateral balance recov-
ery(15).
Is there a reliable, easy and cost efficient way to
measure body strength in the aging person? By
reviewing the studies, stand-alone handgrip
strength can be considered an umbrella assessment
of the body systems that contribute to strength
capacity, and a panoptic measurement of muscle
strength that is representative of overall health
status(16). Results in older adults found that mus-
cle weakness of the leg extensors and forearm
flexors is related to slow gait speed and is suitable
for screening for muscle weakness in older
adults(17). Handgrip strength can also be used in
clinical settings for helping to determine the onset
and progression of cognitive impairment(18).
Looking specifically at the musculoskeletal sys-
tem and how it affects gait/mobility of older adults,
recent studies show that tibialis anterior and vastus
lateralis muscles deserve attention in physical train-
ing for gait. Specifically, tibialis anterior strength
helps with obstacle crossing, and vastus lateralis
assists knee extensors when aiming at improving
gait speed and step length(19). But we should also
condition the entire body, because the entire sys-
tem functions as a unit, muscles affect the brain
and visa versa. After a 12 week program of regular
resistance exercises, the elderly group showed sig-
nificant increases in the average upper body
strength (58%), lower body strength (68%), and
cognitive capacity (19%), these benefits bring en-
hanced life quality(20). For a complete neuro-mus-
culoskeletal effect, adding plyometric training,
which is safe training when done correctly, has
potential for improving various performance, func-
tional, and health-related outcomes in older per-
sons(21).
Balance training over a lifespan can improve
vestibular function and decrease postural deterio-
ration. This training effect can contribute to the
physical capabilities of the person functioning as
been 10 years younger(22). The balance training is
inducing structural neuroplasticity in the human
brain and to enhance cognitive functions. A
September/October 2021 Chiropractic and Naturopathic Doctor 9
FEATURE
12-week study of balance training involving 19-65
year old subjects, found improved balance perfor-
mance which correlated with the increase of
precentral cortical thickness. This area is involved
with visual and vestibular self-motion perception,
spatial orienting and memory. Stimulating
visual-vestibular pathways during self-motion
might mediate beneficial effects of physical exer-
cise on cognition(23).
Dance is multi functional, a great way to have
fun and improve brain function. Dance practice
integrates brain areas to improve neuroplasticity.
In a systematic review, structural changes were
found indicating increased hippocampal volume,
gray matter volume in the left precentral, parahip-
pocampal gyrus and white matter integrity. Func-
tional changes included alterations in cognitive
function such as significant improvement in
memory, attention, body balance, psychosocial
parameters and altered peripheral neurotrophic
factor(24). Dance training promotes mental and
physical well-being of senior citizens(25).
Here is the real potential of the dual-task pro-
gram. A simple approach like walking and simul-
taneously performing a cognitive task, such as
counting backwards from 100 by 3, in older adults,
has been shown to effectively improve the normal
gait cycle and for complex real world tasks (26, Balance training multi-nutrient supplement and aerobic exercise
27). Aging cause declines in executive functions over a lifespan on mobility and cognition in older women 60-70
and basic motor skills such as posture control, can improve years, found significant improvements in self-re-
muscle strength, and balance performance. What vestibular ported emotional well-being with multi-nutrient
would happen if we trained executive functions function and and exercise groups v. placebo. The results suggest
and exercise - resistance training? In a 12 week decrease that the high-DHA multi-nutrient supplement
program of 68 year old males assessing balance postural produces similar improvements in cognitive func-
performance and working memory, the results deterioration. tion to aerobic exercise, offering the intriguing
found that dual-task interventions improved both prospect that supplementation may be able to
balance performance and working memory, but mitigate some of the effects of low physical activ-
more so if cognitive performance was specifically ity on cognitive function in the elderly.(30
trained along with resistance training(28). The aging population needs to be educated
The ability to walk and perform cognitive tasks that different types of exercise, along with dance,
simultaneously is a key aspect of daily life. When dual-task exercises, balance and cognitive train-
they are performance declines in these dual-tasks, ing are all necessary, in addition to taking good
it may be associated with early signs of neurode- supplements and eating properly to enjoy healthy
generative disease and increased risk of falls. living.
Dual-task aerobic exercise and cognitive training
intervention significantly improved cognitive per- REFERENCES
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will see improvements. 2018.
What would be the outcome if we added nutri- 3. Morris R, et al. Gait and Cognition: Mapping the Global and Discrete
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tion to aerobic exercise? There is a complex inter-
play between mobility and cognition in older
adults. High-DHA multi-nutrient supplement
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and psychomotor response latency in older
women. Exercise also improves mobility and cog-
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exercise share a range of overlapping biological
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Speed in Midlife. JAMA Netw Open. 2019 Oct 2; 2(10): e1913123.
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7. Clark B, et al. The Aging Brain & the Dorsal Basal Ganglia: Implications for Age-Related
Limitations of Mobility. Adv Geriatr Med Res. 2019; 1: e190008.
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9. Sparto P, et al. Shared Neural Substrates of Cognitive Function and Postural Control in Older
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Strength and Balance Ability in the Elderly. Scand J Med Sci Sports . 2018 Mar. 28 (3):
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24-Week Traditional Dance Program. Front Aging Neurosci. 2018 Dec 21; 10: 422.
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Mexican adults. Am J Health Promot. 2015 Nov-Dec; 30(2) :77-84.
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Task Performance in Older Adults. Biomed Res Int. 2017; 2017: 8570960.
28. Norouzi E, et al. Dual-task Training on Cognition and Resistance Training Improved Both
Balance and Working Memory in Older People. Phys Sportsmed. 2019 Nov; 47(4): 471-478.
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Task Walking Performance in Healthy Older Adults: Results From a Pilot Randomized
Controlled Trial. BMC Geriatr. 2020 Mar 2; 20(1): 83.
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September/October 2021 Chiropractic and Naturopathic Doctor 11
2021-09-10 12:32 PM
UPFRONT | Columnist

BUSINESS TALK

Being bigger than institutions

Practicing DCs need to become ambassadors of the profession

W
BY DR. ANTHONY J. LOMBARDI, DC

hat a tumultuous two

years this has been. In
between changes in world
leadership, pandemics,
travel restrictions, and
business closures our profession has quietly
been changing too.
Did you know? Of the 45 chiropractic
institutions worldwide that only 14 have
retained the word chiropractic in the school’s
name? Of those 14 schools with chiropractic
in their name only four are in the United
States (Texas, Sherman, Palmer, Life West)
and only CMCC sports the name of the
profession in Canada. Most recently New
York Chiropractic College shed chiropractic
from its name and became Northeast Col-
lege of Health Sciences. This trend worries
me. I fear that a serious identity crisis in the
profession is on the horizon. School are
trading the chiropractic name for a more
general, generic, better marketable moniker.
This might be understandable if the schools
were in financial peril, but most chiropractic
institutions are on solid financial footing.
Most recent annual financial reports show
that NYCC has over $50 million US in as-
sets – yet they still ditched chiropractic from
their name. schools that teach future ambassadors of our profession no
longer make chiropractic a visible priority in their own insti-
Questions tutions? Does the mass re-branding of chiropractic schools
What does this tell chiropractors in the profession? Does it across the world also re-brand the profession of practicing
suggest that schools are putting profits ahead of preservation chiropractors?
of the profession? Clearly these name changes have been
encouraged by the sharp decrease in enrollment and in order The answers
to maintain profits, the institutions feel that a more generic At first this bothered me. Then I thought that I needed to
name will attract a more diverse array of post-graduate stu- take a step back and take whatever positive aspects from this
dents to their school to enroll in allied health curriculums. academic trend. I pondered: Do chiropractic schools make
I wonder, how many medical schools or dental schools are the profession? Or, do practicing chiropractors set the tone
Photo: © Monkey Business / Adobe Stock

no longer called medical or dental schools? Chiropractic has
a young but rich history. Will it hurt our profession if the
ANTHONY LOMBARDI, DC, is a private consultant to athletes in the NFL, CFL
and NHL, and founder of the Hamilton Back Clinic, a multidisciplinary clinic.
He teaches his fundamental EXSTORE Assessment System and practice building
workshops to various health professionals. For more information, visit www.
exstore.ca.
12 Chiropractic and Naturopathic Doctor September/October 2021
for the future? There are tens upon tens of thousands of
practicing chiropractors worldwide: What are we doing to
demonstrate and foster pride in the profession?
The best we can do is to demonstrate clinical and civil
greatness through our actions. Practicing chiropractors can
make an impression on other chiropractors, chiropractic
students, allied health professionals and patients, simply by
being good role models and positive mentors in the profes-
sion.
www.Cndoctor.ca
Be a mentor Mentoring is mutually beneficial
Mentoring is the key for developing and sustaining a satis- Mentoring can provide opportunities that can be mutually
fying career and enables us to grow, learn, transform and beneficial for both mentor and mentee. Mentors can be a
accomplish goals in education, in the clinic or business. coach or ally answering questions as they arise for the
Whether you are an educator, clinician or in the early stages mentee. They act as advocates to help mentees navigate
of your training, mentoring helps build a dynamic commu- the terrain of academia and move forward professionally.
nity for success. By providing guidance, support and other insights, men-
tors can learn and enhance their own leadership skills.
Mentors promote confidence Mentees often bring a fresh perspective to a difficult prob-
The importance of mentoring relationships becomes evident lem, and serving as mentor can provide a renewed sense
as we recognize the value of networking and maintaining re- of purpose in meeting the challenges of chiropractic.
lationships throughout our career.The value of a good mentor
is immeasurable when it comes to learning the tricks of the Be the change
trade as well as becoming connected to those in the know and Ultimately, the responsibility of mentorship rests with
who possess invaluable knowledge about business practice. DCs. Let us not worry about what the academic institu-
Most importantly, a successful mentor demonstrates and tions are doing. That is out of our control. If you do not
upholds the values and ethics of the profession they represent. agree with it then find an aspect of our profession that
A mentor can help alleviate much of the frustration students you can support. It is vitally important for us to help one
and new graduates often feel in their first few months of work- another grow and develop into competent professionals
ing in clinic. By sharing their insight and knowledge on clini- and entrepreneurs. There is no reason why we shouldn’t
cal and business skills, new DCs in the field can be spared a be sharing helpful information with our peers. After all,
great deal of stress. A good mentor can support students, new there is an abundance of potential chiropractic patients
graduates and practising DCs to help avoid unnecessary in Canada.
resignation due to feelings of incompetence and isolation. Lets be positive, Doc!

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www.Cndoctor.ca September/October 2021 Chiropractic and Naturopathic Doctor 13

CND_DesignHealth_SeptOct21.indd 1 2021-09-03 9:47 AM
FEATURE

COLLABORATION

NAVIGATING SCOLIOSIS
Your 13-year-old son has a 53 degree thoracolumbar scoliosis and is
about to enter his growth spurt. What would you do?
BY DR. DEREK LEE, DC

T
wo years ago, our family
doctor caught the initial
24 degree curve after a
routine chest X-ray for a
lingering cough. In retro-
spect, I often look back
on what I have learned
since that heartbreaking diagnosis and
kick myself for missing all the signs that
were staring me in the face for years.
On the top of that list were his thoracic
hypokyphosis and cervical kyphosis,
the former the biomechanical hallmark
of scoliosis progression, the latter, a
proximal junction compensation pat-
tern to the former.
After moving on from the guilt of
missing it earlier, I started to research
all things scoliosis. Yes, I’m an experi-
enced chiropractor, but I rarely see
scoliosis in my corporate practice with
Rogers Communications (21 years) or
my private practice (28 years). I’m
ashamed to say that I can’t recall being
taught anything about scoliosis in chi-
ropractic college and certainly nothing
about scoliosis treatment. It might
seem pathetic, but I turned to Google
for answers. Of course what I found
scared me even more. I found a lot of
misinformation in general with miracle
cures, but also conflicting studies from
(AIS) is bracing followed by a wait and
see approach and if the curve pro-
gresses to 50+ degrees, then either live
with the curve or opt for posterior fu-
sion with rods and screws as the end
game. Neither were great choices. In
my son’s case, it took three months to
get a referral to a local pediatric spine
surgeon and another month to get a
Boston-type symmetrical brace. I was
far from impressed by how the first
spine surgeon managed my son’s care
with an outdated brace design and
dubious follow up plan. In the mean-
time, his curve had more than doubled
to 53 degrees into surgical range. Those Many of the chiropractic treatments for
four critical months were completely scoliosis were developed about 30 years ago
wasted. Unfortunately, this is an all too
common scoliosis story. the top orthotists in North America,
I was completely frustrated, angry Luke Stikeleather based in Virginia,
and looking for help. I reached out to USA.With a combination of daily phys-
Toronto’s Sick Kids hospital for a con- iotherapy specific scoliosis exercises,
sultation. I consulted with chiroprac- traction and muscle work, my son saw
tors throughout North America. Many a 20% curve reduction from 53 to 42
of the chiropractic systems for scoliosis degrees in three months, which was
can be traced back to a posture system excellent considering braces are de-
developed by Dr. Burl Pettibon about signed to stop progression and not to
30 years ago. I also reached out to correct the curve.
physiotherapists who were experienced I was happy for my son and proud of
with scoliosis-specific exercises includ- his dedication to a daily regimen of one
ing Schroth therapy. I also sought hour of exercise and treatment seven
better bracing treatment by speaking days a week for three months. This was
Photo: © Photographee.eu / Adobe Stock

apparent scoliosis experts and re- with several orthotists (brace makers) in addition to being braced 21 hours a
searchers on PubMed. The lack of from across the US and Canada. day which is horrific to witness, much
consensus was everywhere. Six months post-diagnosis my son less partake in. Unfortunately, I knew
The most common medical manage- was fitted with a Rigo Cheneau asym- these results wouldn’t last. He was
ment of adolescent idiopathic scoliosis metric brace from who I feel is one of entering his growth spurt and he had
atypical scoliosis. His spine was stiff
DR. DEREK LEE is a corporate health and wellness Doctor with Rogers Communications (20+ years), with a thoracic lordosis and I knew the
supporting three Rogers GTA on-site health centres in addition to a Markham private practice. He is a bracing, exercise and conservative
scoliosis education advocate: https://www.youtube.com/c/DerekLee. treatments would fail.
14 Chiropractic and Naturopathic Doctor September/October 2021 www.Cndoctor.ca
 Serial low dose EOS x-rays spanning 3.5 years of scoliosis correction from detection to bracing to non-fusion Vertebral Body Tethering surgery
I started doing more surgery focused
research. I even lurked on Facebook
scoliosis forums to see how other sco-
liosis patients with severe curves were
trying to manage their own care. Ridic-
ulous? Actually, these groups were the
most helpful. They shared information
on non-fusion surgical scoliosis correc-
tion techniques that use screws and
cords to maintain spine flexibility.
Vertebral body tethering (VBT) uses
polyethylene terephthalate (PET)
cords instead of metal rods to correct
a scoliotic curve. The basic idea is quite
elegant. Screws are inserted into the
convex side of each vertebrae along the
span of the curve. Cords are tensioned
between each vertebrae to align the
vertebral discs which reduces the curve.
This technique harnesses the Huet-
er-Volkman principle of bone growth
modulation which proposes that bone
growth is retarded by increased me-
chanical compression, and accelerated
by reduced loading in comparison with
normal values. VBT is primarily for
adolescents that are still growing. As
they continue to grow post VBT, the
discs and vertebrae will maintain a more
symmetrical shape which will stabilize
the cure once bone maturity has been
reached. Fusion is avoided altogether.
This sounded like a solution!
Via e-mail, Linkedin, Instagram and
Zoom, I began reaching out directly to
spine surgeons across Canada, the
USA and Europe. These specialists
were the most skilled in non-fusion
scoliosis surgeries and I sought a con-
sensus of opinion. Six consultations
Photo: Author provided.
later, we drove down to Shriners Hos-
pital for Children in Philadelphia to see
pediatric orthopedic and neurosur-
geon, Dr. Amer Samdani. Dr. Samdani
not only led the research necessary for
www.Cndoctor.ca
the FDA VBT approval (summer
2019), he had also performed over
250+ VBT surgeries. His clinical deci-
sion making, experience and expertise
meant everything. On Labour Day
2019, he accepted Jacob as a surgical
candidate for VBT and in December
2019, my son had VBT surgery.
One and a half years later, my son’s
curve is down to 24 degrees from 53
with a fully mobile spine.
Everyone’s influences and approaches
will differ, and chiropractors, naturo-
paths, osteopaths and physiotherapists
will lean on their experience and train-
ing to try and find a solution. But what
about parents and patients? What
should they do, and who advocates for
them? Researching scoliosis treatment
options is a challenge considering all the
My previous consultations
taught me so much – why not
share these insights...?
misinformation and lack of consensus
on the Internet.
From my own experience, I have
learned the best and most relevant data
and information comes directly from
spine surgeons, especially the ones that
publish research papers consistently.
This means they follow up with patients
long term and are experienced and re-
spected by their peers. My previous
consultations taught me so much – why
not share these insights with other par-
ents or patients affected by scoliosis?
Last spring during the first COVID
lockdown, I reached out to Dr. Ahmet
September/October 2021 Chiropractic and Naturopathic Doctor 15
Alanay in Turkey to see if he would be
interested in participating in an inter-
view on VBT. Shockingly, he agreed
and we recorded a 70-minute interview.
Not only did I learn more about VBT,
but the interview gave insight to Dr.
Alanay’s thought processes regarding
surgical decision-making and surgical
approach, but also his personality. This
long format interview reveals much
more than a typical 10 minute consul-
tation most patients get with a surgeon.
Maybe I was on to something.
A year later, I’ve interviewed 30 of
the top spine surgeons from Canada,
U.S., Germany, France and Australia.
That list includes Dr. Amer Samdani,
Dr. Peter Newton (San Diego), Dr. Per
Trobisch (Germany), Dr. John Braun
(Boston), Dr. Noelle Larson (Mayo
Clinic) and many more. I’ve also inter-
viewed scoliosis researchers, orthotists
and other practitioners. These inter-
views have become popular in the
scoliosis world and I’m happy parents
can use this resource to make timely
and informed decisions. The interviews
can be found at https://www.youtube.
com/c/DerekLee.
The only way parents and patients
can advocate for themselves is by edu-
cating themselves as best they can. It
doesn’t matter if you are a practitioner
or a parent. Keep that in mind and it
will serve you well.
FEATURE
visits in their clinic year to graduate,
along with 30-40 new patient assess-
ments and all of the learning objectives
(LOs) that go along with it. During
COVID, interns struggled, and CMCC
moved away from a numbers-based in-
ternship, and guided 4th years through a
competency-based protocol for gradua-
tion. They really had no choice, because
holding back 150+ interns because of
their “numbers” was simply not practi-
cal, nor ethical. The downside of this, is
that CMCC was graduating academi-
cally capable DCs, but with a distinct
disadvantage with regards to patient
management, and technical skills. The
CCEB boards are set to create end of
education and licensing competency.
This is already in place. Missing your
EDUCATION “numbers” will come back to haunt

Keep it
grads who simply didn’t get the experi-
ence. Seeking out strong mentorship for
the first two years of practice will be es-
sential in launching their careers.

simple, silly
The college did indeed recognize this,
and supported enterprising interns who
sought out externships to complete their
clinical education in community clinics
around the country. Dr. M. Jacob Hayes
was one such intern who sought out the
support of Dr. Erik Klein, and Dr. Dan
Our CMCC COVID Comeau for his clinical education,
which took place in New Brunswick.
externship experience This is our story:
BY DR. ERIK KLEIN, DC,
AND DR. M. JACOB HAYES, DC JAKE ‘THE INTERN’
Not having family or strong social con-
nections in the GTA, I knew I was going
to have a great deal of difficulty complet-
This is our experience from both the intern, marked as if the status quo existed is ing my requirements, which led me to

C
and the supervising clinician, on CMCCs
first broad-based externship program.
OVID-19 turned educa-
tion on its head. Every-
one struggled to some
point, especially those
finishing high school and
missing out on many
rights of passage, and
tough. Beyond that, imagine going back
to chiro school and spending $25,000 to
do virtual consults and desperately
hoping some people come in during the
series of lockdowns experienced in the
GTA. This has been a hard time for
chiropractic interns.
Any seasoned doc in the trenches will
tell a student that getting as much
hands-on experience as possible is the
seek out Dr. Klein and Dr. Comeau.
Even though clinic started in June, I
didn’t get into Sherbourne until August
to see my first in-person patient. I
reached out to Dr. Klein to see if he
would be able to help and he was excited.
I learned very quickly how differently
things happen in community clinics vs.
the teaching clinic. My clinicians really
endeavoured to provide a mentorship
Photo: © LIGHTFIELD STUDIOS / Adobe Stock

those entering higher education. The key to a solid start. You need to assess, that would help balance my educational
thought of paying $5,000 for university educate, adjust, and do your rehab. competencies while gaining knowledge
tuition and sitting in your dorm watching Over, and over, and over again. Tradi- of “the real world.”
glorified YouTube videos and being tionally, interns required 350 subsequent As with the beginning of every intern-
ship, your first patient intake appoint-
DR. ERIK KLEIN is a chiropractor and CEO of Town Health Solutions, a network focused on the growth and ment lasts about four hours. History –
development of clinical excellence and entrepreneurship for manual therapists. For more information, talk to your clinician. Ask more questions
please visit www.townhealthsolutions.com/franchising. that you missed – talk to your clinician.
DR. M. JACOB HAYES is a recent graduate of the Canadian Memorial Chiropractic College. He graduated Do a physical examination – talk to your
from the University of New Brunswick in 2017 with a Bachelors of Sciences. clinician. Go back in and complete
16 Chiropractic and Naturopathic Doctor September/October 2021 www.Cndoctor.ca
another SIJ test – talk to your clinician.
You then take about 25 minutes to write
out an ROF (for the first time anyway)
– talk to your clinician.You finally get to
the treatment. But, this is necessary, as
in the beginning we always miss little
things in the history and physical exam-
ination. Now, how applicable are these
little details that we miss? That is up for
debate, but overall this process is sup-
posed to be lengthy and awkward, be-
cause it is something we have never truly
done before. Going through comps in
3rd year CE cannot replicate what you
are about to experience in 4th year. In
addition to this, the school internship
does not necessarily prepare you for the
real world. Especially with the COVID-19
pandemic, this only complicated things
further. No class at CMCC can prepare
you to send a ROF PDF over Zoom and
then explain how the patient can down-
load it, sign it, and send it back. Once I
started my externship, I realized there
was another layer to learn. How to be
efficient in a 20-minute subsequent ap-
pointment. How to get everything done
– history, physical, and treatment in a
one-hour initial appointment, and real-
izing that these patients are paying real
money for our services. I quickly learned
from Dr. Klein how to identify and exe-
cute a focused treatment plan.Test, treat,
re-test, give active care advice. How he
was able to do this over a 20 minute
period amazed me at first, but I quickly
realized that Dr. Klein, with his experi-
ence, prioritizes certain aspects of each
condition that he sees (These priorities
can change depending on the patient,
even if it they have a similar problem).
Some patients in the short term truly
only want pain relief, and some just want
the ability to performed certain function.
Dr. Klein does a good job at siphoning
this out, and dictating the treatment to-
wards the patient’s needs in an evidence
based, and efficient manner. The test
aspect is quick and to the point. I learned
I don’t need to do every single shoulder
impingement test to figure out if some-
one has a shoulder impingement. Apply
pertinent tests depending on the sus-
pected condition, and go from there.
DR. ERIK
It was an absolute pleasure having [the
now Dr.] Jake in the clinic. There is a
saying that in order to learn, you should
first listen, then do, then teach, then
www.Cndoctor.ca
inspire. I took this as an opportunity to
learn, and develop myself both profes-
sionally and personally. I fondly recall my
internship at CMCC with Drs Decina
and deGraauw and I enjoyed having the
opportunity to “pay it forward.”
My teaching goal for Jake was to en-
courage the transition from academic
assessment and treatment to real world
assessment and treatment techniques
while allowing Jake to make decisions on
what he feels will work with his own
ethos. My experience and my academic
research has found that purely focusing
on orthopaedic testing as a stand-alone
assessment tool is largely ineffective, and
frankly not evidence-based (Cox, de-
Graauw, Klein; JCCA 2016). Having
said that, it does form the basis of an
assessment protocol that allows the prac-
titioner to grow further, but they have to
choose to do so. I gave Jake all of my
clinical pearls, my algorithms, and “tricks
of the trade” while keeping in mind he
still had board exams to complete and
encouraging him to keep his brain open
to all angles.
You need to assess, educate,
adjust, and do your rehab.
Jake excelled on all levels, showing
great competency, connecting with pa-
tients, and really gaining traction on
what will be required of him once he
completes his training. He finished with
467 subsequent visits under his belt,
which to me seems like it must be some
kind of record!
JAKE ‘THE INTERN’
I learned to always keep red flags, yellow
flags etc., in mind. I also became more
aware of applying the KISS principle:
“keep it simple silly.” What stuck with me
was the following concept: Abnormal
presentations of common conditions, are
more common, than common presenta-
tions of abnormal conditions. This has
brought me a long way with my clinical
intuition, and not fearing the worst, but
yet being prepared for it. The treatments
I have learned to execute are an expres-
sion of what we find during the testing.
Just because someone has PFPS, does
not mean to do soft tissue passes over
every muscle that influences the knee.
September/October 2021 Chiropractic and Naturopathic Doctor 17
Find the keys, and address them with
whatever tool you see fit. Using every test
and treatment modality available simply
is not practical. In the end of the day,
CMCC gives you a lot of tools, but not
all of them are practical in a real world
setting. For whatever reason, I know way
too much about Myasthenia Gravis, and
not enough about how to manage a torn
hip labrum. Its all about taking these
tools, appraising them, and figuring out
which are practical in a real clinical set-
ting. This will not only make you more
efficient, but it will save the patient’s time
and money down the long run. Re-
sults-driven solutions, in a patient cen-
tered, time orientated, and costly manner.
I saw so many things, from the nor-
mal, to the abnormal, including ectopic
pregnancy, severe hypertensive head-
ache and neck pain, and rare neurolog-
ical disorders. What was more impor-
tant, was seeing all of the different
subtle presentations and trajectories
that low back, hip, neck pain and all
MSK presentations can take so that I
can make the best decision for the pa-
tient AND be effective for them. People
aren’t cyborgs, they are people and we
need to treat the whole person.
DR. KLEIN
For me personally, I definitely grew as
a doctor. It was a lovely opportunity to
teach, AND be taught. We docs out in
practice for 15-20 years still have a lot to
learn, and this was the best opportunity
for me to do so. CMCC provided a
great deal of training and they were very
supportive and responsive. From a
practical stand-point, having an extra
set of hands and eyes in the office al-
lowed me to spread the work a little bit,
freeing me up to take care of some
business matters which made me a
more efficient business owner, and to
support my teams. So as a doc in the
field, if you’re wondering if this is for
you, and you enjoy the idea of paying it
forward. I also encourage CMCC to
make this a permanent option for their
clinical educational program. This is the
most patient-centred path forward.
FEATURE

PAIN RELIEF

PLATELET
RICH
PLASMA
What is it, and how it fits
into multidisciplinary
treatment plans

N
BY DR. CHRIS SPOONER, ND

aturopathic doctors began using PRP for

tendonosis and tendonitis in the late 1990s.
In the early 2000s, PRP essentially became
viewed as the logical next phase in regen-
erative injection therapy and began to be
adopted by practitioners previously trained
in prolotherapy.
Platelet rich plasma is being utilized in musculoskeletal
medicine with increasing frequency and effectiveness by
providers in multiple specialties. PRP has been success-
fully used in various specialties such as maxillofacial,
cosmetic, spine, orthopedic, podiatric and for general
wound healing.1,2
Soft tissue injuries treated with PRP include tendinopa-
thy, tendonosis, acute and chronic muscle strain, muscle
fibrosis, ligamentous sprains, and joint capsular laxity. PRP
has also been utilized to treat intra-articular injuries. Ex-
amples include arthritis, arthrofibrosis, articular cartilage
defects, meniscal injury, and chronic synovitis or joint in-
flammation.
The logic behind PRP is that platelets are the first to
arrive at the site of tissue injury, and thus have the potential
to release growth factors that play a critical role in
DR. CHRIS SPOONER ND, B.SC. is a North Okanagan naturopathic doctor with
Platelets are the first to arrive at the site of tissue injury and have the
potential to release growth factors that play a critical role in healing.
mediating healing. PRP essentially alters cell ratios, by re-
placing red blood cells which do not stimulate healing and
replacing them with platelets to release growth factors that
facilitate healing.
Stages of healing
Wound healing is a well-orchestrated and complex series of
events involving cell-cell and cell-matrix interactions, with
growth factors serving as messengers to regulate the various
processes involved.
Normal platelet activation leads to four necessary stages
of healing: Hemostasis, Inflammation, Proliferation, and
Remodeling. If any of these stages are incomplete – or if
Photo: © PAstudio / Adobe Stock

20 years of clinical experience. In his private practice, Paradigm Integrative
Medicine, Dr. Spooner works with patients looking for a balanced approach
to health care that combines conventional medicine with research informed
integrative approaches. Dr. Spooner has advanced certifications through the
College of Naturopathic Physicians of B.C., including prescriptive authority.
He has been a board member and vice chair of the College of Naturopathic
Physicians of British Columbia since 2008.
18 Chiropractic and Naturopathic Doctor September/October 2021
they proceed unabated – tissue homeostasis is disrupted,
and pain and loss of function may result.
With wounds, and also after surgical incisions, repair
begins with platelet clot formation, activation of the coagu-
lation cascade, and platelet degranulation with release of
growth factors. The inflammatory process is initiated by
migration of neutrophils and subsequently macrophages to
www.Cndoctor.ca
 POST PRP EXERCISE AND
PHYSIOTHERAPY PROTOCOL

The first 48 hours

0-24 HOURS
• Avoid NSAIDs and other • Rest, and avoid loading of the
anti-inflammatory drugs 3 joint and structures where PRP

post PRP involves an days prior to procedure

• Ice and/or cold Laser
was administered
• Light movement

inflammatory immediately following

procedure
• REST

response that should 24-48 HOURS

• Avoid NSAIDs and other (immobilization during sleep if

be monitored to anti-inflammatory drugs

• Avoid ice unless absolutely
needed
needed)
• LIGHT soft tissue to PRP-
treated area and surrounding

ensure that it is not • Avoid weight-bearing or loading

activities
tissue
• Gentle passive range of motion

overly vigorous. Keep active range of motion

gentle and limited
• REST

DAY 3 THROUGH DAY 7

the wound site. Activated macrophages release multiple (BEGINNING THE REGENERATIVE PHASE)
growth factors, including transforming growth factors- • Avoid NSAIDs and other reached by end of 1st week)
and - (TGF-, TGF-), PDGF, interleukin-1 (IL-1), and anti-inflammatory drugs (3X/wk)
fibroblast growth factor (FGF). Shortly thereafter collagen • Begin myofascial release to • Light mobilization to any joint
synthesis begins. This process leads to an early increase in hypertonic muscles and any restrictions (3X/wk)
wound breaking strength, which is the most important scar tissue surrounding injury • Light Proprioception/joint
wound healing parameter of surgical wounds, followed by (3X/wk) stability exercises to
epithelization and the ultimate remodeling process.2 • Ice and electrical muscle associated joints (3X/wk)
Multiple studies have demonstrated a role for plate- stimulation (3X/wk) • Light stretches to shortened
let-rich plasma (PRP) in accelerating and facilitating re- • Gentle passive/active range of muscles (3X/wk)
sponse to injury through enhanced cellular or molecular motion (full ROM should be
activity.1,4–19 Blood plasma and platelets are responsible for
hemostasis, while leukocytes and activated platelets me- WEEK 2 THROUGH 4 (REGENERATIVE PHASE)
diate inflammation, and growth factors derived from • Avoid NSAIDs and other associated joint (2-3 X/wk)
platelet α-granules influence tissue regeneration. Specifi- anti-inflammatory drugs • Continue proprioceptive
cally, the leukocyte content of PRP is thought influence • Continue myofascial release to exercises
the inflammatory phase, while angiogenic and mitogenic hypertonic muscles and any • Stretch and foam roll shortened
growth factor concentrations are believed to aid tissue scar tissue surrounding injury and hypertonic muscles
regeneration.20 (3/wk) • Patient returns for follow-up
The goal of any tissue regeneration therapy is to facil- • Grade 4-5 mobilization to any visit with doctor who
itate the development of a well-organized extracellular joint restrictions (3X/wk) administered PRP injection at
matrix capable of attaining the mechanical performance • Ice and electrical muscle the end of 4th week
and functionality of non-injured tissue. Therefore, it is stimulation (3/wk)
imperative to characterize the molecular constituents of • Functional exercises to stabilize
these therapies when evaluating their efficacies. The cel-
lular response to PRP is influenced by the composition WEEK 5 TO 8 AND FOLLOWING WEEKS AS NEEDED
of the PRP, including the relative concentrations of plate- (FUNCTIONAL PHASE)
lets, white blood cells (WBCs), fibrinogen and fibrin, and • Begin to use natural anti- exercises (3X/wk)
growth factors. inflammatory/NSAID’s (as • Continue progressing through
It must be mentioned that one of the major limitations directed by doctor) proprioceptive exercises
in the field of PRP is that most studies include PRP for- • Myofascial release to hyper- • Begin gait, biomechanical,
mulations obtained by different methods, with different tonic muscles and scar tissue sport-specific training
compositions and characteristics, and therefore the out- surrounding injury (2X/wk) • Stretching and foam rolling as
comes could be different depending on the product used, • Grade 4-5 mobilization to any directed by doctor
even though they are all called PRP. This makes the joint restrictions (2X/wk) • Follow-up visit with injection
comparison among results of different studies often con- • Ice and electrical muscle doc at the end of 8th week
fusing and contradictory.12 stimulation (as needed) • Return to activities when fully
PRP preparation demonstrate great inter-product var- • Continue progressing through functional or as directed by
iability based on the device and preparation methods.21 full weight-bearing functional doctor
Preparations of PRP can vary in many areas, including
www.Cndoctor.ca September/October 2021 Chiropractic and Naturopathic Doctor 19
FEATURE
platelet concentration, number of white blood cells, pres-
ence or absence of red blood cells, and activation status of
the preparation. It is beyond the scope of this article to go
into a detailed discussion, but at the very least, the physician
who performed the PRP injection should be able to the the
other members of the care team 1) The percent red blood
cell concentration; 2) The percent increase in platelet con-
centration; 3) White blood cell percentage; 4) If the PRP
was activated and with what; 5) Volume of injection, and 6)
Whether or no ultrasound guidance was used
Integrating PRP into Multidisciplinary Care:
Post PRP Rehabilitation
In my experience, multidisciplinary post PRP care can
greatly enhance the outcome and I recommend all a patients
consider it. I recommend that PRP be considered after
appropriate first line therapies have been exhausted prior to
the utilization of these PRP matrix grafting protocols. These
include relative rest, appropriate bracing and kinesiotaping,
evaluation of kinetic chain mechanics, and physical therapy
– with or without eccentric loading protocols.
The first 48 hours post PRP involves an inflammatory
response that should be monitored to ensure that it is not
overly vigorous. In my experience this intensity of the in-
flammatory response is determined by the extent of inflam-
mation before the procedure and by the composition of the
PRP graft. The following is the protocol that I recommend
to my patients for post PRP care.
Summary
Platelet-rich plasma has been safely and effectively em-
ployed in many areas, including orthopedics, sports medi-
cine, dentistry, neurosurgery, ophthalmology, urology,
wound healing, cosmetics, cardiothoracic, otorhinolaryn-
gology and maxillofacial surgery. Research has expanded
our knowledge of the role of PRP in the wound healing
process. Initially, it was thought that platelets were used
solely to assist in clotting. However, it has become clear that
platelets are also responsible for releasing many bioactive
proteins and growth factors responsible for recruitment of
macrophages, mesenchymal stem cells, and osteoblasts,
which not only promotes necrotic tissue removal, but also
improves the quality of tissue regeneration and the healing
process. Based on this principle, platelets are now used in
clinical practice to stimulate cells responsible for healing
and increase healing potential and has demonstrated sig-
nificant promise in pain medicine and in treatment of
chronic injury.
For the list of references, please visit cndoctor.ca/
PRPinjectiontherapy

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 COVER STORY
CONTINUED FROM PAGE 7
controls and to patients with Down
syndrome, Parkinson’s disease and
Huntington’s disease (Blusztain et al.,
1990).
Citocholine is another treatment
option. Citicoline exhibits neurore-
generative effects and activates neuro-
genesis, synaptogenesis, and angio-
genesis and enhances neurotransmitter
metabolism (Martynov & Gusev,
2015). In the IDEALE study testing
for effectiveness and safety of citocho-
line by Cotroneo et al. (2013), 1000mg
of citocholine was administered to 349
patients with mild cognitive impair-
ment. Results found that there were
positive results in the treated group in
comparison to the control group
based on MMSE scores 9 months into
the study (Cotroneo et al., 2013).

DHA
DHA is a component of omega-3 fatty acid which is found in
fish oils and plays a role in neuron development. DHA sup-
plementation significantly promotes neurite growth, synapto-
genesis, and increases the levels of pre- and post-synaptic
proteins involved in synaptic transmission and LTP thereby
improving synaptic function (Cao et al., 2009). A double-blind,
randomized controlled trial by Yurko-Mauro et al. (2010)
showed that in 485 subjects, those supplemented with 900mg
daily of DHA had improved learning and memory function.
Considerations
Besides relying on nutraceutical interventions, there are life-
style habits that are foundational to our cognitive health.
Ideally, these are considerations that need to be made along-
side or prior to nutraceutical interventions. These lifestyle
changes influence a major neurotrophin.
One of the most extensively studied neurotrophins is
Brain-derived neurotrophic factor (BDNF). In general, the
functions of BDNF are related to control of development of
neuronal and glial cells, as well as activity-dependent regula-
tion of the synaptic structure and its maintenance, which are
critical for memory and cognition (Kowianski et al., 2018). In
other words, BDNF has a central role in brain plasticity (Ha-
kansson et al., 2017).
There are many ways to upregulate BDNF. Basic activities
include physical activity and sleep.
Physical activity has been shown to affect BDNF levels. A
study done by Hakansson et al. (2017) found that even a
single 35-minute session of physical exercise had a larger im-
Photo: © Daisy Daisy / Adobe Stock
affected our ability to encode memory for regurgitating in
exams, especially with long term memory. In a study done by
Fan et al. (2019), participants with short sleep duration (de-
fined as less than six hours) had decreased BDNF levels
compared with the healthy controls who slept greater than six
hours. There is definitely a need to work with the foundations
of health including optimizing sleep to improve cognition and
BDNF levels.
Although these are interventions that show evidence that
there are benefits to addressing cognitive decline, the primary
care practitioner must first conduct a thorough assessment of
the patient. Understanding which cognitive domain is affected
can provide better insight on which parts of the brain are af-
fected and if it truly is cognitive impairment (eg. Focus,
concentration and working memory and the frontal lobe can
also be misinterpreted as dementia).
In addition to neurotrophic factors, there is a need to un-
derstand that for any chronic condition there are two sides of
the condition. In this case, fortifying synaptogenesis through
trophic factors and supplementation is one approach, but only
if underlying processes that impede the neuronal health have
been addressed. A holistic, functional approach in addressing
cognitive decline is warranted; factors that contribute to the
expression of B-secretase in creating insoluble amyloid plaque
needs to be addressed such as chronic inflammation, dysgly-
cemia and hyperinsulinemia, toxins and heavy metals, cardi-
ovascular health and anemia can impede on the proper
functioning of the brain. By only primarily supplementing
patients with trophic agents only depicts one part of the pic-

pact on serum BDNF than cognitive training or mindfulness
practice. Physical activity is probably the biggest proponent to
cognitive health and cannot be stressed enough!
Sleep also has a significant contribution to BDNF. Chronic
sleep deprivation has been found to be associated with down-
regulation of hippocampal BDNF (Rahmani et al., 2019). In
reading this, there may be some memories of those days back
in studying in medical school; these nights of deprived sleep
www.Cndoctor.ca
ture; without addressing the factors that impede on brain
health, we are not taking a holistic, functional approach in
optimizing cognitive health.
For the list of references in this story, please visit cndoctor.ca/
neurotrophic-dementia
September/October 2021 Chiropractic and Naturopathic Doctor 21
THE BACK PAGE

BUSINESS MINDSET

Trending topics
Get ready for the economic boom BY DR. ELIAS MARKOU, ND

T
he other day I had a favorite
client of ours reach out and
asked if we were still open
during the pandemic. I’d
stressed to them that we’ve
been open since June 12, 2020 and we
had continued seeing patients through
the pandemic lockdown. They were
excited to hear that we were open and
stressed to me that they had not re-
ceived any treatments over the last year
and we’re excited to come and join us
for their first treatment in a long time
at the clinic. This got me thinking, if
this client was one who hadn’t received
a treatment in the last year and was
very excited to come to resume treat-
ment, then how many more patients
were out there waiting to come back?
So this posed a very interesting
question for me, when the pandemic
is over and we’ve reached vaccination
herd immunity and all of the busi-
nesses are finally open, what will this
mean for clinics across Canada who
offer alternative medicine like natur-
opathic care, chiropractic, massage,
osteopathy and any other alternative
care? An interesting idea jumped into
my mind: There is a large cohort of
patients out there who are desperately
craving practitioner care and attention
which they have not received for a
year. This got me to conclude that
health clinics across Canada should
get ready for an economic boom in
2022 that we have not seen for many
years. We will see patients flocking to
clinics in droves looking for care,
hands-on care, from health profes-
sionals in the alternative health care
space.
DR. ELIAS MARKOU, RHN, R.ACU, ND is one very busy naturopathic doctor. He is in private practice move forward. So it is imperative we
in Mississauga, Ontario and is the clinic director of pureBalance Wellness. Dr. Markou (ND) has been have all of our systems in place. We
a naturopathic doctor for 18 years and has conducted over 100,000 patient visits during this period. should be prepared to tackle every
Dr. Markou is a writer and blogger who is regularly featured in the media. Contact him at drmarkou@ patient and their needs post pandemic.
mypurebalance.ca
22 Chiropractic and Naturopathic Doctor September/October 2021
Conventional medicine an influx of patients looking for care in
stepped back the coming months and years. Patients
It is no secret that during the pandemic will be looking for regular massages,
the medical profession stepped back monthly osteopathic visits, alternative
from treating their patients. They only blood work recommended by naturo-
took medical emergency appointments. pathic doctors, chiropractic doctors
Many of our clients told us that it was helping people get back on track as they
tough to get an appointment with their resume regular activity dealing with their
medical doctor, often they had limited aches and pains. What’s interesting is
zoom calls for their clients. Many med- that many clinics have pivoted and gone
ical doctors would not have in-person online. The future of online practice will
visits happening at their clinics,and it be short-lived. Patients will be looking
was recommended that patients go to for hands-on care and not ZOOM
ER when issues arose. We know that the health care. For those clinics that have
hospital system was dealing with many survived the pandemic lockdown, pa-
COVID patients who were reporting tients will be seeking clinics that treat in
there with breathing complications. person – they want acupuncture, hands
Doctors at hospitals were overwhelmed on massage care, a chiropractor that will
with patients with emergency issues adjust. I predict that clinics will be seeing
like cardiovascular episodes, cancer new patient loads, old patients that re-
and with COVID. The biggest issues quire care, and many new patients that
we heard were patients were asked by are looking towards natural alternative
government to stay home. Many of medicine to help them with their medi-
those patients interpreted that request cal needs. All in all there will be a dra-
as meaning stay home, unless they has matic uptick in patient numbers in many
something very serious. Routine blood clinics across Canada.
lab visits became confusing and com-
plicated for patients – they had to book Get ready for the boom
visits online weeks before I encourage you all in the next
their blood draws. Nowhere few months leading up to the
in the medical conventional We should be end of 2021 to sit down and
system could you just show seeing an evaluate your marketing plan,
up anymore for a visit. This influx of the systems you have in place,
created a lot of anxiety in patients and the staff and professionals
patients when they could not looking for that are ready to deliver care.
address their health con- care in the As soon as we return back to
cerns. We observed during coming normalcy post pandemic, we
this time that patient visits months and should be ready for the eco-
and patient numbers did years. nomic boom. I see these as
increase significantly. exciting times, our professions
If my observation and hy- will be under the microscope,
pothesis is correct, we should be seeing our alternative professionals will be
asked to do a lot from the public as we
Get ready for the boom!
www.Cndoctor.ca
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