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9
14

16

Contents 6 Cover story: The heart-brain connection Columnists

Hypertension is more than just heart health
BY DR. ROMI FUNG, ND 14 Business talk
BY DR. ANTHONY LOMBARDI, DC
9 Chronic low back pain and bracing
An evidence-based case report 19 Practice points
BY VICTORIA MCINTYRE, DEREK KONOPSKI, BY DONALD QUINN DILLON, RMT
AND DR. PETER EMARY, DC
22 The X-Files
16 Stay young BY DR. MARSHALL DELTOFF, DC
Aging: more benefits of exercise
BY DR. DON FITZ-RITSON, DC

20 One size doesn’t fit all

Optimizing diet, health and weight through
personal genetics Departments
BY DR. PENNY KENDALL-REED, ND
4 From the editor
Photo: Orapun; salim138; pingebat/Adobe stock

www.Cndoctor.ca September/October 2022 Chiropractic and Naturopathic Doctor 3

UPFRONT | From the editor

September/October 2022
Volume 27, Number 5

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help as soon as possible were some of the main points I walked away with
from the session, as well as the fact that there’s not a one-size-fits all
approach. I know all of you see that everyday in practice. The articles
shared in this issue definitely exemplify that.
Our cover story unravels connections between the heart and brain (page
6), “Stay young” (page 16) highlights research on exercise and how it
impacts aging in a multitude of ways, and the aptly named “one size doesn’t
fit all” (page 20) uncovers how genetics can help with diet, health and
weightloss.
What’s an example of a time when you realized life wasn’t a “one size fits
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COVER STORY
RESEARCH
The heart-brain
connection
Hypertension is more
than just heart health
by dr. romi fung, nd
A
ccording to the 2020 report by Statistics
Canada, Alzheimer’s dementia deaths in
Canada were ranked 9th for the leading
cause of death. In comparison, cerebrovas-
cular diseases were ranked as the 5th
leading cause of death in Canada. It is
interesting to observe that there is a likely
correlation between Alzheimer’s dementia and cardiovascu-
lar disease, especially pertaining to the brain.
Vascular dementia is a decline in cognitive ability caused
by conditions that reduce blood flow to the brain and its
specific regions. As a result, this deprives the neural cells of
oxygen and nutrients (Alzheimer’s Association, n.d.).
Vascular dementia is the second most common type of
dementia, with Alzheimer’s disease being the most common
(Alzheimer’s Society, n.d.). About 5-10% of people with
dementia have vascular dementia alone; however, many
experts believe that vascular dementia remains underdiag-
nosed even though it is recognized as common. It can be
very common if you refer to the number of cardiovascular
diseases that are prevalent that could be the underlying
factors to vascular dementia and potentially Alzheimer’s
Disease.
Looking at cardiovascular disease by the numbers, nearly
1 in 4 aged 20-79 had hypertension 140/90 in a report from
DR. ROMI FUNG, ND, M.SC, PH.D (CAND.) is a naturopathic physician
practicing in Richmond, BC. A graduate of the Canadian College of
Naturopathic Medicine, Romi helps patients living with dementia improve their
quality of life by taking an integrative and functional approach; he believes
that what happens in the body can also happen in the brain and there are
several biochemical connections from chronic diseases correlated to cognitive
decline. On top of his practice, Romi is currently a Ph.D. candidate in Aging
and Health at Queen’s University, an Adjunct Clinical Faculty, and Academic
Faculty teaching Traditional Asian Medicine at the Canadian College of
Naturopathic Medicine – Boucher Campus. DrRomiFungND.com
6 Chiropractic and Naturopathic Doctor September/October 2022
According to the CDC, only one in four adults with hypertension have
their condition under control.
2012-2015 (Statistics Canada, 2020). According to the
Centre for Disease Control and Prevention (CDC), only
one in four adults with hypertension have their condition
under control (CDC, 2022). With the uprise in cardiovas-
cular diseases that coincide with the uprise in dementia
cases, could they potentially be more correlated? Cardio-
vascular disease was associated with a double risk of demen-
tia, and more than three-fold increased risk of vascular de-
mentia (Eriksson et al., 2010).
Current conventional measures still focus on the idea of
treating dementia using antipsychotics and pharmaceuticals
without looking at underlying factors. Rather than putting
the entire emphasis on the brain itself, a clinician should
identify underlying factors that contribute to the brain, in-
cluding cardiovascular health. The brain is a very vascular
organ; although it consists of 2% of our body weight, the
brain receives 20% of the body’s blood supply (Dafny,
2020).
There is growing evidence that there is a significant cor-
relation between high blood pressure and incidence in de-
Photo: paul_craft/Adobe stock
mentia. In the Honolulu-Asia Aging Study where 3734
Japanese-American men were observed over a couple dec-
ades, researchers found that for every 10mmHg increase in
systolic blood pressure, there was a nine percent increase in
risk of cognitive impairment (Gelber et al., 2012). In other
words, those who suffer from Stage 2 hypertension, or have
www.Cndoctor.ca

blood pressure greater than 140/90mmHg, is at an approx-
imate 20% increase risk of developing cognitive impairment
if left untreated.
Cardiovascular disease can be highly prevented; treating
for cardiovascular disease can also prove to benefit our
cognitive health which further adds to the interconnected-
ness of our human organ systems. A meta-analysis con-
ducted by Ding et al. (2019) referenced over 31,000 older
adults aged 55+ that were treated for hypertension. Regard-
less of the antihypertensive medication, risk of dementia and
developing Alzheimer’s disease were reduced by 12% and
16%, respectively (Ding et al., 2019).
It is interesting to note that screening for hypertension is
very often underperformed. According to the World Health
Organization (WHO), an estimated 46% of adults are una-
ware they have high blood pressure. In addition, less than
half of adults with hypertension are properly diagnosed
(WHO, 2021). Ensure that when seeing the older adult
patient, to have a thorough assessment. Early detection,
adequate first-line treatment and discussions of lifestyle
factors are key.
Naturopathic approaches to hypertension
Controlling high blood pressure can reduce damage to the
capillaries and vasculature of the brain. It is no reason why
hypertension can be termed the ‘silent killer,’ as it may
pertain to mortality, but also our brain health. There are
many lifestyle recommendations when it comes to con-
trolling high blood pressure that clinicians need to be
www.Cndoctor.ca
discussing with their patients first and foremost before re-
sorting to monotherapies including pharmaceuticals and
nutraceuticals.
Salt reduction: Probably one of the first things that one
would think of about high blood pressure is reducing salt.
Salt makes it more difficult for the kidneys to remove water,
which contributes to water retention in the blood and put
more pressure on the heart and blood vessels. A meta-anal-
ysis in 2013 gathered a modest decrease of 5.8mmHg in
systolic blood pressure from reducing six grams of salt intake
after adjusting for age, ethnicity and pre-existing blood
pressure status (He et al., 2013).
There are a couple considerations to sodium. With the
convenience of processed and packaged foods, consumers
do not realize how much sodium is contained in these foods
even when they’re avoiding added sodium. Consuming a
whole foods diet will have better control over how much
sodium is consumed.
According to the WHO,
an estimated 46% of
adults are unaware they
have high blood
pressure.
Potassium deficiency: Potassium may also be a factor
in hypertension as it aids in the removal of sodium through
urine, and also eases the tension in the blood vessels (Aburto
et al., 2013). Could it be excess sodium, or a potassium
deficiency? A systematic review by Aburto et al. (2013)
compiled 22 randomized control trials and 11 cohort stud-
ies and observed a 7.16mmHg reduction in systolic blood
pressure when 90-120mmol/day of potassium was con-
sumed.
Potassium-rich foods include bananas, dates, dark choc-
olate, avocadoes, sweet potatoes and root vegetables. (Lan-
ham-New & Lambert, 2012). There is the idea of the sodi-
um:potassium relationship in food to consider as well. Food
groups that have a high sodium:potassium ratio, meaning
foods much higher in sodium than their potassium counter-
part, are processed meats, white bread, and condiments
(O’Halloran et all, 2016).
DASH Diet: Both sodium reduction and potassium in-
take ratio are elements of the Dietary Approaches to Stop
Hypertension (DASH) diet, as well as incorporating foods
higher in calcium and magnesium (Bensaaud et al., 2020).
Appel et al. (1997) has observed participants undergoing
the DASH diet to have their systolic and diastolic blood
pressure reduced by 11.4 and 5.5 mmHg, respectively.
Nitric Oxide Production: Nitric Oxide (NO) helps
support endothelium-depend vasodilation to maintain nor-
mal blood pressure (Sweazea et al., 2018). There are a few
ways to generate NO. Dietary nitrates can contribute to NO
September/October 2022 Chiropractic and Naturopathic Doctor 7
COVER STORY
generation via the nitrate-nitrite-NO
pathway (Sweazea et al, 2018). Besides
the common beetroot, vegetables that
are particularly rich in nitrates include
green leafy vegetables such as spinach
and lettuce, as well as fennel, radishes,
Chinese cabbage and parsley (Sweazea
et al., 2018). .
Physical Activity: An important
way to produce NO is physical exercise.
Moderate-intensity aerobic exercise
augments endothelium-dependent
vasodilation in humans through the
increased production of nitric oxide
(Goto et al., 2003). Moderate intensity
refers to approximately 50% of one’s
VO2 max (Goto et al., 2003). It is in-
teresting to note that Goto et al. (2013)
suggests that high-intensity exercise,
indicated as 75% of VO2 max, possibly
increases oxidative stress.
Walking is a low-cost activity that has
shown benefits in blood pressure. In a
Cochrane report by Lee et al. (2021),
there is moderate evidence suggesting
that walking reduces systolic blood
pressure by 4.11mmHg on average in
participants aged 40 and under.
Nutraceuticals can be supplemental
in supporting a healthy blood pressure.
Magnesium: A meta-analysis by
Dibaba et al. (2017) of 11 RCTs show
that magnesium supplementation had
significantly lowered blood pressure,
both systolic and diastolic values. The
RDA requirement for magnesium for
adults aged 18 and over is approxi-
mately 400mg (National Institutes of
Health [NIH], 2022).
Garlic: There are two trials that
showed a mean reduction of systolic
and diastolic blood pressure by 10-
12mmHg and 6-9mmHg, respectively
(Stabler et al., 2012). Garlic has been
shown to be similarly as effective as
first-line antihypertensive medications.
The active compound in garlic is alli-
cin, or S-allycysteine, which likely ex-
hibits prostaglandin-like effects
(Rashid & Khan, 1985). In a dose-re-
sponse trial by Reid et al. (2013), A
dose of 480mg of aged garlic extract
containing 1.2mg S-allycysteine low-
ered systolic blood pressure by
12mmHg in over 12 weeks.
Summary, implications in
practice, and future
considerations
It is very common to see a patient work
8 Chiropractic and Naturopathic Doctor September/October 2022
“Despite collaboration,
screening for the basics has
become overlooked”
with several health care practitioners
for various conditions. Despite the
collaboration between professionals,
screening for the basics has become
overlooked. Just screening patients
even 18 and over with blood pressure
can make a difference. If blood pres-
sure is not well maintained, there are
many considerations to take.
There is current research applying
changes of the vasculature in the brain
also reflecting in the eyes. A 2019 study
in Ophthalmology Retina showed that
there are small vessel changes in the
retina of patients with later stages of
dementia compared to healthy controls
using Optical Coherence Tomography
Angiography (Lee et al., 2020). Know-
ing that there are changes in vascula-
ture that compromises the brain, this
could be a potential screening tool for
dementia.
Cardiovascular disease and dementia
appear to have an intricate connection.
Empowering patients to self-manage
their blood pressure, along with other
factors of cardiovascular health, can be
a very powerful attempt in mitigating
our risk for cognitive decline.
REFERENCES
Aburto, N. J. et al. (2013). Efefct of increased potassium intake
on cardiovascular risk factors and disease: systematic review and
meta-analyses. BMJ. doi: https://doi.org/10.1136/bmj.f1378
Alzheimer’s Association. (n.d.). Vascular dementia. Retrieved
from: https://www.alz.org/alzheimers-dementia/what-is-
dementia/types-of-dementia/vascular-dementia/
Alzheimer’s Society. (n.d.) What is vascular dementia? Retrieved
from: https://www.alzheimers.org.uk/about-dementia/types-
dementia/vascular-dementia
Appel, L. J., Moore ,T. J., Obarzanek, E., Vollmer, W. M., Svetkey,
L.P., Sacks, F.M., et al. (1997). A clinical trial of the effects of
dietary patterns on blood pressure. New England Journal of
Medicine 336(16):1117-24.
Bensaaud, A. et al. (2020). Dietary Approaches to Stop
Hypertension (DASH) for the primary and secondary prevention
of cardiovascular diseases. Cochrane Database of Systematic
Reviews. https://doi.org/10.1002/14651858.CD013729
Centre for Disease Control [CDC]. (2022). Hypertension Statistics
and Maps. Retrieved from: https://www.cdc.gov/bloodpressure/
statistics_maps.htm
Dafny, N. (2020). Overview of the Nervous System. Retrieved
from: https://nba.uth.tmc.edu/neuroscience/m/s2/chapter01.
html
Dibaba, D. T., Xun, P., Song, Y., Rosanoff, A., Shechter, M., & He,
K. (2017). The effect of magnesium supplementation on blood
pressure in individuals with insulin resistance, prediabetes, or
noncommunicable chronic diseases: a meta-analysis of
randomized controlled trials. The American journal of clinical
nutrition, 106(3), 921–929. https://doi.org/10.3945/
ajcn.117.155291
Ding, J., et al. (2019). Antihypertensive medications and risk for
incident dementia and Alzheimer’s disease: a meta-analysis of
individual participant data from prospective cohort studies.
Lancet Neurology. 2019;pii: S1474-4422(19)30393-X. doi:
10.1016/S1474-4422(19)30393-X.
Eriksson, U. K., Bennet, A. M., Gatz, M., Dickman, P. W., &
Pedersen, N. L. (2010). Nonstroke cardiovascular disease and
risk of Alzheimer disease and dementia. Alzheimer disease and
associated disorders, 24(3), 213–219. https://doi.
org/10.1097/WAD.0b013e3181d1b99b
Gelber, R. P., Launer, L. J., & White, L. R. (2012). The Honolulu-
Asia Aging Study: epidemiologic and neuropathologic research
on cognitive impairment. Current Alzheimer research, 9(6),
664–672. https://doi.org/10.2174/156720512801322618
Goto, C. et al. (2003). Effect of Different Intensities of Exercise on
Endothelium-Dependent Vasodilation in Humans. Circulation;
108: 530-535.
He, F. J. et al. (2013). Effect of longer term modest salt reduction
on blood pressure: Cochrane systematic review and meta-
analysis of randomised trials. BMJ. doi: https://doi.org/10.1136/
bmj.f1325
O’Halloran, S. A., Grimes, C. A., Lacy, K. E., Campbell, K. J., &
Nowson, C. A. (2016). Dietary Intake and Sources of Potassium
and the Relationship to Dietary Sodium in a Sample of Australian
Pre-School Children. Nutrients, 8(8), 496. https://doi.
org/10.3390/nu8080496
Lanham-New, S. A., Lambert, H., & Frassetto, L. (2012).
Potassium. Advances in nutrition (Bethesda, Md.), 3(6), 820–
821. https://doi.org/10.3945/an.112.003012
Lee, J. Y. et al. (2020). Optical coherence tomography
angiogrpahy as a potential screening tool for cerebral small vessel
diseases. Alzheimer’s Research & Therapy. https://doi.
org/10.1186/s13195-020-00638-x
Lee, L. L., et al. (2021). Walking for hypertension. Cochrane
Database of Systematic Reviews. DOI: 10.1002/14651858.
CD008823.pub2.
National Institutes of Health. (2022). Magnesium. Retrieved
from: https://ods.od.nih .gov/factsheets/Magnesium-
HealthProfessional/
Rashid, A., & Khan, H. H. (1985). The mechanism of hypotensive
effect of garlic extract. JPMA. The Journal of the Pakistan Medical
Association, 35(12), 357–362.
Ried, K., Frank, O. R., & Stocks, N. P. (2013). Aged garlic extract
reduces blood pressure in hypertensives: a dose-response trial.
European journal of clinical nutrition, 67(1), 64–70. https://doi.
org/10.1038/ejcn.2012.178
Stabler, S. N., et al. (2012). Garlic for the prevention of
cardiovascular morbidity and mortality in hypertensive patients.
Cochrane Database of Systematic Reviews. DOI:
10.1002/14651858.CD007653.pub2
World Health Organization [WHO]. (2021). Hypertension.
Retrieved from: https://www.who.int/news-room/fact-sheets/
detail/hypertension
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 FEATURE
PATIENT CARE
CHRONIC LOW BACK
PAIN AND BRACING
C
hronic low back pain
(CLBP) is one of the
most widespread mus-
culoskeletal disorders
experienced by individ-
uals worldwide. The
lifetime prevalence of
LBP is reported to be as high as 84%,
and the prevalence of CLBP is approx-
imately 23%.(1)
Causes of CLBP can be complex
with many possible mechanisms. The
prevalence of CLBP in adults has in-
creased by more than 100% in the last
decade and continues to increase dra-
matically in the aging population, af-
fecting both men and women in all
ethnic groups.(2) Chiropractors serve
an important role in assisting patients
with regaining motion and functional-
ity, in turn allowing patients’ bodies to
heal themselves and improve or prevent
pain naturally. The majority of chiro-
practors use “Diversified Technique,”
or High-Velocity Low-Amplitude
(HVLA) spinal manipulation, to treat
musculoskeletal pain and dysfunction.
(3)
Other common forms of chiropractic
interventions for managing patients
with CLBP include soft-tissue manip-
Photo: anut21ng Stock/Adobe stock
ulation and mobilization, Cox Technic,
Graston, Gonstead, and bracing with
lumbar orthoses. Back bracing is often
VICTORIA MCINTYRE and DEREK KONOPSKI are 3rd-year chiropractic students at D’Youville University
in Buffalo, New York. DR. PETER EMARY is a chiropractor at the Langs Community Health Centre in
Cambridge, Ontario. He is a post-doctoral fellow at the Michael G. DeGroote National Pain Centre at
McMaster University, and he also teaches in the Chiropractic Department at D’Youville University.
www.Cndoctor.ca
An evidence-based case report
BY VICTORIA MCINTYRE (HBSC), DEREK KONOPSKI (BA),
AND DR. PETER EMARY (DC)
used for symptomatic management of
CLBP, despite there being limited
supportive evidence justifying its use.
(4)
The objective of this case report is to
analyze the effectiveness of bracing as
a pain-reducing treatment for CLBP.
CASE REPORT
A 48-year-old female presented with
chronic, intermittent LBP of three
years’ duration. The patient had re-
cently aggravated the pain after gar-
dening. She woke up the next day stiff
with muscular spasms and pain and
this progressed over three more days to
a sharp, stabbing pain. Provocative Chronic low back pain is a leading cause of
positions included bending at the trunk disability in the U.S.
into flexion and extension as well as
walking and standing. Palliative mech- symptoms. Both Yeoman’s and double
anisms were heating pads and non-ste- leg raise tests also provoked her pain.
roidal anti-inflammator y dr ugs Palpation revealed tenderness and joint
(NSAIDs) as well as sitting or lying restriction in the right and left L4-5
supine with her legs elevated. Her pain and L5-S1 facet joints. Neurologic
at the time of presentation was at 7/10 testing was normal bilaterally. Grade I
and she reported that the pain would spondylolisthesis was visualized on
wake her up at night. radiographs at L4 on L5. The history
The pain was described as a radiat- and physical exam findings revealed a
ing pain across the low back, but it did working diagnosis of an acute exacer-
not radiate down the patient’s legs. The bation of chronic, recurrent LBP with
straight leg raise, Hibb’s and Fabere’s bilateral lower lumbar facet joint syn-
orthopedic tests were negative. Kemp’s drome and underlying grade I L4-5
test and lumbar range of motion, espe- spondylolisthesis.
cially in rotation, provoked her (Note: This case report was written as
part of a third-year chiropractic course,
Evidence-Informed Chiropractic Practice,
at D’Youville University. As such, the re-
port herein was based on a patient scenario
rather than an actual patient.)
September/October 2022 Chiropractic and Naturopathic Doctor 9
FEATURE
CLINICAL QUESTION
After being referred by her family phy-
sician for chiropractic treatment, the
patient in our case had inquired about
whether or not to purchase a back
brace to help with her CLBP. Her phy-
sician had prescribed NSAIDs
(Naproxen) and heat pad application,
but these only provided mild relief.
After analyzing the patient’s case his-
tory and clinical presentation, we
wanted to provide feedback for her on
whether or not a back brace would be
a good alternative treatment. To do
this, we utilized the following clinical
question: In a 48-year-old patient pre-
senting with chronic, recurring LBP
from lumbar facet joint syndrome and
L4-5 grade I spondylolisthesis, is brac-
ing the low back a more effective form
of treatment compared to not bracing
at reducing pain?
P (Patient) = 48-year-old female
with chronic, recurring LBP from
lumbar facet joint syndrome and
L4-5 grade I spondylolisthesis
I (Intervention) = Bracing
C (Comparison) = No bracing
O (Outcome) = Reduction in pain
LITERATURE SEARCH
A randomized controlled trial (RCT)
is the second highest level of evidence
for evaluating therapeutic modalities
(5,6)
(Figure 1). The database that was
used in our search was through the
National Library of Medicine (Pu-
bMed). Since the topic of interest was
about bracing and CLBP, the search
terms that were used were ‘chronic low
back pain’ and ‘bracing,’ initially using
the Boolean term ‘AND.’ As this
yielded 74 articles, we decided that
additional inclusion and exclusion
criteria were needed. We filtered our
search to ‘human trials,’ published
within the past ‘five years’; thus, articles
older than five years were excluded.
The age range of patients was filtered
to between ‘18 and 85 years.’ All articles
with children were excluded. In addi-
tion to these criteria, studies had to
include patients with uncomplicated
CLBP, so any articles that included
CLBP with radiculopathy, or had
symptomatic scoliosis were not se-
lected. We defined CLBP as LBP that
lasted greater than 12 weeks. We also
searched for systematic reviews, which
would have been a higher level of
10 Chiropractic and Naturopathic Doctor September/October 2022
research evidence than a single RCT,
but none were available. Our final
search yielded seven articles that were
specific to our PICO question.
The article chosen was an RCT from
2021 on lumbar bracing for CLBP by
Annaswamy et al.(4) RCTs are the most
appropriate study design for research
on therapeutic modalities, such as
lumbar bracing for CLBP, and is ulti-
mately why we chose this article, in
addition to the relevance and similari-
ties between the RCT and our clinical
case.
CRITICAL EVALUATION OF THE
EVIDENCE
Prior to utilizing lumbar bracing on our
patient as a therapeutic modality, the
article by Annaswamy et al.(4) was ana-
lyzed using the Critical Appraisal Skills
Program (CASP) for RCTs.(7) This
article was appraised with regard to its
validity, importance and applicability
to whether or not bracing for CLBP
would be a viable treatment plan for
our patient.
(i) Are the results of the RCT by
Annaswamy et al. valid?
The article by Annaswamy et al.(4) was
an RCT that analyzed the effectiveness
of back bracing as a treatment for pa-
tients with CLBP. The study’s main
objective was to analyze if there was a
beneficial effect of bracing uncompli-
cated CLBP in individuals with stable
degenerative spondylolisthesis. The
other objective was to see if there were
additional symptomatic benefits to
bracing CLBP in conjunction with ex-
ercise and education of lumbar stabili-
zation training. The study clearly fo-
cused on these objectives and
incorporated a specific population
based on the study’s inclusion and ex-
clusion criteria. The same intervention
was given to all participants, with the
exception of a semi-rigid back brace, the
Horizon 627 one-size adjustable lumbar
orthosis back brace,(4) which was also
given to participants in the treatment
group. All participants were randomized
into either a control or treatment group
using a computer-generated numbering
system, numbered 1-120, to help elimi-
nate systematic (confounding) bias.
Although some participants dropped
out before the end of the study, the
reasons they discontinued the trial were
STUDY DESIGNS
(IN DECREASING ORDER OF
EVIDENCE STRENGTH):
1. Systematic reviews and meta-
analyses
2. Randomized controlled trials
3. Cohort studies
4. Case-control studies
5. Case series
6. Case reports
7. Editorials and expert opinion
8. Animal research and laboratory
studies
Figure 1. Hierarchy of quantitative
research evidence (adapted from
Haneline [6]).
unremarkable (e.g., time constraints,
non-compliance) and accounted for. An
intention-to-treat analysis was also per-
formed. The treatment intervention was
pragmatic because each participant in
the trial was managed in a way that was
similar to how they would be managed
as if being treated in a chiropractic or
other clinical office setting. Moreover,
the treatment intervention was com-
pared to usual practice (i.e., education
and exercises) rather than to a placebo,
and patients in the intervention group
were also instructed to wear the brace
as needed for symptom relief. Partici-
pants and clinicians were not blinded in
this study due to the nature of the inter-
vention being provided (i.e., a back
brace is a visibly obvious intervention).
Nevertheless, based on the uniform
intervention, control of systematic bias,
and a clear concise research question,
we deemed the study valid.
(ii) Are the valid results of the RCT
by Annaswamy et al. important?
The valid results of this study are im-
portant, in terms of the negative differ-
ences at follow-up in patient-reported
outcomes between the control and
experimental groups. Descriptive sta-
tistics were used to analyze the baseline
sociodemographic characteristics of all
study participants, and outcome meas-
ures were collected at baseline, 6-week,
12-week and six-month time points in
both the control and experimental
groups. Both groups had similar socio-
demographic and clinical characteris-
tics at baseline. The study measured
the differences in outcomes at fol-
low-up as the standardized mean
www.Cndoctor.ca
difference (SMD) and found a statisti-
cally significant difference (p < 0.05)
between the treatment group and
control group over 6 months. The
treatment group reported increased
scores on the PDQ (Pain Disability
Questionnaire) (SMD, 0.84; p = 0.04),
the PROMIS (Patient Reported Out-
come Measurement Information Sys-
tem) (SMD, 0.78; p = 0.005), and the
EQ-5D (EuroQol 5-Dimension)
(SMD, 0.06; p = 0.01), compared to
the control group. This indicates statis-
tical significance for increased pain and
disability, as well as decreased func-
tionality and quality of life for the
treatment group versus the control
group. Effect sizes of 0.2 to 0.5 are
small/slight, 0.5 to 0.8 are moderate,
and >0.8 are large/substantial.(7) This
means that, based on the statistical
analysis from the study, bracing sub-
stantially increased pain and disability,
as well as moderately decreased func-
tionality and slightly decreased quality
of life. Because of the negative out-
comes observed in the intervention
group, this trial was halted early before
completion.(4)
(iii) Are the valid, important re-
sults of the RCT by Annaswamy et
al. applicable to this patient?
In the study by Annaswamy et al.,(4) the
clinical symptoms and qualifications
outlined in the RCT aligned with the
patient in our case. For instance, the
RCT’s inclusion criteria of age range
(18-85), CBLP with stable spondylolis-
thesis, and greater than 12 weeks of
LBP, were all shared by the subjects of
the RCT and our patient. The exclu-
sion criteria indicated no instability
with the spondylolisthesis, or any spinal
surgery. In addition, patients were ex-
cluded if they had used a lumbar brace
before, had taken part in rehabilitation
therapy programs within the last year,
or had a mental illness. All individuals
that were part of a vulnerable or mar-
ginalized population were also ex-
cluded.
The application of the tested inter-
vention would likely have yielded sim-
ilar outcomes in our CLBP patient
based on the participant similarities in
the clinical inclusion and exclusion
criteria from the trial. Therefore, the
results from the RCT were deemed
applicable to our patient.
www.Cndoctor.ca
APPLICATION OF THE EVIDENCE
In the RCT by Annaswamy et al.,(4)
bracing for CLBP substantially in-
creased pain and disability, as well as
moderately decreased functionality
and slightly decreased quality of life
among participants. These results
would guide our decision and recom-
mendations to the patient to avoid
using bracing as a therapeutic modality.
Instead, we would provide education
and exercise as treatments in addition
to standard chiropractic manipulation
for our patient. In addition, we would
communicate to the patient that all
subjects who participated in the study
by Annaswamy et al.(4) benefited from
both education about CLBP and add-
ing exercise into their daily routines to
manage or decrease pain. The lumbar
brace was passive and appeared to work
more as a reminder to individuals that
they had CLBP rather than provide a
helpful form of treatment. We would
stress the importance that bracing
works to keep the spine stiff and immo-
bile, which may do more harm than
good, whereas exercise is active and
more effective at managing pain.(8) The
patient’s preference for treatment
would likely be towards conservative
management rather than, for example,
cortisone injection or surgery, so exer-
cises and education on proper ergo-
nomics and mechanical lifting in her
garden and daily activities would be
recommended. Based on our critical
appraisal of the study by Annaswamy
et al.,(4) bracing for CLBP would not
be a treatment recommendation for
this patient.
EVALUATION OF THE OUTCOME
From the evidence presented in the
RCT by Annaswamy et al.,(4) bracing
as a treatment modality for CLBP
would not be expected to provide our
patient with any significant pain relief,
improvement in functionality, or in-
creased quality of life when compared
to not bracing. It can be expected that
if this treatment was applied to our
patient that she would have scored
equal to or worse at follow-up on out-
come measures such as the PDQ,
PROMIS, or EQ-5D. Had the patient
not been informed that bracing CLBP
has the potential for negative treatment
effects, her quality of life and function-
ality may have decreased. In addition,
September/October 2022 Chiropractic and Naturopathic Doctor 11
the patient’s NSAID intake may have
increased in order to compensate for
the potential increased pain and dis-
comfort after bracing with a lumbar
orthosis. After further analysis of the
results of this RCT, it would be an
informed decision between us and the
patient to not only avoid the recom-
mendation of bracing for CLBP, but it
would also be within reason to advise
her against pursuing this treatment
option on her own, using a “supermar-
ket” approach.(9) As a result, we would
recommend that other evidence-based
treatment options for CLBP be con-
sidered.(8)
SUMMARY
A 48-year-old patient presenting with
chronic, recurring LBP had a ques-
tion of whether or not she should
purchase a back brace to help reduce
her pain. Through our analysis of the
RCT by Annaswamy et al., (4) it was
determined that the utilization of a
back brace for CBLP would not be an
effective form of treatment. Instead,
education and exercise for the low
back, in conjunction with chiropractic
adjustments, would be recommended
as a multi-modal intervention for this
patient.
REFERENCES
1. Will JS, Bury DC, Mille, JA. Mechanical low back pain. Am Fam
Physician. 2018; 98(7):421-428.
2. Allegri M, Montella S, Salici F, Valente A, Marchesini M,
Compagnone C, Baciarello M, Manferdini ME, Fanelli G.
Mechanisms of low back pain: a guide for diagnosis and
therapy. F1000Res. 2016; 5:F1000 Faculty Rev-1530.
3. Clijsters M, Fronzoni F, Jenkins H. Chiropractic treatment
approaches for spinal musculoskeletal conditions: a cross-
sectional survey. Chiropr Man Therap. 2014; 22(1):33.
4. Annaswamy TM, Cunniff KJ, Kroll M, Yap L, Hasley M, Lin CK,
Petrasic J. Lumbar bracing for chronic low back pain. Am J
Phys Med Rehabil. 2021; 100(8):742-749.
5. Miller PJ, Jones-Harris AR. The evidence-based hierarchy: is
it time for change? A suggested alternative. J Manipulative
Physiol Ther. 2005;28(6):453-457.
6. Haneline MT. Evidence-Based Chiropractic Practice. Sudbury,
MA: Jones and Bartlett; 2007.
7. Critical Appraisal Skills Programme. CASP Checklists. Oxford:
CASP UK; 2022 [Available at: https://casp-uk.net/casp-tools-
checklists/ (Accessed August 22, 2022)].
8. Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P,
Owens DK; Clinical Efficacy Assessment Subcommittee of the
American College of Physicians; American College of
Physicians; American Pain Society Low Back Pain Guidelines
Panel. Diagnosis and treatment of low back pain: a joint
clinical practice guideline from the American College of
Physicians and the American Pain Society. Ann Intern Med.
2007; 147(7):478-491.
9. Haldeman S, Dagenais S. A supermarket approach to the
evidence-informed management of chronic low back pain.
Spine J. 2008; 8(1):1-7.
 SPONSORED
NSORED CONTENT CONTENT

Creating an
bservations in a new light
luxation: A case of mistaken identity?
R L

Evidence-Based Practice
r. George Roth

ntly searched the Internet for scientific Startling Observations:

ence to support chiropractic. Unfortu- Bone Enlarges with Injury!
A Scientific Basis for Spinal Manipulation
ly, most of the references emphasized While studying radiology in chiropractic
lack of scientific validation or measur- school, I noticed that the size of a structure on
By Dr. George B. Roth, DC, ND, CMRP
tcomes to support the basic tenets of one side of the body was often different than
fession. At best, there are a few studies its counterpart on the other side. For example, A Testable Hypothesis for a Molecular Origin of
monstrate a modest advantage for chi- the proximal femoral or humeral head, or the Fracture Resistance Figure 3, Pre-treatment: Femoral and
ic manipulationMyover Search
some prescription tibial plateau on one side was noticeably larger A tibial epiphyses enlarged, approximately 5
mm. compared to the right. *Note relative
tions for certain conditions, such as than the opposite
In my 40+ years in practice, I have continuously pur- side in the same individual. narrowing of the medial joint space.
ain. However, the overall impression is My professors were unable to shed any light on Before impact
sued the goal of creating an evidence‐based prac-
iropractic science is still relatively un- these findings. As an anatomy lab instructor at
tice, basedareononly
and that chiropractors quantifiable
mini- the andcollege
predictable
and from clinical
subsequent observations the shape of the bone is possible and appears
improvement.
ccepted as part of the health careIn other
team. words, I was determined
of cadaverous specimens, to I was able to confirm B allow for the restoration of the joint space an
find the for
e been a chiropractor holy grail
over of treatment:
40 years, 1. Precisely
these differences. At deter-
the time, these facts were As an impact biomechanical function, resulting in improve
mining
y in my career, I became theconvinced
underlying thatstructural
filed away,or and
biomechanical
it was only many years later that begins to
separate fibrils
healing of the entire joint complex.
ot achieving the
cause kindsof ofthe
results prom- which
problem, these early
was observations
producing the came to be viewed in a
hen I attended school. I also witnessed new light, based on my clinical research.
symptoms (pain and/or dysfunction). 2. Providing Subluxation:
f my colleagues becoming disheartened By carefully examining a better quality skel- C A Case of Mistaken Identity?
reproducible therapeutic
ng in practice. They had come into this interventions, which would NORMAL
etal model, which is cast from a real skeleton, MOLECULAR STRUCTURE RESTRICTED MOLECULAR STRUCTURE
The subluxation theory and the idea that bone
on with high produce
expectationsconsistent and measurable
and a sincere outcomes.
you can verify many of these same Flexible, Balanced
discrepan- Rigid, Expanded “go out of place” has long been questione
to help their fellowI knew that ifbutI could
humans, the confidently produce,
cies for yourself. Besides andthe examples of the Based on:
However, I believe that the entire premise ma
f treatments demonstrate
they were taught consistently
did not positive
femur, tibiaclinical
and improve-
humerus mentionedFigure 2:earlier,
Normal and Restricted Tensegrity Structure “The
be Architecture of Life”Scientific
a matter of mistaken identity. By this, I mea
to these expectations.
ment, both I and the patientawould close inspection
know that of wethewerespine can be very re- that the palpatory American
impression 1998of “misaligne
D
many of you, I pursued a long search vealing. Note the differences in the size (width, vertebra” may be the result of enlargement
on a path to recovery and resolution, rather than just
itional modalities to improve my results, depth and height of the articular processes) at part of the vertebral segment (see Figure
temporary
and give pain relief. Overvarious
the years,
levelsI throughout
have notedthe spine. one was able1 to explain these findings. It was only
After the impact
my outcomes me the confi- Figure is over lecular level. This explains above).many The of factthe thatstructural
many patients achiev
that most patients,
o be able to find and resolve my patient’s even when they were still in some
demonstrates these differences many in the years
size oflater that I encountered the scientific and bio-electric changes benefit observed
through in our clinical
chiropractic adjustment ma
4, 5
degree
ons. In this search, of blessed
I was discomfort,
to meetwouldthestay with the
articular courseofofthe atlas.
processes basisI for
contend
these changes. research (see: Figure 2).
be due to its influence on the actual structu
treatment,
researchers and clinicians because they were
from other that able to directlythese
on palpation, expe-areas of enlargement Figure 2: Microscopic Evidence of Bone of the osseous
Expansion with Injury, Paul Hansma Lab, Finally, I had a proven model for enlargement,
the structurealbeit of inadvertent
(cell biology, rience
biomedical engineering,
objective evidence ofmay be easily mistaken
improvement, such foras:a relative rotation or University of California, Berkeley, 2005. (With
edic medicine, osteopathy and physical A Sound Scientific Basis the body that appeared on the part of the practitioner. In my opinion,
to explain how tissue expands
improved ranges‐of‐motiontranslation and jointof stability,
the vertebral segment (see: Sub- permission from the author)
as Over the years, I was fortunate to meet several re- with injury at the cellular practitioners were made aware of the fact th
andalters
molecular levels. Re- of bone in th
ne). They were making amazing discov- luxation: A Case of Mistaken Identity, below). injury the shape and size
well as normalization of posture, structure and neu- searchers of and
Cal- clinicians from player,
variouswho
fields
hadof been search from the University
studysuffering of California
garding the underlying effects of injury Recent evidence from the University male hockey spine and throughouthas the con-
body, they wou
rological function.
omechanical dysfunction at the cellular, ifornia, revealed by the powerful(cell Atomic biology,
Force biomedical
from knee engineering,
pain for several orthopedic
months, which firmed the fact that bone beenlarges
eager to with
applyinjury,
methods just that
as would mo
ctrical and even the molecular level. I microscope, under the direction of physicist
medicine, prevented
osteopathy, and him from medicine),
physical playing. Thewho injury also
I had observed, so manyprecisely
years earlier
target. these
(see Figure
areas and3). thus achiev
zed that for An Unexpected
a system of therapeutics Discovery
Paul Hansma and his team 1, has confirmed the caused considerable pain during normal daily even to better
5
results.
were uncovering the underlying effects of injury and Bone has also been shown cause the bio-electric
alid, it had to be congruent
During my studies withinthis presenceschool,
chiropractic of certain
one protein
of my structures within activities, such as climbing stairs, which he
the bone that expand with anbiomechanical injury. These dysfunction at the
to cellular, molecular changes6, which I have found to be a crucial fac-
ng science.
earliest discoveries was that the size of certain os- and bioelectrical level. I ultimately recognized that, tor in the diagnosis andNeurological
was only able accomplish in a slow, hob- Evidence
treatment of these injuries.
findings are consistent with my clinical obser- bling manner. Fortunately for me, orthopedic One of the major factors, which drew me
seous structures, such as vations, the tibial plateau, distal
which were first madefor over any40system
years ofsurgeons
therapeutics to be valid,
were monitoring theitsize
hadof to
the bones chiropractic in the first place, was its emphas
femoral condyle, patella, femoral ago (seeproximal
Figure 2).head and be congruent withatthis the emerging
knee withscience.
a high degree of precision, Objective Evidence on of the Clinical
central importance of the nervou
acetabulum, or the proximal epiphysis of the humer- The underlyingdue to an underlying
structure of the bodygenetic
is nowcondition.
under- As Improvement
a system. This made absolute sense to me, as
us on one side of the body, Restorationwas often largerofthan Bone its Size result, they took consistent measurements to
stood to be based on the inherent properties of the One of the major clinical disruption of neurological
breakthroughs that I signals
and to any are
counterpart on the other side. andI first
Joint Healing
noticed this by cytoskeleton and the within one-hundredth of a millimetre. They of the body, could lead to serious function
extracellular matrix (ECM). These
were all surprised when the femoral condyle my colleagues were able to accomplish was that
observing radiographs andOne of the significant clinical breakthroughs
cadaver specimens. No ground‐breaking discoveries were madeofbythe
orthopedic bone size appeared tounique
consequences and even threaten survival. Th
be restored to normal with
that my colleagues and I were able to ac- and the tibial plateau left knee, which anatomical structure of the spine
complish was that bone size appeared surgeon, toStephen
be Levin,
had beenM.D. , the originator
approximately
1
5 mm of the thanthe
larger its type of treatment we had developed.
exquisitely designedAttofirst, affordwesubstantial pr
restored to normal with treatment. termAt “biotensegrity”,
first, we counterpart cell biologist Donald
on the right, had suddenly questioned these results
Ingber, shrunk and followed
tection to the spinal them up while
cord, with still allowin
questioned these results and followed Ph.D.2upand by
M.D., them that amount
others after only aframework,
.3 This structural few treatments (seeprecise measurements for using calipers
mobility andand tape mea-
flexibility. However, it was
with precise measurements using callipers and Figure 3 and 4). Subsequently, the young man’s ways aappeared
mystery totome why there
: Model of C1, cast from a real which I have referred to as the Tensegrity Matrix, pro- sures. Inter‐tester validation confirm our was never an
l specimen. Note the enlargement tape measures. Inter-tester validation appeared parents noted that he was once again “flying mention in the chiropractic literature regardin
ght articular process and the spinal to confirm our findings. vides a balance between stability and mobility and
up” the stairs with absolutely no pain. This case findings.
the most significant concentration of neuron
Several years ago, I treated explains many of verified
the observed phenomena thatrelated to ofI treated a 15‐year‐old male hockey player,
which measured 2 mm. larger in
imension.
a 15-year-old my contention normalization in the body, housed in the equally protectiv
body support, movement, response to stress and trau- who had been suffering with knee pain for several
ma, as well as the effects of therapeutic interventions. months, which not only prevented him from playing,
As described by Donald Ingber and others 2, 3, the but also caused considerable pain during normal
cytoskeleton and the extracellular matrix respond to daily activities, such as climbing stairs. Fortunately
dd
red_Content_DPS_Dec19_EJS.indd
18 2-3
injury (strain or impact), by expanding at the mo- for me, orthopedic surgeons monitoring his condi-
2019-11-21 9:01 AM

Figure 1: The Architecture of Life,
D. E. Ingber, Scientific American, Jan. 1998
“Molecules, cells, tissues, organs, and our entire bodies use [bio]“tensegrity” architecture to
mechanically stabilize their shape, and to seamlessly integrate structure and function at all size
scales. Through use of this tension‐dependent building system, mechanical forces applied at the
macroscale produce changes in biochemistry and gene expression within individual living cells.
This structure‐based system provides a mechanistic basis to explain how application of physical
therapies might influence cell and tissue physiology.” Donald E. Ingber, M.D., Ph.D.
 SPONSORED CONTENT SPONSORED CONTENT SPONSORED CONTENT

Observations in a new light

R L
“I view it as prudent toSubluxation:
patients, as well as participating in the training
program himself. In his recent best-selling
book, The Brain’s Way of Healing, he comments:
It is my belief that Roth has solved the
have a Matrix assessmentA case of mistaken mystery
identity?
after a blow to the head… observing such cases of the vertebral subluxation. My
has led me to hope By thatDr. George
soon, Roth
Matrix Repat- experience… has taught me that vertebral
terning will be routinely applied in hospital subluxations are caused by the effects of
emergency departments.” 2 injury absorbed by bones and other struc-

I
The Evolution of Chiropractic
recently searched the Internet for scientific Startling tures, sometimes spinal, and often remote
Observations:
Through a combinationevidence to support
of relentless question- chiropractic. Unfortu- Bone Enlarges from thewith spine,Injury!
which create patterns of
ing and evaluation of nately, most of
measurable, the references emphasized While studying
objective compensation
radiology throughout the body that
in chiropractic
the lack of scientific
radio-validation or measur- school, I noticed that the size of a structure on
changes (biomechanical, structural, involve the spine. I have found that the
graphic, biochemicalable and outcomes
neurological) to support
in my the basic tenets of one side of the body was often different than
our profession. At best, there are a few studies its counterpartreason
on thevertebral
other side.subluxations
For example,recur is that
A Testable Hypothesis for a M
own practice and those of my students and
Figure 4, Post-treatment: Femoral and that demonstrate
colleagues, I was gradually able to evolvea modest a advantage for chi- the proximal the underlying
femoral patterns
or humeral head, of
or absorbed
the FractureinjuryResistance
tibial epiphyses restored to same size as tibial plateau and
the right side, following treatment. *Note method to identify ropractic
and manipulation
resolve many of over some prescription
the compensation
on one have
side was noticeably not been
larger Aaddressed.

opening of the medial joint space. medications

osseous (and other fascial) effects offorinjury
certain
and conditions, such as than the opposite side in
The work the same
routinely individual.
resolves subluxations,
back pain.
thus improve our clinical However,
outcomes. Overthe theoverall impression is My professors were unable to shed any light on
thatbeen
chiropractic science
and since I have been doing it, I have not
years, this protocol has recognized by a is still relatively un- these findings. As an anatomy lab instructor at
Figure 6: Model of C1,chiropractors
cast from a real are skeletal specimen. found
fromit subsequent
necessary observations
to adjust anyone.
to structure of the cranium. It was only when I growing number of proven and that
chiropractors, as well as only mini- the college and
nd embarkedFigure
on a3:study
Microscopic Evidencemedicine
of osteopathic of Bone Expansion withand
clinicians Note thefrom
In-researchers
mally enlargement
accepted
various as partof of
fields.theIthe
right articular
health process of
care team. andcadaverous Dr. Allen Berger
specimens, Denver
I was able Colorado
to confirm B

ed jury, Paul
that I realized howHansma
profound Lab,
thisUniversity
omission of California,
was. gratifiedthe
Berkeley,
have been to spinal
I have
note canal,
thatbeenmany awhich measured
chiropractor
of them for 2over
mm.40larger
years,in every
these differences. At the time, these facts were
The more I investigated this important aspect have been able to but earlythe
dimension.
reproduce in my same career, I became convinced that filed away, and it was only many years later that
measur-
2005. (with permission from the author)
of human anatomy and the common injuries, able outcomes, whichI Iwas not achieving the kinds of results prom- these early observations came to be viewed in a
observed.
which can ised when I attended school. I also witnessed new light, based on my clinical research.
tionoften
had lead
takento life-altering
consistent outcomes,
measurementsMyto goal has always
within benefitbeen
many
to find
through
of techniques
measurable
spinal manipulation,
my colleagues
may be due to that can provide profound and lasting solutions to
the more I recognized how important it was for evidence to support any of the we, becoming
as disheartened By carefully examining a better quality skel- C
one‐hundredth of a millimeter. They were surprised itsorinfluence on this osseous enlargement, albeit in- many of the painful
fromand limiting conditions afflicting
es me to incorporate a rational approach to the chiropractors, provide. Ifailing have in oftenpractice.
wondered They had come into this etal model, which is cast a real skeleton,
ed. treatmentwhen thearea.
of this femoral condyle and the tibial how plateau of be
things might advertently,
profession
different if with on
ourthe highpart of the practitioner.
expectations
profession and a sincere now can the
I am you public.
verify many By integrating
of these the latest developments
same discrepan-
ay the left knee,
By applying which had
the principle of been approximately
identifying were to5embrace
mm. and of desire
the opinion
integrate thethat,
to help their
latest ifdevel-
practitioners
fellow humans, were
butmade
the aware in cellular
cies for yourself. biology,
Besides molecular
the examples biomechanics, and
of the
an larger thantheitsstructure
and normalizing counterpart on the
of the right, had
cranial opmentssuddenly of types
in cell biology, themolecular
fact that biomechan-
of treatments injurythey actually alters the
were taught did shape and tibia
not femur, bioelectricity,
and humerus I ammentioned
convincedearlier, that we can improve
ed bones, asshrunk by that
with other areasamount afterweonly
of the body, havea fewics,treatments size
biomedical engineeringliveofupbone
andto thesein the expectations.
bio-electricity spine4, and throughout the body, a close inspection
upon the ofcare the wespine can beprovide
already very re- and evolve even
witnessed of success in the5young Like many of you, I pursued a long search vealing. Note the differences in the size (width, D
of (seea Figures
remarkable4 and degree
5). Subsequently, . Theseman’s
emerging theydisciplines
would
for additional
arebecrucial
eager to to
our apply methods that would further to provide truly evidence‐based therapeutics.
1, helping individuals recover from many dev- understanding of the effects of injurymodalities
at the mostto improve my results, depth and height of the articular processes) at
parents noted that he was once again ‘flying up’ the more precisely
validate my target these
outcomes and areasmeand
give the thus
confi- achieve
various I believe
levels that thisthe
throughout willspine.
allowFigure
spinal1manipulation and
ve astating neurological consequences, including fundamental level of the human body. It is my
ay stairs
cognitive, withauditory,
visual, absolutely no pain.
vestibular andThis
neu-case verified
belief my scientific
that these evendence better
to beresults.
advances ablewouldto findsup-
and resolve my patient’s structural
demonstrates these therapy
differences to intakethe its
sizerightful
of place in the
re contention
romuscular that Several
conditions. normalization of the shape
independent port much of the
of what weconditions.
already provide In thisand search,
help I was blessed to meet the articular field processes
of physical of medicine
the atlas. and health care in general.
I contend
tly, bonehave
researchers is possible and outcomes.
verified these appears to3, allow
4 for the resto-
us evolve The
even further asEvolution
several researchers
a truly ofand
science-based Spinal Manipulation
clinicians from other that on palpation, these areas of enlargement Figure 2: Microscopic Eviden
Expansion with Injury, Paul
if ration ofDoidge,
Dr. Norman articular
MD,structure
who is onand function.
faculty profession. I senseThrough fields
that there (cell isbiology,
a combinationa growing biomedical engineering,
of relentless may be easily mistaken for a relative rotation or University of California, Berk
questioning
orthopedic medicine, osteopathy and physical translation of the vertebral segment (see: Sub- permission from the author
hat at Columbia University and the University of desire among many and in evaluation
our profession
medicine).
ofwereto see
measurable, objective changes REFERENCES:
roleThey making amazing discov- luxation: A Case of Mistaken Identity, below).
he
ld
Vertebral Misalignment: A Case of
Toronto, is a world-renowned expert in the chiropractic take its rightful
field of brain injury and neuroplasticity. After care industry, as leaders
in eries
my own
inregarding
the field of
in the
practice
health
and thoseeffects
thephysical
underlying of myofstudents
injury and 1. The Importance of Soft Tissues for Structural Support of the
Recent evidence
Body, SMfrom Levin,the In:University of Cal-Therapy:
Positional Release male Assessment
hockey player, who h
re Mistaken Identity?
hearing about our approach, he conducted an colleagues,
and
medicine. The way ahead benefits not only our I
biomechanicalwas gradually
dysfunctionable atto evolve
the a
cellular, method
ifornia, revealed by the of
& Treatment powerful Atomic Dysfunction,
Musculoskeletal Force from knee pain
K D’Ambrogio & for severa
ve in-depthOne of the underlying
investigation, which concepts of subluxation
included obser- profession but alsoto the
theory, identify
bio-electrical and and
countless resolveevenmany
individuals of the structural
the molecular level. I effects
microscope, GB Roth, the
under Mosby‐Elsevier,
direction St. of Louis, 1997. prevented him from playing
physicist
1, has confirmed the
vations isofthat bones ‘go
treatments, out ofinterviews
patient place’. This
withconcept
who has are long
looking forof recognized
injury andthat
real solutions thus forimprove
for a systemour
many of clinical
therapeuticsoutcomes.
Paul Hansma and his
2. Ingber DE,team
The Architecture caused
of Life, Scientific considerable
American, Vol. pain du
numerous beenconcussion
questionedand andpost-concussion
it is my belief that the and
painful limitingOver
entire to be thevalid,
conditions. years, it had
thistoprotocol
be congruent
has been with this presence of 1,certain
recognized 1998. protein structures within activities, such as climbing
emerging science. the bone that expand with an injury. These was only able to accomplis
premise may simply be a matter of mistaken iden- by a growing number of clinicians and researchers 3. The Extracellular Matrix and Ground Regulation, Basis for
to findings are aconsistent
Holistic Biological
with myMedicine,
clinical Aobser-
Pischinger,
blingNorth AtlanticFortunately f
manner.
tity. By this, I mean that the palpatory perception of from various fields. I have been gratified to note that
References: vations, which Books,
wereBerkley,
first 2007.
made over 40 years surgeons were monitoring th
sis
us vertebral
1. Fantner GE,misalignment
Hassenkam T,may, Kindtin fact,
JH, be the
Weaver JC,result
Birkedal many of L,
of H, Pechenik themCutroni haveJA,been able to reproduce the same ago (see 4.Figure 2). Medicine, The Scientific Basis, JL Oschman.
Energy at the knee with a high de
Churchill
a enlargement
Cidade GA, Stuckyof part of the DE,
GD, Morse vertebral
Hansma segment (see bonds
PK, Sacrificial measurable
and hidden outcomes,
length which I observed. Livingstone, New York, 2001. due to an underlying genet
dissipate energy as mineralized fibrils separate during bone fracture, Nat Mater.
Figure 6, below). The fact2005
thatJul
many Restoration of GE,
Bone Size T, Kindt JH, Weaver
17. patients achieve My goal has always been to develop techniques
ea 5. Fantner Hassenkam result, they took
JC, Birkedal H, consistent
2005 Aug;4(8):612-6. Epub
nal and JointPechenikHealing L, Cutroni JA, Cidade GA, Stuckywithin GD, Morse DE,
one-hundredth of a
2. Doidge, N., The Brain’s Way of Healing, Penguin Books, New York, 2016.
he One of the Hansma
significantPK, clinical
Sacrificialbreakthroughs
bonds and hiddenwere lengthalldissipate
surprised when th
3. Tommerdahl, M, Dennis, RG, et al., Neurosensory Assessment of Concussion, Mil energy as mineralized
that my colleagues and I were fibrils
ableseparate
to ac-duringandbonethefracture,
tibial plateau of th
is Med. 2016 May;181(5 Suppl):45-50
complish was Natthat
Mater.bone
2005sizeAug;4(8):612‐6.
appeared to Epubbe2005hadJul 17.
been approximately 5 m
ro-
ng
4. MacGuintie LA, Streaming and piezoelectric potentials in connective tissues, In: restored 6. Chakkalakal
to normal withDA, Mechanoelectric
treatment. At first,transduction in bone. J Ma-
we counterpart on the right, had
Blank M (ed) Electromagnetic fields: biological interactions and mechanisms. ter Res]. 1989;4:
al- Advances in Chemistry Series 250. American Chemical Society, Washington DC, ch. questioned these results and1034‐1046.
followed them up by that amount after only a f
ny 8, pp 125-142, 1995. Figure 1: Model of C1, cast from a real with precise measurements using callipers and Figure 3 and 4). Subsequentl
ng 5. Chakkalakal DA, Mechanoelectric transduction in bone. J Materskeletal Res]. 1989;4: specimen.
1034-1046. Note the enlargement tape measures.
ABOUTInter-tester
THE AUTHOR: validation appeared parents noted that he was
of the right articular process and the spinal to confirm our findings. up” the practic-
stairs with absolutely
ns canal, which measured 2 mm. larger in
Dr. George Roth has been
ve For more information: matrixforpractitioners.comevery dimension.
Several years ago, I treated ing a 15-year-old
as a chiropractor verified my contention that
and a naturo-
pathic physician for over 40 years.
He has taught at chiropractic, na-
turopathic, medical, osteopathic,
physical therapy and medical
schools throughout North America.
CC_Matrix_Sponsored_Content_DPS_Dec19_EJS.indd
CC_Dec19_EJS.indd 18 2019-11-06 8:38 AM 2-3 He is the co‐author, with Kerry
D’Ambrogio PT, of Positional Re-
lease Therapy (Elsevier, 1997), and
the author of The Matrix Repatterning Program for Pain
Figure 4: Pre‐treatment: Femoral and tibial epiphyses en- Figure 5: Post‐treatment: Femoral and tibial Relief (New Harbinger, 2005). His work is also featured in
the Brain’s Way of Healing, by Dr. Norman Doidge (Penguin,
larged, approximately 5 mm. compared to the right. *Note epiphyses restored to same size as the right side, follow- 2016). For more information, visit: www.matrixforpracti-
relative narrowing of the medial joint space. ing treatment. *Note opening of the medial joint space. tioners.com.

For more information visit matrixforpractitioners.com

UPFRONT | Columnist

BUSINESS TALK

How acupuncture was saved

The amazing story everyone should hear BY DR. ANTHONY LOMBARDI, DC

I
n early February 2022, the provin- exactly? It seems like this Bill literally that TCMO will be fully consulted on
cial government introduced bill came out of nowhere. any other changes being contemplated,
88 which would de-regulate Acu- Kenny:Yes it did.You can imagine how we remain vigilant.
puncture in Ontario. The bill 88 shocked the profession was when ad-
would ensure the practice of acu- vised by email from the CTCMPAO 3. This recent media frenzy has
puncture would become public do- that they had been advised by the brought more awareness to the
main and anyone would be able to do Ministry of Health that the CTCM- TCM profession. How do you think
it without a license. PAO was to begin the process of wind- this could benefit the profession
To fully comprehend and understand ing up operations and that the profes- within the complimentary health
what exactly took place I interviewed sion would be de-regulated. That day arena?
Heather Kenny (R.Ac), a registered was Monday, February 28th, and Bill Kenny: Actually, this highlights the
acupuncturist practicing in Peterbor- 88 and Schedule 5 had passed first need for cross-professional support,
ough and Oshawa, Ontario. She is the reading in the Legislature. A group of cooperation and education. Through
President of the Traditional Chinese representing professionals, schools and greater understanding and more in-
Medicine Ontario Association. students came together swiftly and, depth knowledge of the scope of pro-
within hours, we had mobilized our fessionals and application of modali-
1.To give readers some background, government relations firm, initiated a ties, all RHP’s can offer benefits and
who is the TCMO? What is their letter writing campaign, an online pe- achieve better healthcare outcomes for
role? And, who can be members? tition, and organized a press confer- their patients. And, truly, isn’t that
Kenny: Traditional Chinese Medicine ence, fundraising and media outreach. what all healthcare professionals want:
Ontario is an association representing Within only three short days, the peti- Better healthcare for their patients.
TCM-trained professionals in Ontario. tion had garnered an astounding This also throws into sharp focus that
Our members are Registered Acupunc- 66,000 signatures. MPP’s offices re- the government must always seek to
turists (R.Ac.’s) and Registered Tradi- ceived hundreds of letters from the fully consult with all stakeholders on
tional Chinese Medicine Practitioners public on the issue, fundraising topped an issue in order to gain the knowledge
(R.TCMP’s) practicing in Ontario and $10,000, and the story was being cov- and understanding of the possible im-
students in related programs in On- ered by multiple media outlets across plications of decisions that are being
tario schools. We advocate on behalf of Canada. By Friday of that week, the made.
our membership to government and to Government committed to
the regulatory College, the College of complete removal of the Be cooperative 4. What can TCM practi-
Traditional Chinese Medicine Practi- Schedule deregulating TCM with other tioners, chiropractors, and
tioners and Acupuncturists of Ontario from the legislative Bill. Over professions, naturopathic doctors do
(CTCMPAO), we represent the views the course of the next few because now - so that this attempt of
of the membership to government and days, it continued to become change is on de-regulating the TCM pro-
other healthcare bodies (extended clear that the Government the way for fession never happens
health insurers) and to the public. We did not consult the CTCM- RHP’s in again?
offer a suite of benefits to our members PAO, Associations, Schools, Ontario and Kenny: Every single practi-
including professional liability insur- members of the profession, together we tioner reading this article sim-
ance discounts, access to extended or members of the public can be suc- ply MUST join their respective
health and dental policies, educational prior to introducing the de- professional association; it is
cessful.
opportunities/discounts, advertising regulation legislation. not enough to be a member of
and networking within the community. While the profession has garnered your regulatory College. And, once you
2. In the government’s recent attempt commitment from government that are a member of your association, vol-
at de-regulation, what happened deregulation is now “off the table” and unteer your time to the benefit of your
profession, become a leader, offer your
ANTHONY LOMBARDI, DC, is a private consultant to athletes in the NFL, CFL and NHL, and founder of the time for marketing, for public outreach,
Hamilton Back Clinic, a multidisciplinary clinic. He teaches his fundamental EXSTORE Assessment System for government relations, get involved!
and practice building workshops to various health professionals. exstore.ca.

14 Chiropractic and Naturopathic Doctor September/October 2022 www.Cndoctor.ca

 time, chiropractors felt little support
from associations who should of “went
to bat” for them to fend off the pro-
posed government changes. However,
on December 31, 2004 chiropractic
was delisted from OHIP. There is a
lesson here. We should strive to be fully
independent of any government or
insurance subsidies. We should try to
make our practises cash-based so that
we can survive based on the value of
our clinical results.
Furthermore, chiropractors have a
lot to learn from this experience that
acupuncturists went through. How is it
that their associations were able to
collaborate so quickly in order to fight
for their practice freedoms? Are chiro-
practic organizations taking note?
Chiropractors have a lot to learn from this experience that acupuncturists went through.
Photo: Max Tactic/Adobe stock

They very well should be.

Your future depends on it. Be vigilant The lesson

and also cooperative with other profes- I was in my third year of practice when
sions, because change is on the way for the Ontario government removed chi- Visit cndoctor.ca to view more
RHP’s in Ontario, and together we can ropractic from the Ontario insurance business talk articles and to sign up
be successful. healthcare plan. Seemingly, during this to our newsletter.

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www.Cndoctor.ca September/October 2022 Chiropractic and Naturopathic Doctor 15

CND_BOOKAD_HALF_NOVDEC_BAS.indd 1 2021-10-26 11:07 AM
FEATURE

NUTRITION AND FITNESS

Stay
young
Aging: more benefits
of exercise
by dr. don fitz-ritson, dc

R
esearchers have shown that a compression of
morbidity that improves healthy aging is more
valuable than further increases in life expec-
tancy, and that targeting aging offers poten-
tially larger economic gains than eradicating
individual diseases. They showed that a
slowdown in aging that increases life expec-
tancy by one year is worth US$38 trillion, and by 10 years,
US$367 trillion. Ultimately, the more progress that is made
in improving how we age, the greater the value of further
improvements. “They state that it would reduce the inci-
dents of cancer, dementia, cardiovascular disease and frailty.
In total, the U.S. is spending 17 percent of everything we
generate on health care – and largely that’s spent in the last
year of life.” Currently, a person who turns 65 in the next
few years will spend anywhere from $142,000 to $176,000
on average on long-term care during their lifetime, accord-
ing to a recent report commissioned by the U.S. Department
of Health & Human Services.(1) For Canada, we divide those
numbers by 10.
Physical exercise has been shown to benefit the aging
person. It is cheap and anyone can partake. Physical exercise
represents a powerful tool, doable with few or no side effects
and produces a multitude of benefits. This article will high-
light some of the lesser known, but still significant benefits
of exercise for everyone, including the aging population.
Muscle
Exercise easily stimulates young muscle compared to aging
muscle. More genes are expressed in the young muscle com-
pared to the aging muscle.(2)These gene changes are necessary
to protect the integrity of the aging muscle.(3) The Mediter-
ranean diet can help the telomeres which protect the genes,(4)
and exercise can help rejuvenate muscle stem cells, providing
new muscle cells.(5) This means that due to decreased gene
expression, the aging muscle has to work harder to achieve
the same effects as the young muscle. Aging people therefore
have to keep their muscles as healthy as possible, so they re-
spond better to exercise or physical activity.(6)
Neuromuscular junction
With aging there is loss of motor units which make up the
neuromuscular junction. By age 80, these loses start to
become functional impairments. Lifelong physical activity
has a protective effect on the motor units.(7)
Muscle-bone interaction
Physical activity/exercise can, through biochemical signal-
ing encourage the cross-talk of bone to muscles and this will
help to delay osteoporosis and sarcopenia.(8) Muscles can
affect bone by releasing myokines when stimulated. These
myokines regulate muscle metabolism, bone and more
Photo: lordn/Adobe stock

distant tissues such as liver and brain.(9) Exercise/activity can

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.
16 Chiropractic and Naturopathic Doctor September/October 2022
also affect bones by stimulating them to release proteins
which affect muscle and other organs in the body. This is
mediated via the immune system, and enhances aging mus-
culoskeletal health.(10) Because of the important effects of
www.Cndoctor.ca

exercise and muscle on the body, a new word has been
coined to cover the interaction. “Exerkine” has emerged as
the umbrella term covering any humoral factors secreted
into circulation by tissues in response to exercise. Exer-
cise-related adaptations include muscles, bones, the cardi-
ovascular, nervous, metabolic, locomotor and immune
systems.(11) Therefore, exercise will help or prevent the de-
velopment of many chronic diseases.(12)
Gut-muscle axis
Research shows there is cross-talk between gut microbiota
and skeletal muscle health. This gut-muscle axis mediates
changes in muscle, depending on the gut health. With aging,
gut health decreases and will affect aging skeletal muscle
size, composition, and function.(13) The gut microbiota di-
rectly affects protein synthesis in muscle, and this indicates
why the health of the gut microbiota is necessary.(14) Exercise
will now easily assist muscle size and health,(15,16) and con-
suming more animal protein will add to muscle function,
which will positively affect cognitive function.(17,18)
Muscle-brain axis
Physical activity/exercise affects 82% of the total grey matter
volume of the brain.(19) It is logical that there must be a
muscle-brain axis. Physical exercise causes muscle to se-
cretes myokines that contribute to the regulation of
www.Cndoctor.ca
hippocampal function, enhance BDNF production and
contribute to neurogenesis, memory and learning.(20) Some
of these exercise induced muscle secreted myokines are
transported via the blood to the brain to assist with neuro-
genesis and cognition, especially in the aging brain.(21) Mi-
trochondria (ATP), is increased in muscle by exercise.
Mitrochondria (ATP) is central for the communication
between muscle and brain and for the release of the myok-
ines which often depends on mitochondria, and possibly
direct mitochondrial transfer. These exercise myokines and
mitrochondria(ATP), will help protect the brain against
neurodegenerative diseases such as dementia, Alzheimer’s
and Parkinson’s.(22) Exercise myokines and mitrochon-
dria(ATP), will also protect the retina and help to delay
macular degeneration.(23)
Gut-brain axis
The gut-brain axis is very significant and can modulate the
brain for health or pathology depending on the state of both
areas. As mentioned above, exercise will help keep the gut
healthy. Diet and probiotics will also help the gut function
normally.(24) Neurodegeneration of the brain can manifest
via the gut-brain axis as it is a bidirectional communication
through neuroimmune, neuroendocrine, and direct neural
pathways such as the vagus nerve.(25)Restoring the gut mi-
crobiota and keeping it healthy can decrease the progression
of Parkinson’s disease.(26,27) Healthy gut microbiota regulates
the production, transportation, and functioning of neuro-
transmitters, helping brain and cognitive functions.
Bone-brain axis
Exercise effectively modifies the release and the circulating
levels of osteokines, which has beneficial effects on brain
functions which relates to a bone-to-brain communication.
It is hypothesized exercise may support the treatment of
neurodegenerative diseases, such as Alzheimer’s and Par-
kinson’s diseases.(28) Exercise can help with osteogenesis,
lymphopoiesis, which is an important mechanism by which
exercise promotes strengthening of bone and immunity, (29)
and support aging bone.(30)
Exercise and the brain
Studies have shown that physical exercise promotes the
release of molecules, involved in neuronal survival, differ-
entiation, plasticity and neurogenesis in the brain, from
several peripheral organs.(31) Exercise also improves the
protein structure in synapses to preserve them. This can
occur even in the aging person, so it is never too late to
begin exercising, or increasing ones physical activity.(32)
However, the brain pays a price for maintaining these func-
tions. The brain weights about 2% of body weight, but uses
about 20% of the body’s oxygen so that it can convert
glucose via the mitrochondria to produce ATP energy to fire
the nerves and maintain brain function. Even at rest, the
fuel consumption is the result of the leaky pool of vesicles
at synaptic terminals which has to be maintained for quick
firing of the neurons. Any decrease of the production of the
ATP, will slow the function of the synapses, contributing to
inflammation and degeneration in the brain.(33) New data
supports microglial activation as a physiological pathway by
September/October 2022 Chiropractic and Naturopathic Doctor 17
FEATURE
which physical activity relates to brain
heath in humans. More research is
needed, but physical activity via micro-
glia synaptic neuron connections, may
be a modifiable behavior leveraged to
reduce pro-inflammatory microglial
states in humans.(34) The brain, specif-
ically the hypothalamus, responds to
exercise activity and modulates energy
metabolism through stimulation of the
sympathetic nervous system and cat-
echolamine secretion into the circula-
tion. This has an endocrine effect on
muscle.(35) Exercise also affects the
blood brain barrier –BBB by diminish-
ing BBB permeability as it reinforces
antioxidative capacity, reduces oxida-
tive stress and has anti-inflammatory
effects.(36) As an example, Omega-3
fatty acid is essential for neurological
development and function, specifically
the brain and eyes, and it is derived
from dietary sources and is transported
via the BBB and blood retina barrier.
(37)
In summary, there is scientific basis
for the clinical application of aerobic
physical exercise in the fight against
brain disorders.(38)
Exercise, inflammation, diet
Regular exercise will improve immuno-
surveillance and immunocompetence,
which strengthens the Immune System
and helps to control inflammation in
the body.(39) Regular exercise and the
Mediterranean-type diet, alone or in
combination, provide key interventions
to both prevent and control the rise of
non-communicable diseases (mainly
cardiovascular diseases, cancers,
chronic respiratory diseases and Type
2 diabetes) which are the main causes
of death worldwide. (40) With aging,
good nutrition along with the inclusion
of micronutrients and macronutrients
interact via the gut microbio-
ta-gut-brain axis to impact brain func-
tion in general and cognitive processes
in particular.(41)
Exercise benefits
Biological aging can be improved by
lifelong exercise by decreasing DNA
damage, keeping telomeres healthy and
enhancing DNA methylation.(42) Dis-
ease risks can be modulated with exer-
cise by epigenetic rewiring of skeletal
muscle enhancers, which control
muscles healthy activity.(43) We evolved
to be active throughout our lives, our
18 Chiropractic and Naturopathic Doctor September/October 2022
bodies need physical activity to age
well.(44) Exercise is effective in the pri-
mary prevention of 35 chronic diseases.
(45)
New research shows that exercise
and diet can reverse epigenetic aging.
(46)
The body thrives on movement/ac-
tivity/exercise – this is health. Put more
movement/activity/exercise in your day.
References
1. Sinclair DA, et al. The economic value of targeting aging.
Nature Aging 2021:V 1, 616–623.
2. Rivas D, et al. Diminished skeletal muscle microRNA
expression with aging is associated with attenuated muscle
plasticity and inhibition of IGF-1 signaling. FASEB J.
2014:28, 4133-4147.
3. Tumasian R 3rd, et al. Skeletal muscle transcriptome in
healthy aging. Nat Commun. 2021 Apr 1;12(1):2014.
4. Fernández de la Puente M, et al. Modulation of Telomere
Length by Mediterranean Diet, Caloric Restriction, and
Exercise: Results from PREDIMED-Plus Study. Antioxidants
(Basel). 2021 Oct 12;10(10):1596.
5. Larrick J, et al. Exercise Partially Rejuvenates Muscle Stem
Cells. Rejuvenation Res. 2020 Jun;23(3):262-265.
6. Izquierdo M, et al. International Exercise Recommendations
in Older Adults (ICFSR): Expert Consensus Guidelines. J Nutr
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www.Cndoctor.ca
 COLUMN
PRACTICE POINTS
Flesh and bones
When anatomy and art conflate
A
natomy is a pillar of edu-
cation for any practitioner
of the haptic arts. I find
anatomy to be a subject
of breadth and depth – a
study one returns to again and again.
My recent interest in restudying anat-
omy stems from a childhood avocation
in drawing coupled with a keen voca-
tional fascination with écorché (human
figures with skin removed to display the
underlying musculature). After 30+
years of practice, I emphatically ac-
knowledge I have more to learn. I
thought I knew anatomy well, until I
attempted to draw it from memory.
“At times when there was a shortage
of cadavers to examine, artists became
the principal dissectors of the human
body, and were the main font of ana-
tomical knowledge,” shares Andrew P.
Zbar, retired surgeon and anatomy
instructor. Zbar is the curator of the
remarkable broadcast Anatopod (ana-
topod.podbean.com). Zbar explains
how the doctrine of Galen (who evi-
dently never dissected a human
corpse), prevailed for 1,000 years,
yielding with no small resistance to
upstart Andreas Vesalius (1514-1564),
determined to confirm or repudiate
Galen’s teachings through direct em-
pirical examination via dissection.
Prior to Vesalius, anatomy instruc-
tion was delivered orally from the
writings of Galen, with a central table
of dissection and aspiring physicians
observing ex cathedra (“from the
teacher’s chair”). Vesalius democra-
tized the study of anatomy by inviting
physicians into the pit of the Theatrae
Anatomia to learn, first-hand, directly
Photo: Wirestock/Adobe stock
dissecting their subjects. Vesalius, with
uncredited illustrator Jan Stephan van
Calkar, would go on to produce the
seminal Fabrica Humani Corporis,
DONALD QUINN DILLON, RMT is a practitioner, practice coach and author. Find him at DonDillon-RMT.com.
www.Cndoctor.ca
BY DONALD QUINN DILLON, RMT
which would revolutionize the study
and appreciation of anatomy, bringing
it to a broader audience.
Anatomists and artists would collab-
orate on a number of works together to
facilitate the transfer of knowledge in
accessible ways. Some artists – Leon-
ardo Da Vinci and Michelangelo
Buonarroti among the most famous –
would conduct their own dissections to
better conceptualize the organs below
the surface. Zbar affirms, “Anatomists
and illustrators have at times shared an
impetuous and even fractious alliance.”
There existed a natural tension in the
relationship – anatomists insisting on
structural accuracy while the artists
imposed stylistic features in their illus-
trations.
Some illustrations, like van Calkar’s,
portray animated, skinless figures,
strolling through countryside with
fields and recognizable landmarks in
the background. Odoardo Fialetti por-
trayed cadavers complicit with their
audience’s fascination, lifting layers of
their own skin and connective tissue to
display the organs underneath. Jacques
D’Agoty illustrated personable sub-
jects with hair, skin tone and amenable
facial expression, while simultaneously
displaying an abdominal or cranial
incision with organs resting to the side.
September/October 2022 Chiropractic and Naturopathic Doctor 19
Others, like Charles Bell (brother of
anatomist John Bell) were critical of
these renderings, preferring realism in
portrayal of dissection. “The expres-
sion of the corpses are tormented and
sorrowful forcing us to bear witness to
their surrender and sacrifice” recounts
Zbar in one episode.
The intersection between anatomy
and art is not limited to those in the
health sciences. The Getty Research
Institute in California – housing a li-
brary and collections in the visual arts
available for public viewing – staged an
exhibition this year entitled Flesh and
Bones: The Art of Anatomy. I note
from various social media the interest
for the precise study of anatomy drives
application in medical illustration for
pharmacy or health sciences marketing
and education, in graphic design for
video games and fantasy memorabilia,
and in film and television towards
medical and crime drama.
Zbar laments the diminishment in
the direct engagement of anatomical
dissection. “Today surgeons are largely
removed from the tangible closeness of
the innards of their patients by foot-
long working instruments inserted
through miniscule windows and snaked
through body cavities.” On discussing
simulators and digital anatomy study
guides: “Perhaps the only thing truly
missing from this approach is a tangi-
ble sensibility of how an organ can give
way under the pressure of the scalpel,
the elasticity of its physical encroach-
ment upon neighbouring tissues.”
Zbar asserts contextualization is
paramount for the serious study of
anatomy. “Anatomy is far more than its
elemental annotation of the things that
sit and fit together inside. It brings with
it a connection to practices shaped over
half a millennium, and a mythology
that imposes itself upon any contem-
porary dissection.”
FEATURE
our genetic makeup, the emergence of
numerous studies examining the cor-
relation of SNP variants with disease
risk made them relevant to my practice.
The potential to improve diagnostic
accuracy, more clearly define risk and
hone my therapeutic regimens accord-
ing to individual genetics was exciting
and, in terms of naturopathic medicine,
somewhat of a Holy Grail for person-
alized health.
As increasing numbers of patients
both presented with their genetic anal-
ysis or elected to complete it having
consulted with me, I recognized that
this truly was the next exciting frontier
of medicine. Patients were unique and
did not fit into pre-designed boxes. As
I went over their results, explaining why
NUTRITION they felt a certain way after different

One-size
foods, with varying types of exercise
and when stressed or losing sleep, their
eyes lit up with a recognition that I
truly understood them and their indi-

doesn’t fit all

vidual issues. Patients for whom I had
scratched my head trying to figure out
why my protocols were not working
were suddenly doing amazingly well
with simple SNP-based tweaks to their
treatment.

Optimizing diet, health and PERSONAL GENETIC TESTING

The number of people ordering com-
weight through personal genetics mercially available DNA tests is going

W
BY DR. PENNY KENDALL-REED, ND up exponentially. In 2014 there were
approximately 1 million tests ordered
worldwide. By 2019 this number was
e used to think lifestyle, our diet, our supplements, we above 25 million and numbers are
there was lit- can not only optimize the genetic blue- more than doubling each year. Ances-
tle we could print we have been given but we can try.com and 23andMe comprise over
do about the actually alter the way genes work. 90% of these tests. Individuals submit
genes we’d Starting around 2011, I noticed an a spit sample or cheek swab to the
been given. increasing number of articles referenc- company, which runs the analysis and
T h e y we r e ing individual areas of genetic variation provides a report of varying content
carved in stone and we were at the called single nucleotide polymor- and complexity. Some are more fo-
mercy of their bidding. It was a fatalis- phisms, or SNPs. (Pronounced cused on heritage and geographic ori-
tic attitude often used as an excuse to “snips.”) Individual differences in these gin, while others advise on different
avoid making changes to our lives. SNPs are called “alleles” and these aspects of health including disease risk,
What was the point if our genes were alleles provide the basis of your per- nutrition and exercise. Platforms differ
immutable? sonal genetic coding results from DNA primarily in terms of the genes they test
Well it turns out that we were wrong. testing. Articles discussed the associa- and the advice provided. From my
Although it is true that we cannot tion of SNP alleles with metabolic experience, patients often present with
change our genetic code, we can greatly function, weight management and the their genetic data, confused by the re-
influence the expression of many genes risk of disease, particularly diabetes. port and uncertain how to address
Photo: lucadp/Adobe stock

and control the effects they have on our So, although SNPs had been recog- many of the health issues they are now
body. By making small changes to our nized for many years as components of aware of.
The five cornerstones of health in my
DR. PENNY KENDALL-REED, ND is is a naturopathic doctor in Toronto. Dr. Kendall-Reed is the author practice are metabolism, diet, stress,
of five national bestselling books. In 2013 she was voted Naturopath of the Year and in 2018 was the inflammation and detoxification. Opti-
recipient of the top Naturopathic Doctor. mizing these is the foundation of good
20 Chiropractic and Naturopathic Doctor September/October 2022 www.Cndoctor.ca

“Personal genetic analysis lets
you identify your own strengths
and weaknesses”
health and the reduction of disease risk.
In this book we will be looking at genes
and SNPs that impact your metabo-
lism, diet and stress. These three fac-
tors are closely interlinked when it
comes to your weight, energy levels and
diet. Some of them are associated with
the development of diseases such as
Type 2 diabetes but it is important to
bear in mind that such diseases have
multiple etiologies and contributing
factors. Personal genetic analysis lets
you identify your own strengths and
weaknesses and allows you to make
sensible lifestyle choices to potentially
improve your overall health and
well-being. It may also help you achieve
your ideal weight. If it can help reduce
your risk for certain diseases, then that
is an added benefit.
GENETIC CASE STUDY
Anna is a 36-year-old professional
woman who came to see me because of
unwanted weight gain despite her strict
diet and exercise regimen. Her weight
had increased 18 pounds in eight
months. She felt hungry all the time,
had low energy and had muscle and
joint soreness.
Anna had originally wanted to eat
more healthy and planned to lose about
five pounds. On the recommendation
of a friend, she had radically changed
her diet from a higher protein, moder-
ate carbohydrate diet with “minimal
fats” to more of a “ketogenic” diet in-
corporating high fat, low to moderate
protein, and restricted carbohydrates
with fewer vegetables, and no fruits,
whole grains or starches.
Within a couple of months she began
to feel “puffy” and inflamed and then
started to put on weight. To counteract
this she began running 30 minutes to
one hour, four times a week and be-
came stricter with her diet. Despite
this, she reported increased feelings of
hunger and craving and continued to
gain weight. She felt progressively more
fatigued, particularly during exercise.
www.Cndoctor.ca
Prior to our initial consultation,
Anna had run herself through the
23andMe DNA test. Having signed up
though the 23andMe website, Anna
received a testing kit within 1 to 2 days,
which included a specimen bottle for a
saliva sample and instructions on how
to fill it. She returned the specimen to
23andMe in a pre-paid envelope along
with a signed form. Three to four weeks
later Anna received an email indicating
that her genetic data was available. She
was then able to log into her account
and access both her raw data and a
basic report. The raw data is a huge file
containing gene and SNP codes for
approximately 1500 genes and is not
useful in any practical manner. How-
ever, I am able to process the file using
my GeneRx.ca program to produce a
report, which is both informative and
practical in terms of providing a diet,
lifestyle and supplement protocol.
Anna sent me her raw data file and
prior to our meeting I ran it through
the program. Part of the report based
on Anna’s genetic profile indicated the
following: 1) Significantly increased
weight-gain and hunger when consum-
ing more than 22 grams of saturated fat
per day. 2) Moderate increase in desire
for energy rich foods and increased
weight gain with a low protein, high
saturated fats diet.3) Higher risk of
progressive weight gain and worse with
a high saturated fat diet. 4) Overall she
handles carbohydrates well. 5) In-
creased inflammation with endurance
exercise.
By ignoring her genetics and follow-
ing the latest “ketogenic” dietary trend,
Anna not only failed to lose weight, she
actually gained more. In addition, the
diet had caused an imbalance in the
systems in her body and brain con-
trolling feelings of hunger. The diet had
also resulted in higher levels of inflam-
mation resulting in feelings of soreness,
“puffiness” and fatigue.
By dropping her carbohydrates and
increasing calories from saturated fat
September/October 2022 Chiropractic and Naturopathic Doctor 21
Anna’s genetic coding had led to in-
creased fat accumulation, particularly
around the abdomen, which posed a
significant health risk. It also led to
higher levels of her hunger hormone
(ghrelin), which resulted in poor satiety
and cravings for energy-dense foods.
Restricting her carbohydrates was un-
necessary as she actually coded well for
these and by doing so she limited her
energy supply leading to additional
fatigue. Increased fatty weight contrib-
uted to increased inflammation.
Based on her genetics I recom-
mended the following protocol:
1) Reduce her daily lean protein intake
calculated according to her body
weight. 2) Slightly increase whole
grains to 2/3 the physical size of her
protein portion. 3) Vegetables and sal-
ads allowed in unlimited quantities.
4) Reduce her saturated fat intake to
less than 22 grams per day. 5) Supple-
ments. 6)Resveratrol Extra. 7) Tri-Met-
abolic Control (TMC)
Anna lost three pounds in the first
week, and 16 more over the next eight
weeks. The “puffiness” and inflamma-
tory feeling were significantly reduced
by day 10 and completely gone by two
weeks. Energy levels, both day-to-day
and with exercise, were back to normal
by four weeks. At two-year follow-up
Anna continued with a moderate and
balanced diet and had maintained a
healthy weight.
Diet trends come and go and they
work for some people but not others.
In some cases, like Anna’s, they can be
detrimental. Genetics provides insight
into your individual metabolism and
allows a highly personal, safe and effec-
tive program to be designed.
Anna’s Detailed Genetic SNP cod-
ing:
• APOA2: CC – significantly increased
weight-gain and hunger when con-
suming more than 22 grams of satu-
rated fat per day.
• FTO: TA – moderate increase in
desire for energy rich foods and in-
creased weight gain with a low pro-
tein high saturated fat diet.
• PPARG: GG – higher risk of pro-
gressive weight gain and worse with
a high saturated fat diet.
• TCF7L2: CC – handles carbohy-
drates well.
• IRS1: TT – handles carbohydrates
well.
THE X-FILES

THE X-FILES

The “Terry Thomas” sign

BY DR. MARSHALL DELTOFF, DC

A
colleague in Bermuda sent
this case to me. A 47-year
old male presented expe-
riencing right wrist pain
over the scapholunate
joint after jamming it in extension
while playing ice hockey. It is a very
sharp pain and there is swelling over
the area. He is having sharp pain with
gripping or rotation.

DIAGNOSIS:
Rupture of the scapho-lunate ligament,
resulting in the “Terry Thomas” sign
(arrow). The increased distance indi-
cates scapholunate dissociation and
often can be associated with rotary
subluxation of the scaphoid.
The sign is named after well-known
British comic Terry Thomas. Terry
Thomas (1911 – 1990) had a large gap
between his two front teeth [front den-
tal diastema] and this made his smile
very peculiar. Scapholunate dissocia-
tion is a wrist injury that occurs due to
falling on an outstretched hand or
FOOSH injury.
The rupture of the scapholunate
ligament leads to separation of the lu-
nate and scaphoid bones. The injury
also causes rotation of scaphoid bone.
Most authorities agree that a gap of 3-4
mm is diagnostic in most cases. In fact,
a gap of more than 3mm is pathogno-
monic for scapholunate dissociation by
some authors. For newer students who Above: Rupture of the scapho-lunate
do not know who Terry Thomas was, ligament, resulting in the “Terry Thomas”
this finding might also be known as the sign.
David Letterman sign, or the Madonna Left: An example of dental front diastema.
sign because both of these celebrities
also have dental front diastema. But
Photo: Westend61/Adobe stock

their gap is not as big and as classic as

Terry’s.

DR. MARSHALL DELTOFF, DACBR, FCCR(C), FEAC, is a Professor of Radiology at Barcelona College of
Chiropractic. He offers an online X-ray reporting service for colleagues across Canada and can be reached Visit cndoctor.ca for more case
at: marshdel@yahoo.ca. He is also offers live interactive CE zoom webinars for your association or local reports like these.
society.

22 Chiropractic and Naturopathic Doctor September/October 2022 www.Cndoctor.ca

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