Dr Nick Straiton - Back Pain Physician

Blog 1 Hormones – are yours OK? by Moira Houston December 2011

Hormones – are yours OK?
No sex drive - men and women, menstrual problems, menopause with its memory loss, decreased strength, hot flushes and mood changes and so on?
Do men have an ‘andropause’? Hormone changes occur as men age too and contribute to loss of libido, low mood, lack of motivation and decrease in physical strength and fatigue.
We are all hugely affected by our hormone cycles from puberty onwards, and before by the effects they have on our parents!
Use of artificial hormones has become commonplace in recent years and as we learn more there is a lot to consider about their effects on our bodies as well as the benefits. Very recently bio-identical hormones have become of interest in the search for safer, possibly more ‘natural’ help and men’s hormonal health needs to be included.
Bio-identical Hormones are hormones that are identical in molecular structure to the hormones in our bodies. They are not found in this form in nature but are made, or synthesized, from a plant chemical extracted from yams and soy. Technically, the body can’t distinguish bio-identical hormones from the ones your body produces and to this extent they are natural in their effect. Many of the conventional HRT formulas are not body identical.
The effects of bio-identical hormones are consistent with your normal biochemistry and therefore side effects are usually minimal. The same caution needs to be taken with some of the hormones as would be the case in HRT but progesterone cream for example does not have the side effects of the conventional product and is considered safer as well.
We can now measure for any deficiency in your hormone levels by blood, saliva or urine sample and each method has different uses. From this a unique prescription can be made to meet your specific needs.
Other factors in your health need to be included as hormone levels are closely related to the overall state of physical, mental and emotional health. I am trained as a GP and homeopath so offer a holistic approach to help you with nutritional advice, stress management and homeopathic remedies as well as hormones.



Blog2. Acupuncture for Male Infertility December 6th 2012

Most couples who have regular sexual intercourse without protection have a pregnancy within the year but infertility affects 1 in 7 couples with male factors being the cause 25 % of cases. There are myriad causes of male infertility many of which are irreversible for example genetic chromosomal defects, mumps or absence of the vas deferens. Lack of sperm in the semen analysis is basically due to inadequate production of sperm or obstructive causes. For quite some time there have been reports in the Chinese literature regarding the treatment of male infertility by the use of acupuncture .More recently it was shown in a pilot study of 20 men that acupuncture affected sperm production particularly when there was genital tract inflammation, sperm density on average increasing by a factor of ten. This was similar to previous work by the same author which showed that acupuncture increased the sperm count significantly in 15 out of 17 patients suffering from scrotal hyperthermia who had genital inflammation. Of note was that success was associated with a lowering of scrotal temperature. Your mother’s or doctor’s advice of avoiding hot baths and tight underpants might not seem so ridiculous after all!
If indeed acupuncture is effective in improving male fertility it must be acting in some way on one of the reversible causes that is either on factors crucial to sperm production or its passage along the vas deferens. As we know that acupuncture has an effect in the brain possibly it is acting on the release of hormones which are vital in the regulation of sperm production. At the testicle it could be affecting sperm production by changes in the autonomic nervous system altering blood flow or temperature. Recently researchers in Turkey showed that there was a significant increase in testicular blood flow when electro acupuncture at a certain specific frequency was used at the point Stomach 29. Acupuncture might be improving the flow of sperm at the autonomic level by increasing vas deferens contractions when there is an obstructive element to the infertility.
From a Western Medical point of view, not taking into account the Traditional Chinese Medical interpretation, there does seem to be many ways in which acupuncture could help with male infertility and there is now some published work to justify this opinion albeit in small quantity at the moment. Being a safe procedure, couples suffering from infertility might want to consider this option particularly when the conventional approach has failed to help but yet no definite explanation for their failure to conceive has been found.





Blog 4. Shoulder Pain by Dr Nicholas Straiton March 6th 2012


One of the most difficult musculo-skeletal conditions I find to treat is chronic shoulder pain and in particular when there is an impingement syndrome. Before commencing any treatment for a patient with this problem I try to make a specific diagnosis of where and why the impingement is taking place. The reason for this is that I believe that certain types are theoretically more likely to respond to acupuncture treatment than others. For example outlet impingement when there is some structure actually impinging on the rotator tendon is probably going to be more resistant to physical treatment than non outlet causes where the impingement is due to bio mechanical factors allowing the humeral head to move superiorly with certain movements, in particular abduction, causing impingement of the rotator cuff tendons as they traverse the sub acromial space. Mann (1999) also makes the point that acupuncture has limited effect in the shoulder with patients where there has been some degenerative change in structure present. When there is no outlet obstruction it has been suggested that myofascial trigger points could be the cause of pain, weakness and a reduced range of motion and that acupuncture may help maintain rotator cuff balance reversing this effect (Osborne,2010).
Investigations are not always necessary and the differentiation between the two impingement types can often be made on the history for example when there have been previous fractures in this area or there are signs and symptoms of arthritis increasing the likelihood of their being sub acromial osteophytosis present. In my patient not only were there signs of impingement, for example a painful arc was present, but there was also pain and some difficulty in getting the arm into full abduction alongside the neck. I now find this is a particularly important sign which shows the importance of paying attention and examining all the muscles involved in full shoulder abduction and not just the ones involved in movement at the gleno –humeral joint in the first phase of abduction which is only from 0 to 90 degrees. The second and third phases of abduction are due to scapulo-thoracic and spinal motion (Kapandji,1982) and I believe it is vital that the musculo-skeletal elements involved in this motion are examined thoroughly when one is searching for the explanation for the shoulder dysfunction. With this in mind I now make a thorough search for trigger points in muscles involved in all phases of abduction that is supraspinatus and deltoid which provide abduction in the first phase as well as infraspinatus and teres minor the lateral rotators which displace the greater tuberosity posteriorly delaying locking, trapezius and serratus anterior constituting the couple acting at the scapulo thoracic motion and finally the cervical and thoracic spinal muscles which are important in the last 30 degrees of full abduction. At the recent BMAS Winter Symposium (2011) during some discussion concerning shoulder pain mention was made of the frequency of the presence of trigger points in the infraspinatus and I agree with this viewpoint particularly in the case of impingement when normally functioning lateral rotators are vital to normal full abduction. Mann(1999) recommends both small Intestine 2 and Hansen I in the treatment of shoulder problems both points being in the vicinity of the infraspinatus muscle. In this case I was able to identify Trigger point not only in the rotator muscles infraspinatus and teres minor but also in the muscle concerned in scapulo-thoracic motion such as trapezius and levator scapulae. These muscles were accessible to acupuncture although caution was needed with the muscles close to the chest wall making sure that the needles were inserted tangentially to avoid causing a pneumothorax.
A Cochrane review in 2008 concluded that there was not much evidence one way or the other for the use of acupuncture in the treatment of shoulder pain although there may be shorter term benefits in with respect to pain and function however there were few clinical trials and these were methodologically diverse. However when one looks specifically for evidence concerning acupuncture treatment for rotator cuff problems there are some positive findings, for example Kleinhenz (1999) in a RCT showed positive benefits with acupuncture compared to placebo needling in a group of patients with rotator cuff tendinitis. Johansson(2005) showed in a RCT that it was more effective than ultrasound in groups of patients who were also given a home exercise regime. Osborne (2010) found Trps in infraspinatus and teres minor leading to functional problems in abduction and abduction with 90 degrees of internal rotation. In a motion so complicated such as that occurring at the shoulder where a smooth gleno-scapular rhythm is dependent on co-ordinated contraction and relaxation of a number of different muscle groups at speed it easy to imagine how a dysfunctioning muscle that is stiff or weak could so easily disrupt this action. Active Trps can cause pain and if latent shortening, stiffness or weakness of the muscle with associated reduced range of motion and postural changes can occur (Davies,2004). Lucas (2004)using electromyography to measure muscle activation patterns of the scapular rotator muscle group showed that deactivating Trps by needling significantly normalised the temporal sequence of muscle activation with shoulder motion. Wang (2000) showed that in a group of volleyball players where the majority suffered diffuse pain in their dominant shoulder there was a significant difference in the external to internal rotation strength ratio between the dominant and non dominant arms. This strength imbalance may cause a predisposition to tissue damage and the development of Trps in the weaker external rotators by causing instability or overload of the gleno-humeral joint.
In summary Acupuncture can be very useful in the treatment of this type of shoulder pain but should, I believe, be used in conjunction with a suitable rehabilitation regime to strengthen the rotator cuff musculature,

REFERENCES

Davies,C. (2004). The trigger point therapy workbook. 2nd edn. Oakland, CA. New Harbunger Publications Inc.
Green,S, Buchbinder, R. & Hetrick, S.E.(2008).Acupuncture for shoulder pain (Review). The Cochrane Library, Issue 4.
Johansson,K. M., Adolfsson, L.E.& Foldevi,M. O. M. (2005). Effects of acupuncture versus ultrasound in patients with impingement syndrome: randomized clinical trial.Physical Therapy ,85, 490-501.
Kapandji.I.A. (1982) The physiology of the joints. Singapore. Longman Singapore Publishers Pte Ltd
Kleinhenz,J., Streitberger, K., Windeler, J., Güssbacher, A., Mavridis ,G.& Martin,E. (1999). Randomised clinical trial comparing the effects of acupuncture and a newly designed placebo needle in rotator cuff tendinitis. Pain, Nov,83(2),235-41.
Lucas,K.,Polus, B.& Rich, P. (2004). Latent myofascial trigger points: their effect on muscle activation and movement efficiency. J Bodyw Mov Ther, 8,160-6.
Mann F (1999). Reinventing Acupuncture (2nd Ed). Oxford: Butterworth-Heinemann.
Osborne,N.J. &Gatt, I.T. (2010). Management of shoulder injuries using dry needling in elite volleyball players. Acupunct Med, 28(1),42-5.
Rokito ,A.S.,Jobe ,F.W.,Pink,M.M., et al. (1998). Electromyographic analysis of shoulder function during the volleyball serve and spike. J Shoulder Elbow Surg,7,256–63.
Wang,H.K.,Macfarlane ,A.& Cochrane, T. (2000).Isokinetic performance and shoulder mobility in elite volleyball athletes from the United Kingdom. Br J Sports Med,34,39–43.






Blog 5. Mesothelioma posted 10/4/2012

Mesothelioma Symptoms is a great resource that offers information on this rare type of cancer caused by exposure to Asbestos.
Not only does their database give a general overview of this condition,it gives specific details pertaining to complimentary treatments that may help the symptoms from this rare disease.



Various health related articles. perry

Blog 6. Posted 17/5/2012 No one for tennis! Is shoulder pain ruining your Summer Sports?


As the rain stops and summer arrives eventually many of us will find our thoughts wandering in the direction of quintessential English activities. The alluring sweet sound of leather on willow, the patter of deconditioned feet as they scuttle in vain across the tennis courts of Blakers Park, Cream Teas and Pimms, the warmth of the sun beating down on our closed eyes as we listen to the sounds of the birds amongst the trees, the gentle amble across the Downs whilst attempting forlornly to hit the funny little white ball towards a flag in the distance. For many of us summer is the time when we indulge in our favourite sports. These often involve hitting a ball with some sort of implement and this action unfortunately can bring on pain from joints and muscles which haven’t been doing much for the preceding part of the year apart from lifting cups or glasses to our lips whilst watching East Enders, especially if we have poor technique.
Shoulder pain is particularly common with ball players as this is the joint that takes the jarring stress when a ball is firmly struck. How frustrating to be thwarted by an episode of shoulder pain that puts us out for the summer and prevents us from living out our Wimbledon phantasies . A common cause of shoulder pain is the ‘rotator cuff’ syndrome. The rotators are a group of small muscles attached to the shoulder blade which all come together to be inserted into the top of the upper arm. There job is to stabilise the head of the humerus (the upper arm) in the shallow joint of the scapula (glenoid cavity). The shoulder joint is extremely mobile allowing us to place our hands in every conceivable position and this mobility is due to the fact that the joint is very shallow and unconstrained. The stability of this joint is therefore very much dependant on the power and co-ordination of the protecting rotator muscles. If these muscle fail to do their job adequately the humeral head becomes unstable as it moves producing aberrant movements allowing the head to impinge on the tiny tendons that are lying just above it. With time, if this situation continues, this impingement will cause inflammation, the tissues will become swollen and every time certain movement allows the unstable humeral head to rub up against them further pain will be produced. Very characteristically a pain pattern is produced which comes on with certain actions, such as lifting the arm up above the head, but relieved when the arm is resting by the side.
Happily this condition is reversible if managed and treated correctly. The mainstay of treatment is to reduce the inflammation and then rehabilitate the rotator cuff muscles so that the joint becomes stabile thus preventing a recurrence of the problem. In the acute phase anti inflammatory medication may be helpful followed by some form of manual therapy to help reduce the symptoms. I personally find acupuncture very useful in reducing this form of shoulder pain (information concerning this can be found on our website blog page). Very occasionally a more interventional approach is needed including steroid injections or even surgery but this is exceptional. It is essential to commence a regime to improve the strength and co-ordination of the rotator cuff muscle as soon as the pain has diminished (again you can access a regime of these exercises at my website www.nicstraitonosteopathy.com in the blog section). Next Summer before you pick up that racquet or bat it might also be worth having some coaching!

ROTATOR CUFF STRENGTHENING EXERCISES

1.Hold light weight (1kg) in front of you with elbow at right angles. Rotate the arm outwards keeping the elbow tucked into the side. Repeat 20 times (approximately). Rest for one minute and then repeat. Try to do three sets of 20 twice a day. Gradually increase the number of repetitions as you become stronger.

2.Lie on your side holding the weight on the uppermost arm in a similar position as in exercise No 1. Once again rotate the arm outwards and carry out the same routine. Make sure you are keeping the elbow tucked into your side. As you are now working against gravity you may need to start off with fewer repetitions.

3.Lie on your back with the weight in front of you as in No1. Rotate the arm outwards and then back to the original position. Make sure you are keeping the elbow tucked into your side. Repeat as above.

4.Acquire a resistance band (local sports shop usually has these). Attach it to the wall or wrap around a door handle. Move away from the attachment to take up some tension holding the arm in a similar position as in No 1. Then keeping the elbow tucked into the side rotate the arm outwards against resistance. Repeat as in No 1.

5.Same as No 4 but turn around this time so that on this occasion you are rotating the arm inwards.

Try to do these exercises every day.



Various health related articles. dumbells

Blog 7 Posted 20/8/2012 'The Inspired Generation'


As our memories of the glorious two weeks of Summer Olympics begin to fade already the inspired generation can be seen all around us. Creaking knobbly kneed middle aged joggers in GB leotards and false sideburns are now a familiar sight wheezing around Blakers Park whilst Jessica Ellis clones pole vault over the tennis court nets or race the 5b at great speed up Beaconsfield Villas. Flocks of ageing cyclists can be seen whizzing down Havelock road at great speed, their toupees, whigs and false teeth dangerously flying off at alarming angles causing great concern to the open mouthed traffic wardens punching parking tickets on our windscreens with the speed and good humour of Nicola Adams. In the early hours of the morning no lanes are left in the Velodrome and even the seagulls are nervous as young archers and modern Pentatheletes roam around the streets honing their skills with bows and air rifles. My cat in despair left the area many weeks ago blaming Lord Coe, a message was left by her bowl informing us that she will return when all this hysteria has died down and we have gracefully returned to our armchairs in front of the telly.
But all this inspiration comes with a price. Aching muscles, strained backs and shin splints are a common sight in Zeina Clare’s Sports Injury Sessions at the Glovers Yard Clinic. Sometimes simple measures can prevent these injuries such as a simple stretching regime before and after exercise. A slow increment in activity over a long period of time is less likely to produce injuries so why not start off slowly, throw away the remote control, change the channels manually and before you know it you too could be an Olympic champion.



Blog 8 posted 12/11/12 Dr N Straiton

I attended the inaugural PPDA conference in New York last month ‘When Stress Causes Pain'. PPDA stands for Psychophysiologic Disorders Association which is a group of like minded healthcare professional who have an interest in Mind Body conditions. That is in physical or mental illnesses whose underlying cause is due to emotional distress and the way that it is processed rather than alterations in the body tissue. The conference included fascinatingly eclectic presentations from both physicians and psychotherapists alike that gave a meaningful insight into the presentation and management of these complex problems which so often baffle the medical profession especially when the significance of mental thought processes in the manifestation and treatment of illness is ignored. As Henry Maudsley so wisely stated many years ago "The sorrow which has no vent in tears may make other organs weep."

The conference message was that when a illness persists where there is no evidence of tissue damage one must abandon ‘faux’ labelling, that is dubious syndromes fabricated to make sense of often paradoxical symptoms or signs, and start to understand the patient as a sentient living being with a unique rubric of physical and psychological attributes that determines, to a certain degree ,its ability to maintain homeostasis or good health on its personal journey through the joys and vicissitudes of live.

The link to the PPDA is on my TMS page. I would particularly recommend Dr Howard Schubiner’s wonderful book ‘Unlearn your Pain’ to anyone interested in Mind Body conditions.



Blog 9 Tennis Elbow June 2013 Dr N Straiton

Tennis Elbow or Lateral elbow tendinopathy is a painful conditioning affecting the elbow region. The problem is thought to be due to repeated microtrauma to the area of tendon insertion to the bone leading to a cycle of degeneration and repair resulting in weakening of the tendon. Typically the pain is worse with gripping or extending the wrist. In racquet players change in racquet size, grip size or string tension may be relevant as well as any recent modifications of technique. The diagnosis is usually easily made clinically and therefore further investigations are seldom needed. Research has shown that commonly grip strength and its mechanism is compromised after a while in this condition which need to be corrected at some stage in order for a full recovery is made. This means that, as well as any passive treatment modality required to reduce pain and facilitate healing, active rehabilitation to correct grip strength deficit and upper limb coordination impairment is vital to ensure a complete recovery. A number of treatment modalities have been shown to be beneficial for this condition including manual therapy, acupuncture, bracing, extracorporeal shock wave therapy, corticosteroid injections and autologous blood injection. Steroid injections are very effective in producing symptomatic relief in the short term but there are concerns that there may delayed complete recovery and greater recurrence with their use. There is therefore increasing interest in the use of autologous blood injections in producing a more permanent solution to the problem. Surgery is possible if all else fails but is seldom necessary.
Several recent studies have demonstrated that Autologous Blood Injection (ABI) for tennis elbow and also for the treatment of other tendonoses such as plantar fasciitis and patella tendonoses can be helpful. It is assumed that ABI works via Transforming Growth Factor Beta and Basic Fibroblast Growth Factor carried in the blood will act as mediators to induce a "healing cascade".
Normally repair involves neovascularisation and this tissue contains a large number of pain receptors Excessive amounts of this tissue has been postulated as a possible cause for the symptom of pain in tendinosis although this is a simplistic theory.
Using ultrasound scanning, it has been seen that following autologous blood injection there is a reduction in tendon thickness and inflammatory changes seen with the tendon. There is also a partial resolution of tendon tears following injection. One of the first studies by Edwards and Calandruccio showed that after an average follow up of 9.5 months there was an improvement in pain and movement in 22 out of 28 patients.
The actual procedure is very simple essentially, blood being taken out of one arm and injected into the problematic region. One injection is normally only required, pain relief usually occurring within the first 4-6 weeks but there may occasionally be a requirement of a second injection four weeks later.
From recent studies it would appear that autologous blood injections have a more permanent effect on long-term benefit than that achieved with injection of corticosteroid (cortisone injections). This is probably related to the healing benefits of ABI causing the tendon to return to its pre-injury state rather than simply relying on the anti-inflammatory action of corticosteroid injections.


References:
Sheth U, Simunovic N, Klein G, Fu F, Einhorn TA, Schemitsch E, Ayeni OR, Bhandari M. Efficacy of autologous platelet-rich plasma use for orthopaedic indications: A meta-analysis. J Bone Joint Surg Am 2012 Jan 11.
Creaney L, Wallace A, Curtis M, Connell D. Growth factor-based therapies provide additional benefit beyond physical therapy in resistant elbow tendinopathy: a prospective, single-blind, randomised trial of autologous blood injections versus platelet-rich plasma injections. Br J Sports Med 2011;45:966-971.
Van Ark M, Zwerver J, Van den Akker-Scheek I. Injection treatments for patellar tendinopathy. Br J Sports Med 2011;45:1068-1076
Edwards SG, Calandruccio JH... Autologous blood injections for refractory lateral epicondylitis. J Hand Surg 2003;28A:272-278
Iwasaki M, Nakahara H, Nakata K, Nakase T, Kimura T, Ono K. Regulation of proliferation and osteochondrogenic differentiation of periosteum-derived cells by transforming growth factor-β and basic fibroblast growth factor. J Bone Joint Surg 1995;77A:543-554.
Connell D, Burke F, Coombes P, McNealy S, Freeman D, Pryde D, Hoy G. Sonographic examination of lateral epicondylitis. AJR 2001;176:777-782
Kraushaar BS, Nirschl RP. Tendinosis of the elbow (Tennis Elbow). Clinical features and findings of histological, immunohistochemical and electron microscopy studies. J Bone Joint Surg 1999;81-A:269-278.
Lian O, Holken KJ, Engebrestson L, Bahr R. Relationship between symptoms of jumper's knee and the ultrasound characteristics of the patellar tendon among high level male volleyball players. Scand J Med Scit Sports 1996;6:291-296
Khan KM, Cook, JK. Overuse tendon injuries. Clinical Sports Medicine, McGraw-Hill 2nd edition January 2001.



20 November 2013 How to be happy!

How to be happy!

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