Health Article

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Low Back Pain

Roughly 85% of the general population experiences back pain at some point in their lives. Anyone who has endured serious back pain, has most likely heard all their friends' and neighbors' back pain stories — what worked for them and what didn't. The low back is mechanically one of the most complex areas of the human body. So, one person's back pain may be due to different structures being injured than another person's. The treatment for each type of back pain should be unique.

ANATOMY
The anatomy of the lower back region is rather complex and will be touched on in Part II. However it is important to understand that there are many different structures which can be injured, and this will dictate the type of exercise which is appropriate. Inappropriate exercise may further damage the low back.ANATOMY

The eleven bones of the low back area consist of the lumbar spine (which are the last five vertebrae, or moveable segments, of the spine), the sacrum and tailbone (the bony area between the buttocks), the pelvis and, to a certain extent, the hips (femurs). Joints are surfaces where bone meets bone. Without going into excruciating detail, there are approximately 20 joints included in the low back area. Each joint is surrounded by ligaments. Ligaments act similarly to tape by holding the joints together, allowing movement in some directions while restricting it in others. Muscles not only move the bones, and consequently the trunk, but they also stabilize the trunk when the extremities are moving. The lower back area has large muscles extending more or less from the sacrum all the way up to the arms (i.e. latissimus dorsi), as well as many smaller muscles which only span one or two joints. Between the vertebral bodies are discs, which act as shock absorbers. The spinal canal runs inside the vertebrae and includes the spinal cord and spinal nerve roots. The nerve roots exit in-between the vertebrae and travel to all different parts of the body. The nerves which exit between the lumbar vertebrae supply the buttocks, thighs, legs, feet, as well as organs such as the intestines.

PATHOLOGY
A person experiencing low back pain may have damaged any of the structures mentioned above. Some of the most common problems are:

Joint locking/subluxation
If the joints are not moving symmetrically in all possible directions, an imbalance is created. The locking itself may be painful or may lead to compensations, such as tight muscles, improper body mechanics, irritation of the structures adjacent to the locking. The lumbar facet joints and the sacroiliac joints often exhibit this problem. A slight joint dislocation or malposition of bones is often called a subluxation (although chiropractors will also often include joint locking under the term subluxation as well). This is commonly seen in the sacroiliac joints. Joint locking or subluxations predispose one to many of the following problems. Treatment: chiropractic adjustments. Assess for predisposing factors, such as muscle imbalances.

Muscle strain
A tear in the muscle fibers. Usually a mechanical cause, such as lifting a couch awkwardly, or spending a long period of time doing an unaccustomed activity, such as gardening. Muscle strain may also result from poorly functioning joints (see above). Treatment: Initially ice, then alternate ice and heat, rest the muscle, physical therapy modalities (such as ultrasound, interferential current), assess for predisposing factors such as joint locking, muscle imbalances.

Ligament sprain
A tearing of the ligaments. Similar causes as above, but usually associated with trauma. Ligament injuries may lead to instability, especially of the sacroiliac joints. This in turn may cause muscles to tighten, and nerves to become irritated. Treatment: Same as above, although my preference is to stick with ice, and only use heat if you find it helps, assess for predisposing factors as above.

Facet Syndrome
An irritation of the posterior joints of the lumbar vertebrae. This may cause localized pain and muscle spasm, as well as sciatica (see below). People with Facet Syndrome often find swimming in a long course pool irritating to their low back. Short course allows them to flex their spine on each flip turn. Dolphin kicking or butterfly swimming may also aggravate this problem. Treatment: Same as above. The MacKenzie exercise protocol tends to aggravate Facet Syndrome. Stick with flexion exercises until asymptotic.

Piriformis Syndrome
A tightness/spasm of the piriformis muscle (connects the sacrum to the top of the femur/hip; a muscle deep in the buttocks). Typically this will cause pain into the buttocks, which may radiate down the thigh to the leg (sciatica). Treatment: Stretch the piriformis muscle, physical therapy modalities to the muscle, acupuncture or triggerpoint work to the muscle, stretch the piriformis muscle.

Disc related problems
Discs may bulge, herniate, or prolapse. However, this kind of problem may also result in all sorts of symptoms such as sciatica (nerve pain into the buttocks, thigh, often to the foot), tingling, numbness, and/or weakness of those same areas, muscle spasm, and in severe cases paralysis of the lower extremities. Treatment: Most cases are amenable to chiropractic treatment with the use of physical therapy modalities and rehabilitation exercises (MacKenzie protocol often very helpful here). It is only the rare case that requires surgery. It is important to note that about 40% of the population not experiencing low back pain will show some disc bulging on an MRI study. Swimmers with disc problems need to be especially cautious when diving. Unless it is extremely important that you dive, start from the water. Also, during the acute phase be gentle during or avoid flip turns.

Low Back Rehabilitation Exercises
Generally, one can break down low back rehabilitation exercises into four schools of thought:

McKenzie — The Lordosis Theory

Low back pain is due to a flattening of the normal lumbar curve (also known as a lordosis), thereby stressing the pain sensitive muscles and other lower back components (such as joints or ligaments). Treatment is directed toward low back extension (backwards leaning, Cobra position in yoga), thus accentuating the lordosis. These exercises are often given to people with a herniated disc.

Williams — The Flexion Theory
There is a lower incidence of back pain in agrarian cultures in which people regularly assume a "squat" position, thus flattening the lumbar spine. Low back flexion exercises and treatment maneuvers were developed based on this observation. People with pain in their posterior lumbar joints (facet joints) or those who've strained their lower back muscles benefit from these exercises.

Muscle Imbalances
Tight muscles, such as hip flexors (psoas, rectus femoris) inhibit weaker muscles, such as abdominal muscles. The treatment is first directed toward stretching the tight muscles and then strengthening the weak muscles. Although certain patterns exist, each patient must be assessed individually.
An example from swimming: A good strong flutter kick requires strong hip extensor muscles (gluteus maximus, hamstrings). If yours are weak (due to any number of factors which should be diagnosed), you will tend to use your inappropriate low back muscles instead (lumbar erector spinae muscles). Needless to say, you will probably not be the swiftest flutter kicker, and you'll probably experience low back pain after long kick sets.

Proprioceptive Deficits
Proprioception is the ability of the brain/nervous system to assess the position of a joint in space. Good proprioception is important for balance. While many rehabilitation exercises are floor exercises (on a stable surface), most people injure themselves when their body is off balance (i.e. pulling clothes out of the dryer). Proprioceptive exercises train the body to maintain stability and balance in different situations. These exercises are often done with the Swiss ball and/or rockerboards and wobbleboards.

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Nutritional Management of Primary Dysmenorrhea

Essential Fatty Acids
Essential fatty acids (EFAs), such as linoleic acid (LA) and gamma-linolenic acid (GLA), are vital precursors of prostaglandins. The anti-inflammatory series 1 PGs are derived from LA, which is converted to GLA by the enzyme delta-6-desaturase (D6D), and then to dihomo-gamma-linolenic acid (DGLA). Nutrients known to increase the conversion of EFAs to the anti-inflammatory series 1 PGs include magnesium, vitamin B6, zinc, niacin, and vitamin C. Factors that interfere with the production of anti-inflammatory PGs include diets rich in saturated fats, alcohol consumption, and catecholamines released from the adrenal medulla during stress.
Arachidonic acid (AA), found in animal fats, is the precursor of the pro-inflammatory series 2 PGs. Much of the AA used for 2 series PG formation comes from dietary sources, notably meat and dairy products.7 A deficiency of EFAs, either due to inadequate intake or failure of normal conversion of linoleic acid to GLA, and a high consumption of saturated animal fats can result in overproduction of AA to the pro-inflammatory PGs.
Because there is little GLA or DGLA in the usual human diet, supplementation with GLA-rich evening primrose oil or borage seed oil may effectively reduce the production of pro-inflammatory PGs in favor of anti-inflammatory PGs.
Magnesium
Magnesium’s role in dysmenorrhea may be due to several factors:
1) magnesium has a direct effect on vascular tone and can act physiologically to control and regulate the entry of calcium into smooth muscle cells, acting as a naturally occurring calcium channel blocker. Through controlling calcium, magnesium influences the contractility, tone, and relaxation of the uterine smooth muscle;
2) magnesium is required for the synthesis of second messenger cAMP (cyclic AMP) from adenosine triphosphate (ATP).cAMP, a ubiquitous nucleotide derived from ATP through the action of the enzyme adenylate cyclase, plays a crucial role in the communication process between the gonadotropins (LH, FSH) and the ovaries
3) magnesium plays an important role in the conversion of LA to GLA, a rate limiting step in anti-inflammatory series 1 PG synthesis, and may inhibit the synthesis of PGF2α;
4) magnesium is involved in estrogen conjugation and the activation of the B vitamins, especially vitamin B6.
Large numbers of women may be at risk for magnesium deficiency. Dietary intake studies consistently show intakes of magnesium to be below the RDA in many age groups, with teenage girls and adult women among those most at risk of low intakes. Magnesium depletion can be compounded by the use of diuretics, increased alcohol and dietary fat intakes, a high intake of dairy products, stress, and malabsorption syndromes.
Vitamin B6
Vitamin B6 (pyridoxine hydrochloride) is an important cofactor for the conversion of LA to DGLA in the production of antiinflammatory PGs; for enzymes involved in estrogen conjugation in the liver; and for the synthesis of several eurotransmitters. With decreased levels of B6 in the body, the liver cannot conjugate estrogens, thus causing an increased blood level of estrogens. Vitamin B6 also stimulates cell membrane transfer of magnesium and increases intracellular magnesium, which plays a role in muscle relaxation.

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Conventional Treatment Options for Primary Dysmenorrhea

PG synthetase inhibitors (non-steroidal anti-inflammatory drugs), such as ibuprofen, mefanamic acid, naproxen, and indomethacin, have been used as analgesic treatment for dysmenorrhea since the early 1970s.1,19 Prior to their discovery, women who had dysmenorrhea were dependent largely on narcotics or oral contraceptives for pain relief.8 PG inhibitors block PG synthesis early in the inflammatory reaction by inhibiting the cyclooxygenase pathway. Once pain has become severe, relief is unlikely. However, these drugs should not be used prior to the onset of menses because of their teratogenic potential.
In a comprehensive review of clinical trials of PG inhibitors in the treatment of primary dysmenorrhea, it was found that significant pain relief was reported for each of the PG inhibitors for the majority of women.1 However, the authors concluded that 9% to 22% of dysmenorrheic women will not benefit from PG inhibitor treatment, possibly because some of these women may have secondary dysmenorrhea. While PG inhibitors are generally recognized as effective against pain, there are drawbacks. These drugs are not selective in their inhibition of PGs, translating to a reduction of all PGs, good or bad. In addition, possible side effects include dizziness, headache, nausea, vomiting, heartburn, and diarrhea, as well as GI damage with protracted use.
Cyclic administration of oral contraceptives, usually in the lowest dosage but occasionally with increased estrogen, is also used to alleviate pain. The mechanism of pain relief may be related to absence of ovulation or to altered endometrium resulting in decreased prostaglandin production during the luteal phase. Surgery is a rare form of intervention used in women who do not respond to medication.

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Your First Pelvic Exam

Having routine pelvic exams are important for good reproductive health. A woman should have her first GYN exam when she is first thinking about becoming sexually active, or as soon as she becomes sexually active, or by the time she is age eighteen. There are many female gynecologists, nurse practitioners, and physician's assistants today if you prefer a woman to provide you with your GYN health care. It’s usually easy to find one in the United States and Canada. Of course, many women still use male health care providers or gynecologists for their GYN exams.

Whomever you choose, it’s essential that you be comfortable and honest with her/him, and that you feel confident that you will receive quality, attentive care. If you are not satisfied with someone you have seen, find someone else.

Before your appointment be ready with some information about your family medical history which you may be asked to provide. Among the most common questions are the following:
* When did your last period start? (Or, when was your LMP; LMP= last menstrual. period.)
* At what age did you start menstruating?
* How long does your period usually last?

These question are an important part of your GYN history and in the future may help you to get pregnant if and when that time comes.

At the visit to the gynecologist you will have a short general physical exam including a breast exam. You will wear some sort of hospital gown and nothing else. For the actual pelvic examination, you will lie down on an examining table with your feet resting in elevated "stirrups" -- props that support your legs in the air. Stirrups might look a little scary, but they are really just there to rest your feet in and keep you more comfortable. Your legs will be spread apart, with your knees falling to each side to expose your genitals. Almost everyone feels uncomfortable and vulnerable the first few times they are in this position... of course, who wouldn't, but it's important to relax and realize that everyone goes through this, and soon you won't feel so uncomfortable. Even the health care provider who is examining you (if it is a woman) goes through the same exam.

The pelvic exam should not hurt and if at any point it does, make sure to let the practitioner know. If it is stressful or uncomfortable, the best way to help is to try to relax with some deep breaths. As with any other medical procedure, if you tense up your muscles and go stiff, the exam becomes more difficult. If you are informed ahead of time about what the exam involves, and you're comfortable with your practitioner, there is no reason to be nervous. She or he will most likely tell you what they are doing when they are doing it. Make sure they know if this is your first pelvic exam.

The External Exam
The practitioner will visually examine your vulva for discoloration, irritation, swelling and other abnormalities, and she will gently feel for glands.

The Internal Exam
There are two parts to the internal exam. The first involves a speculum (speck-you-lum), which is a metal or plastic instrument that the practitioner inserts into the vagina. The speculum is shaped sort of like a duck's bill, and once it is inserted into the vaginal canal it can be gently widened to spread the interior vaginal walls. (The vagina is collapsed in its relaxed state, but it can widen easily to accommodate tampons, fingers, penises, and even babies.) As the vaginal walls are spread, the practitioner is able to see clearly the walls of the vagina itself, and up the vaginal canal to the cervix. In viewing the vaginal canal and the cervix, the practitioner can look for discoloration, abnormal discharge, lesions, growths and signs of infection. It is possible for you to look at your own cervix during this process by propping yourself up on your elbows and using a mirror. Some practitioners ask if you would like to do this, but feel free to ask to if she doesn't mention it first. It is incredibly enlightening to actually see what your anatomy looks like, and it can clear up a lot of confusion.

Pap Smear
Next the practitioner will take a pap smear. She/he uses a long stemmed cotton tipped swab to collect a sample of the cells in the cervix. Some women feel a slight cramping sensation when their cervix is touched. The collected cells are smeared onto a slide and sent to a lab for testing and examination. The pap smear is extremely important for picking up abnormalities of the cells in the cervix which may indicate infection or disease.

Testing For STDs
If you are sexually active, the practitioner will then test for STDs. Be sure to ask the person to do them. She or he will swab the inside of the cervix with what looks like a long cotton swab or two. The speculum is then slid out of the vagina. The samples are sent out to a laboratory where they tested for various STDs. The tests will take a couple days or more depending on how busy the lab is. Ask when your results will be back so you can call them if you want your visit to be totally confidential. If you want to be tested for HIV, syphilis or hepatitis you need to have blood taken. They can do that there also. But, they may not do that routinely, you will need to ask. (See our STDs section for more details.)

There is a blood test now that can show if a person has been infected at any time with genital herpes (HSV). There are also newer blood tests that can tell whether a person has been infected with HSV-I and/or HSV-II. This test will not be done routinely, so that is also something you would ask for if you are or had been sexually active.

Manual Exam
The second part of the pelvic exam is called the manual or bi-manual exam. The practitioner will insert one or two fingers into your vagina and press with her/his other hand on the outside of your lower abdomen. They will use a lubricant on their fingers so it is more comfortable and easier to feel things. The person can then feel the uterus, fallopian tubes and ovaries, and check for any swelling or tenderness. Once the doctor or nurse practitioner is finished checking your uterus and ovaries, the exam is complete. Even though reading about it may make it seem long, the entire pelvic exam (the parts involving your vagina, cervix, uterus, and ovaries) really only takes about 3 to 5 minutes.

Breast Exam
The doctor or nurse practitioner will give you a breast exam by pressing with his or her fingers on different parts of your breasts. This is necessary to help look for "normal" lumps (which are quite common and are harmless), cysts, or, in very rare cases, breast cancer. After finishing, he or she may ask you to examine yourself, or may move your fingers to show you how to do it. Although breast cancer is very unusual in teenage girls, it's important that you learn to examine your breasts yourself, since knowing how your breasts feel early on can help you detect problems later. The doctor or nurse practitioner will explain exactly how and when to do breast self-exams and answer any questions you have.

Writer: Amy Otis, RN

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All You Need To Know About Hypnosis

There are many stories about hypnotherapy being dangerous, turning people into chickens, people not being able to wake up, and unscrupulous hypnotists exploiting their ‘vulnerable’ patients. However there are many people who are adamant that it has helped change their lives, helping them succeed in their goals. Millions of people swear that it has helped them with many issues such as weight loss, quitting smoking, other addictions, confidence, phobias, stress, success, IBS, and many more issues.

There is a large and growing tradition of hypnosis being used for therapeutic purposes, not just for entertainment. In fact therapeutic and entertainment hypnosis are two very different things. A clinical hypnotherapist does not aim to create the illusion of having people ‘under’ his control. Stage hypnotists do this with the clever use of pressure, showmanship, and choosing the correct participants.
Many people are missing out on this powerful yet safe therapeutic tool because they are too afraid to use it. I hope to dispel these fears by answering these common questions about hypnotherapy.

Can I be hypnotized?
Most people can go into a hypnotic trance. The only types of people that cannot be hypnotised are …
1. Those suffering from psychosis or a thought disorder
2. A person with a low IQ
3. A person does not want to be hypnotised. It is very easy to resist hypnosis (in all its forms) if you want to.

What is a hypnotic trance?
It is a normal and natural state that most of us experience several times a day. It commonly happens when people are driving. Have you ever driven somewhere and not really remembered the journey? It also often occurs when reading a book or watching TV. Sometimes you can be so absorbed in the book or TV programme that you are not consciously aware that someone is talking to you. Hypnosis is the focussing of the conscious attention in such a narrow corridor of influence. The conscious mind is so intensely focussed that other influences are not being critically analysed by the conscious mind. We still hear them, although we are not always aware. A good example of this is when you are in a place where there are several conversations going on at once. They may all sound like a mass of background noise. However if someone in one of those conversations mentions your name, you then consciously focus on that conversation. How did you know someone said your name? Your subconscious mind (which is far more powerful than your conscious mind) was listening to EVERY conversation AT THE SAME TIME! That is perhaps a reason why you can sometimes “just know” something. Your subconscious mind has absorbed it without you consciously being aware.

What does hypnosis feel like?
When in a trance you feel more mentally and physically relaxed. It is a very pleasant experience, and you can tell that you are still in control. You can still hear exactly what is going on around you, unless you choose to drift your attention away. You become aware that you can easily stand up, talk, or move whenever you want. A lot of people (me included) when they first experience a hypnotic trance move their fingers or hands in order to test whether they can move at will. Sometimes a patient can be a little difficult to wake up. This is not a sinister thing as it has been portrayed. No one has ever been stuck in trance. It is more a case that a patient just “can’t be bothered” to wake up as it feels so pleasant. However they soon become bored and will wake up pretty soon. One trick the old hypnosis pro’s use is to tell the patient that they are charging for the time. It’s amazing how quickly they then wake up!

Is hypnosis dangerous?
A hypnotic trance is actually a very natural state that almost everyone goes into several times per day. In 1955 the British Medical Association set up an inquiry which favourably reported hypnosis as a therapeutic tool. It even recommended that it should be taught at medical schools. Hypnosis was also approved by the Council of Mental Health of the American Medical Association in September of 1958 as a safe practice with no harmful side effects. Since then there has been acceleration in the establishment of hypnosis societies for doctors, dentists, and psychologists. No one has been seriously hurt with hypnosis.

Can I be made to do things against my will?
You could never be made to do anything against your will or contrary to your value system. If this was actually possible, would there not be criminals learning the art of hypnotherapy in order to hypnotise their bank managers to opening the vaults and handing over a large sum of cash?! In a trance, you would not unknowingly reveal your deepest secrets. You can even lie when in a trance, which is one reason why testimony in hypnosis is not permissible evidence in a court of law. It is only used by police to help with the investigation. A person will only act upon suggestions that serve them in some way or reinforce an expected behaviour, anything else their subconscious will just ignore. Most people develop these misperceptions from seeing or hearing about a Stage Hypnosis show. However they largely achieve their results from showmanship, selection of the more extrovert people, and peer pressure.

How long will it take before I notice a change?
In one session, you can expect to become more relaxed than you are right now. Most people do not relax enough, and some people never seem to relax! Being more relaxed can help most mental and physical problems that you may have. I have often had patients report back to me that people noticed that they seemed more relaxed after just one session. In the past I have significantly helped problems such as IBS, skin complaints, and addictions, simply by doing relaxation work.
Hypnosis can bridge the gap between your head and your heart, making your goals much more emotionally compelling, and therefore increasing your chances of permanent change. Depending upon the intensity and number of sessions, you will notice suggestions for the desired behavioural changes spontaneously popping into your conscious mind almost immediately.
Please keep an open mind when deciding if to use hypnotherapy. I have been a clinical hypnotherapist, trained by the London College of Clinical Hypnotherapy (LCCH), for several years. During this time I have witnessed many things that, quite frankly amaze me at times! I have helped so many people in so many ways, that I feel it would be such a shame for people to opt out simply due to unfounded fear and misinformation. Make sure you find a therapist that has received good training from a well respected body, such as the LCCH, and you will not be disappointed. It is not perfect. Hypnosis does not solve everything all the time. However it does help almost all of the time, and can create amazing changes some of the time. With a well qualified practitioner, you are pretty much guaranteed a comforting, relaxing, and enjoyable experience, as well as a shot at gaining very good ground towards your goals. I hope you are not missing out for the wrong reasons.

About the Author

Jon Rhodes is a well respected UK clinical hypnotherapist. He runs a free hypnosis site at http://www.freehypnosistreatment.com

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