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  Fundamental MedicineTeresa Gryder, ND

What to Do for a Shoulder Injury

9/13/2018

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Shoulders are complicated. They're not like the hip, with a deep socket that makes them stable. The socket for the shoulder is a shallow divet on the front face of the shoulder blade, and the parts are held together by a collection of sinew, muscle and bone known collectively as the shoulder girdle. The shoulder has the biggest range of motion of any joint in the body, and because of this it is more vulnerable to injury.

The bones of the shoulder girdle are the shoulder blades and collar bones. The breast bone is considered part of the axial (midline) skeleton and serves as a kind of keystone in the arch of the shoulder girdle, keeping the shoulders wide. The shoulder blades are big flat bones that slide around on your upper back. They are held in place by sheets of fascia and the muscles that attach to them. The sinew of the girdle is fascia, tendons and ligaments. When these strong connective tissues are disrupted the whole thing falls apart. When all the parts are strong we can swing from trees like other primates, do hand stands and push-ups, reach forward to do fine work with our hands, throw a spear or a ball, swim long distances and reach the finest liquor on the top shelf. You may never realize, until you injure one, just how many things a shoulder does.

There are many ways to hurt your shoulders. You can tear the labrum, which is a disc of cartilage inside the joint that provides padding and a connection point for some tendons. You can injure the rotator cuff, which is a set of four small muscles and their tendons that comprise the deepest part of the joint capsule and help prevent dislocations. The supraspinatus tendon is one of the most commonly injured parts of the rotator cuff, and the injuries accumulate with age. We also are more likely to have arthritis and impingement syndromes with age. There are lots of muscles outside the rotator cuff that can get torn up. You can stretch or rupture the ligaments that hold the collar bones in place, most commonly the AC (acromioclavicular) ligament but there are others. You can tear the big muscles of the shoulder or you can even completely dislocate the ball from the socket, which can damage lots of things including nerves and blood vessels. You can make such a mess of your shoulder that you think you will never be able to pick up your own arm again, but unless you have ruptured tendons, it may heal on its own. You can even function without some of the tendons; the body has redundancy and it adapts. Given time and the ingredients for healing, our bodies can do amazing things.

I am a whitewater kayaker. Kayaking is almost as hard on shoulders as throwing or swimming. Not only are your shoulders part of the propulsion linkage for paddling, but they are used for balance in bracing, and for righting yourself when you flip over by using the Eskimo roll. I have injured my shoulders many times, and I have supported a lot of friends and patients as they go through shoulder injuries and surgeries. The most recent time I was injured I thought it would require surgery. I took 6 months off from kayaking (which was a long time) and my return to the river was gradual. After a year I was getting after it—without having surgery. People who get surgery rarely have outcomes better than that. Shoulder injuries are painful and slow to heal. The good news is that they usually do, you just have to be patient enough and keep moving.

Most people will go see their primary care doctor when the injury is painful, interferes with daily activities or favorite sports, and doesn’t get better fast enough. If you go to a doctor for your shoulder, you should get a proper shoulder exam. The doctor should test your strength and range of motion with a bunch of strange challenges. They’ll tell you to push out. Pull in. Lift your elbow against my hand. Pat your belly. If the doctor doesn't do a thorough exam, go to another doctor. The shoulder is complicated, and not every doctor is an expert on it. A person who knows the anatomy of the joint and how to examine it will be able to diagnose the injury better than all the fancy imaging in the world. This is called a clinical diagnosis, and with shoulders a good clinical diagnosis is more useful than imaging. With a good exam and clinical diagnosis you get better information about the prognosis and treatment for your shoulder than what you can get from an MRI, but again, this all depends on your doctor having knowledge and exam skills specific to the shoulder.

If the injury is severe and you have good insurance, your doctor may send you for an MRI and refer you to a surgeon for a consult. If you go this route, odds are good that the surgeon will want to operate. After all, that is what they do. This is when you should slow down and take some deep breaths. Do not rush under the knife. It is common to be told that you should get it done immediately. Take that statement with a grain of salt. If a tendon is completely ruptured, the muscle will dissolve away if it is not reattached soon, so that is a reason to get it done now. If that's not the case then get a second opinion. Odds are good that the second opinion will be different from the first, and if that is the case, you can go with the one you trust more, or get a third opinion for a tie breaker.

In most cases doctors will suggest physical therapy before considering surgery. Surgery is something to avoid unless it is really necessary. Shoulders can be badly hurt and refuse to work at all, and then later recover completely, or completely enough that you can do everything you want to do. So do not give up. If you decide to do physical therapy, do the exercises and keep after it. Over time you will learn more exercises and graduate to harder ones. Save the instructions and make a notebook of shoulder exercises for yourself. The same exercises you use to rehabilitate after an injury may be useful in the future for prevention.

If you decide that surgery is indeed what you must do, shop around for the best shoulder surgeon in your region. Surgeons will usually tell you that they do not know what they will do to your shoulder until they stick a camera in there and start working on you. But each surgeon has a slightly different approach. Ask about the procedures that they do most, and their strategies with regard to the shoulder. Find out as much as you can about their approach and philosophy and compare surgeons with each other. Surgeons don’t always communicate very well—they may prefer their customers anesthetized. Get someone to go with you to your consults to make sure you get the information you need. Find a surgeon you trust.

If you decide to avoid the knife and heal up your shoulder yourself, it's important to be gentle with yourself. Healing up from an injury usually takes less time than healing after a surgery, but for shoulders both are slow because there’s not a lot of blood circulating inside the shoulder joint. PT’s can offer expert advice about what kinds of exercises to do. Your average personal trainer could do you harm.  Therapeutic shoulder exercises usually involve bands or light weights, and having good posture really helps. You will want informed recommendations on diet, botanical medicine and other alternatives to enhance healing. I can offer those things and provide referrals for injection therapies (prolo or PRP), hydrotherapy and other treatments as needed. Depending on your injury it could be 6 months before you feel comfortable returning to your usual activities, and a year or more before you are all the way back up to speed. Definitely keep exercising however you can, because keeping yourself fit supports your body's efforts to fix any injured parts.

Keeping moving is always key. It's OK to rest a body part for a little while when it's hurting from an injury, but move the rest of you, and move the hurt part as soon as you can stand to.  If you keep a shoulder still too long it can freeze in place and it is excruciating to break a frozen shoulder free. Learn the exercises to strengthen the small muscles of the rotator cuff and the big muscles of the shoulder girdle and do them properly. Develop routines for moving your shoulder through its entire range. Swing like a monkey, do push-ups and other intense exercises only when your shoulders are ready.

If you need help or encouragement in making decisions about surgery, or for healing a shoulder whether they operated or not, I would be glad to assist. I can help you find the right shoulder surgeon if you need one, and come with you to appointments to be your medical advocate.  I have a great protocol for surgery prep to increase your odds of an excellent outcome, and I can set you up with a recovery protocol specific to you and your needs. While PT’s specialize in exercises and conventional doctors give meds and do surgery, I can help with all the other ways to support healing. You can use the contact form on this website or contact me directly for more information.
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CPR UPDATE 2015

3/29/2015

 

You probably don’t want to think about it.  It’s gross, it’s difficult, it’s sad.  Most people who get CPR are goners.  Maybe you never want to take another class.  OK, I can accept that.  What I can’t accept is that you might not even try to do CPR, or that if you do try, your efforts could be ineffectual and wasted.  I’m writing this to encourage you to know the basics of quality CPR, even if you don’t get the certification.  You wouldn’t stand idly aside if someone were dying in front of you.  We would all do what we could.  CPR is what we can do.  So please read this and make mental notes, just in case.  Print out the steps at the end and stick them in your car or first aid kit.  If you try to help and do the best you know, you are protected from liability by the Good Samaritan Law.  Some people get CPR and live.  You could save a life.

The American Heart Association updates their teachings each five years, and the last update meeting was in 2010.  This is what they have taught since then.  The next meeting will be in October 2015 and the update will come out in April 2016.

Science has shown that it’s more important to get the blood moving right away than it is to try and push air in.  They’ve cut the beginning part short to get you doing compressions sooner, because it makes a big difference in survival.  The sooner you start moving blood, the better the victim’s chances.  There’s enough oxygen already in the blood to keep the brain alive for a while, you just have to get it there.

Before you dive into the assessment process, look around to be sure the scene is safe.  Think about it and take care of yourself.  If you have to, move them.  CPR works better if they are laying on a hard flat surface, and if you cut or lift any interfering clothing including a bra.  Don’t have a committee meeting about it, just do it.  Don’t torque the neck if there is a risk of head or neck trauma.  Look for any life threatening injuries, like heavy bleeding or a broken neck.  It doesn’t help to save a person from one threat while another one kills them.

Quickly make sure they’re not napping.  If they don’t respond to a light touch and loud voice, assess for responsiveness by rubbing a knuckle on their collarbone or breastbone, or flick the foot of a baby.  If there are no obvious signs of life and consciousness, have someone call 911.  Next check for a pulse in their neck (the carotid artery).  This is something to practice, so that you know where that pulse ought to be.  If you aren’t sure, or can’t find a heartbeat, start compressions.  If there’s a defibrillator (AED) around, send someone for it.  Likewise it’s very nice to have a face mask of some kind if it’s available. Positive pressure oxygen can also help.

They’ve stopped telling us to measure our hand position on the chest.  Just mash hard on the bottom half of the breastbone with the heel of your hand.  Using straight arms and both hands, drop your upper body weight to compress the chest at least 2 inches on adults.  The compressions should be less for small people; compress no more than 1/3 the body thickness.  Lift up in between compressions to let the chest rebound as far as it will.  This gets to be the hard part when you are tired; don’t lean on the chest.  The best quality compressions get about 30% of normal blood flow.

When you start doing CPR on an adult, you can expect for cartilage and ribs to make crunching sounds.  Don’t let it stop you.  You can expect the patient to vomit; don’t let it stop you.  You can expect to get tired.  Switch positions every 2 minutes if you have help.  If you see this going on, rotate in.  You could save a life.

The rate of compressions is at least 100/minute (max 120), same as the BeeGees song “Stayin’ Alive”.  If you know it, sing it internally and get the beat.  The ratio of compressions to breaths for adults is 30:2 for both one and two person scenarios.  The person doing compressions is supposed to count out loud. This keeps you from going too fast.  

Getting air in requires that you open the airway, pinch the nose shut, and blow in the mouth.  The head tilt chin lift is the standard way; bend the head back and pull the jaw forward with fingers under the chin.  It is possible to tilt the head too far and close the airway.  You will know if you are getting air in.  Blow in a smallish normal breath, about 200ccs of air, just enough for the chest to rise.  Don’t overventilate.  If you blow too much air in you fill the belly instead of the lungs, increase the vomiting, and decrease the freedom of the diaphragm to move.  If they vomit, roll the victim on his side and finger sweep out the vomitus before blowing more air in.

There are differences for children up to the age of puberty.  The ratio 15:2 if there are two rescuers, but the same 30:2 for one rescuer.  If you are alone and don’t know how long the kid has been down, do 2 minutes of compressions (5 sets of 30) before you even go for help.  Be extra careful not to overfill them with air; small puffs instead of breaths is all you need to make the chest rise.  Instead of compressing an infant’s chest with both hands, use two fingers.  Also, if you have two people working on a baby, the person doing the compressions can put both hands around the sides of the baby’s chest and do really good compressions with the thumbs.  The air person stays by the head and blows air into the mouth and nose, two breaths at a time with the head gently tilted back, watching for chest rise and no more.

New research shows that in a hospital setting, extended CPR increases a patient’s odds of going home by 12%.  The lesson: don’t give up too fast.  Keep going for at least 15 minutes, and for 30 minutes if you can.  It’s a workout, so help each other, take turns, take breaks.  You can stop when paramedics take over, the victim wakes up and starts breathing again, there is a danger to yourself, or you are too exhausted to continue.


CPR STEPS

  1. Practice finding pulses on yourself and others; develop a feel for them.
  2. PERSON DOWN!  Assess scene safety, move if needed.
  3. Assess for responsiveness.
  4. If no obvious signs of life, get help, call 911.
  5. Check pulse in neck for adults, upper arm for babies.
  6. If no pulse or uncertain, begin 30 chest compressions, at 100bpm+ and 2”+ deep on adults.
  7. Ventilate with 2 gentle breaths (see chest rise) for each 30 compressions.
  8. Keep going at least 15 minutes or until relieved by more trained people.
  9. After it’s all over, find a way to decompress emotionally.
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Lyme Disease Month

5/16/2012

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May is the month designated by ILADS to increase awareness about Lyme Disease.  Infections are on the rise, or at least, lots more people are being diagnosed now than ever before.  More infected ticks are being found too.

I have studied under two doctors who specialize in Lyme (Dr's Newman and Ambrose, see bottom for links).  I haven't been tested, but I would not be surprised to discover that I too carry the spirochete that causes it.  The fact of the matter is that lots of people have this parasite, but most of us don't have symptoms until we get run down or toxic, or otherwise challenged healthwise.  The unfortunate thing about having an assortment of parasites on board is that you feel fine until you don't, and then you go downhill quickly.

Lyme is caused by Borrelia burgdorferii, which is a very small bacterium in a spiral shape, ie. a spirochete.  Spirochetes are sneaky.  They don't get inside our cells like Chlamydia does, instead they have an assortment of defensive mechanisms that make it hard for our immune systems to detect and eradicate them.  They make slime barriers around themselves.  They shrink back into little hard cysts.  Once established in our tissues they are just about impossible to get rid of completely, even with intensive treatment.  A person who has this parasite needs to keep themselves healthy enough that the parasite doesn't cause them trouble.  And this is where naturopathic medicine comes in.

In naturopathic medicine, we may attempt to eradicate a disease-causing agent, but we are also interested in increasing the host's health so that such bugs are kept in check by our own bodies.  The disease-destroying treatments that are used for Lyme---either longterm antibiotics, or longterm antimicrobial herbs---are not enough.  If you have lyme, or if you think you have lyme, the best thing in the world you can do is get ahold of your diet and lifestyle.  It's easy to say, and oh so hard to do.  Believe me, I know.  But to start with, eliminate, or at least reduce, sugar and refined grains in your diet.  Eat a wide range of fresh organic vegetables.  Exercise daily.  Manage or avoid stress.  These basics, if actually employed and not just talked about, may have more effect than all the doxycycline and cat's claw in the world.  

Still, if you are struggling with severe symptoms, don't waste time, get help NOW.  And if you just got a tick bite, get help NOW, because at the beginning of an infection the spirochete CAN be eliminated.  Last but not least, if you have a way to do so, avoid getting deer ticks on you.  I don't mean that you should not go in the woods, but be aware about ticks, and avoid deer tick bites.  Learn when tick season is in your area.  Prevention is better than treatment 10 times out of ten.

Look it up:
International Lyme and Associated Diseases Society http://www.ilads.org/ 
Dr Satya Ambrose http://www.starfireclinic.com/#!about-us
Dr Daniel Newman http://www.rising-health.com/portland-or-holistic
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Whitewater Kayaking in the French Alps

9/25/2011

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At some time in life we stop worrying so much about what is to come, and start really enjoying ourselves.  We don't live forever, so NOW is the time.  An old friend of mine is prepping to guide a group on another round of river running and old world pleasures this coming May.  The trip on offer is ten days, beginning and ending in Lyon.  I went with him in 2002 to explore this region's rivers.  It was fantastic.  I love the Alps!  I skied in them as a teen, and since then no other mountain range has ever captured me in the same way.  I have been invited to go again, this time to safety boat, drive and assist!  I'm thrilled.  If you know any advanced whitewater kayakers who haven't had enough French wine and food yet in this lifetime, this is a bucket list item for sure.

Here's where you can get the whole scoop: http://alpinewhitewaterfrancaise.com/


I remember, when I went to France before, that I was pretty out of shape and more than a little bit overweight.  Now I am considerably leaner, but I know that when I get to France, I will be relatively pudgy.  People there are svelte.  It's not just the models; the cultural standard is different.  The first time it was a bit of a shock.  Now I know to expect it.  Or get a little extra lean before I go.  Which is what I intend to do.
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On Waiting vs Taking Action

7/29/2011

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They aways say time 
changes things 
but actually you have to 
change them yourself.
--Andy Warhol

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    Author: Teresa Gryder

    Integrative Physician and Student of Life, Medicine, and the River.

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