Eating Healthier -- Part III

By G. Douglas Andersen, DC, DACBSP, CCN

Fruits and Vegetables

The new recommendations for healthy diet in this country include four or five servings of fresh fruits and vegetables each day. A lot of your patients may only have one or two servings of fresh fruits or vegetables a week.

I have found that suggesting the traditional four to five servings daily will totally overwhelm those patients on the standard American junk food diet. Instead, I ask them to consume one piece of fresh fruit five days a week, such as an apple or an orange, in place of their normal snacks of candy, chips, or pastries.

One Bean, One Green, Three Colors

I urge my patients to try to eat a large salad every other day. You will find many patients consider a salad as iceberg lettuce with a cherry tomato, covered by a healthy (no pun intended) amount of thousand island or blue cheese dressing. Other patients call iceberg lettuce with processed cheese, ham, egg, and gobs of dressing, a chef salad. Neither of these count as salads. Many restaurants now have salad bars that are full of junk. Items that are called salad, such as carrot salad, egg salad, potato salad, macaroni salad, and coleslaw, when prepared at commercial establishments, are generally very high in fat. Instruct your patients to steer clear of these salad bar items. My rule of thumb for making a salad is one bean, one green, and three colors, topped with non-fat or low-fat dressing. This formula will usually result in a healthful salad. Finally, for those who state they are still hungry after eating a salad for a meal, I point out to them that they didn't eat enough salad. I give them an example of what a salad should be: start with a half head of red leaf lettuce or salad bowl lettuce, then grate a whole carrot and a whole large zucchini. To this I have them add a whole bell pepper, chopped, and a can of rinsed and drained beans. This mixture is topped with a low calorie or fat-free salad dressing. I guarantee that the majority of your patients who say salads don't fill them up will not be hungry after consuming a salad like this. Now that you have influenced your patients to increase fruit and vegetable consumption, below are some pointers on raw vegetable preparation.

PREPARATION POINTERS
Eat Normally	Wash	Special Attention
Bananas	Cabbage -- #1	Spinach -- #4
Corn	Cucumbers -- #2	Apples -- #4
Melons	Eggplant	Broccoli -- #4
Grapefruit	Zucchini	Peaches -- #4
Oranges	Peppers	Carrots -- #4
Jicama	Tomatoes	Pears -- #4
	Cauliflower
Footnotes	Cherries
#1 = discard outer	Grapes
leaves
	Celery
#2 = peel, if waxed
	Green beans
#3 = cut out any buds
	Lettuce -- #1
#4 = buy organically,
if possible or	Potatoes -- #3
thoroughly scrub
(soak in bowl of	Berries
water with liquid wash
detergent	Mushrooms
for 3 minutes &
rinse thoroughly)	Sprouts

In conclusion, start with small, easy goals (three salads a week). As your patients begin to improve their diet, look and feel better, they will be more receptive to continuing a change toward a healthier diet.

Reference

Nutrition Action Health Letter, April 1989.

Pediatric Low Back Pain

By Peter Fysh, DC

Case Report

A mother brings her 11-year-old daughter to the chiropractor because of pain in the lower back, which her daughter has been experiencing for the past several weeks.

The daughter has been a competing gymnast for the past three to four years. She complains of back pain after each training session. Her program requires that she train for four hours each day, five days a week. After each session, the back pain is significantly worse, but it improves with rest, usually after lying on the bed for 45 minutes to an hour. On questioning the patient further, the pain is described as a sharp aching pain, precisely located to a small area in the low back just left of center at the belt line.

Physical examination reveals no significant findings other than the lower back pain located over the left lumbosacral junction. The patient can bend over to touch her toes without pain, but when lying face down, arching her back upwards and extending the spine reproduces the pain in the exact area of complaint.

Discussion

The incidence of low back pain in children is significantly lower than that which occurs in adults. The most common adult low back pain is due to "deconditioning," with lack of exercise and general physical fitness being the main cause of the deconditioning process. In children, however, this is not the case. Children generally do not suffer from such problems. Low back pain in children is more commonly caused by a spondylolysis defect in the pars interarticularis, or facet tropism at the lower lumbar spinal motion segments (L4-5 and L5-S1). Another possible cause of low back pain in the pediatric age group could be infection of an intervertebral disc, known as diskitis.

Spondylolysis is present in five percent of the adult population and in children the incidence reaches this level at about seven years of age.¹ In gymnasts, the incidence of spondylolysis has been found to range from 11 percent to 15 percent, most frequently associated with a stress fracture in the pars interarticularis of a lower lumbar vertebra. Slippage of a spondylolysis into a spondylolisthesis occurs most often during an adolescent growth spurt, between the ages of 9-15 years. Further slippage of the affected vertebra rarely occurs after the age of 18 years.

Facet tropism, where the planes of the facet articulations are asymmetrically aligned, is a heredity condition which has common occurrence in the population. It is a frequent cause of low back pain in children, especially those engaged in sports which involve hyperextension of the lower spinal segments, e.g., gymnastics, dancing, volleyball, and basketball.

The possible causes of the back pain in our 11-year-old patient should include all of the above and an appropriate diagnostic protocol should be used to evaluate the exact site and nature of the problem. The fact that the patient can bend forward and touch the floor without pain should rule out ligament sprains and muscle strains. Low back strains and sprains normally improve with hyperextension, and since this patient's problem is exacerbated by this move, we have further reason to rule out sprain/strain injury. Since gymnasts are extremely flexible, care should be taken in interpreting range of motion tests. A straight leg raise which ends at the patient's nose is not abnormal in gymnasts.

Diagnosis

To confirm the diagnosis, AP, lateral, and oblique radiographs of the lumbar spine should be obtained. If spondylolysis is present, evidence of a separation of the pars interarticularis should be visible on the oblique view. If no separation is visualized, then the lower lumbar facet joints should be examined for evidence of asymmetry. Asymmetrical alignment of the facet joints can predispose to instability of the associated spinal motion segment, especially in the lower lumbar region, where the presence of the sacral base angle causes additional stress to be placed on any truly sagittal facet joint. Disc infection can be ruled out by radionuclide bone scan, which will be positive very early in the course of the infection. If none of these possibilities are evident, then the patient may be treated specifically for facet joint and sacroiliac fixations, taking appropriate care not to exacerbate any existing hypermobile joint structures.

Management

Treatment should be appropriate for the confirmed diagnosis. If spondylolysis is encountered, then a lumbosacral brace may be prescribed to be worn for 22 hours each day until the patient is asymptomatic, which may be as early as three weeks.² Concurrently, hyperextension activities should be restricted and a rehabilitation program commenced. Frequently, gymnasts will have a hyperlordosis of the lumbar spine associated with weak abdominals, tight lumbosacral fascia, weak hamstrings and tight rectus femoris muscles. This pattern of muscle imbalance is characteristic of a poor training regimen coupled with weak abdominals from constant stretching in back walkover maneuvers. The rehabilitation program should include abdominal and hamstring strengthening exercises, posterior pelvic tilts in both the standing and supine position, and stretching routines for the tight quadriceps.

Summary

Early and appropriate management of spondylolysis may produce a complete healing of the stress fracture. In dealing with facet tropism, it must be remembered that the symptoms are likely due to a hypermobility of a unilateral facet joint, secondary to a congenital anomaly. The persistence of this anatomical variant will predispose to reoccurrence of the problem, especially if hyperextension activities are not eliminated.

Our 11 year old patient actually had an anomalous facet joint at the left L5-S1 level, due to facet tropism, and is doing well after two months on the rehabilitation exercise program. Her symptoms have subsided; she is back to gymnastics with instructions to limit her hyperextension activities, and to work on correcting any faculty movements in her routine.

References 

1. Wiltse LL: Treatment of spondylolisthesis and spondylolysis in children. Clin. Orthop., 117:92-100, 1976.
   
   
2. Michelli LJ: Back injuries in gymnastics. Clin Sports Med., 4:85-93, 1985.

Eating Healthier -- Part II

By G. Douglas Andersen, DC, DACBSP, CCN

Food preparation tip lists are another way to painlessly improve your patient's diet. Below are a few examples:

Preparation Tips 

1. Grated cheese instead of sliced cheese (less cheese will go further).
   
   
   
2. Use oat or wheat bran as a sauce, soup, or stew thickener (an easy way to increase soluble and insoluble dietary fiber).
   
   
3. Add one part non-fat yogurt to one part avocado when making guacamole (this results in a lower fat, higher protein dip).
   
   
4. Use the 50/50 principle. If your patients can't tolerate the change to lower fat, higher fiber, and less refined foods, suggest to them that they blend healthier alternatives to the foods they now consume. For example: (a) add one part non-fat yogurt for each part of sour cream, (b) add one part non-fat milk to each part low-fat milk, (c) add one part non-fat salad dressing to each part regular salad dressing, or (d) one part unsweetened applesauce to each part sweetened applesauce. You can be creative, and after analyzing the foods your patients normally consume, you can give them customized suggestions.
   
   
5. For patients who eat canned or frozen foods, have them try to add something fresh or a legume to their meal. For example, if they eat canned chili, have them add a fresh bell pepper, onion or tomato. If your patient eats frozen foods such as a pot pie, after cooking stir in a can of rinsed, drained beans.
   
   
6. For your patients who will not buy whole wheat or whole grain pancake or cookie mixes, try having them just add a tablespoon of wheat or oat bran to the batter. They will not taste it, but the benefits are obvious. Imagine, just a teaspoon of fiber for each cookie each American consumes, the health care savings from intestinal disease would be staggering.
   
   
7. When ordering sandwiches out ask for mustard instead of mayonnaise, and vinegar instead of oil.
   
   
8. Have your patients cover one-half of the holes on their salt shaker at home. Instruct them not to use salt until after cooking, and always taste their food before salting.
   
   
9. Instead of butter, cheese, and sour cream, and for those who don't like yogurt, try non-fat cottage cheese on baked potatoes -- it's great.

Tips for the Junk Food Patient

Even these people can painlessly improve their diet. For example, instead of ordering a cheeseburger, large fries, and a large soda, suggest they order a hamburger, salad, and juice or tea. When dining out order salad dressing or potato toppings on the side: when done this way people will tend to use less. For those patients who hit the doughnut shop in the morning, suggest that they order a muffin instead of a doughnut. Even though most doughnut shop muffins are not low calorie foods, at least they are not deep-fat fried in rancid oil.

For your "pizza" patients, suggest they order their pizzas with a little less cheese. Suggest that if their pizzeria offers whole wheat crusts they try it. This author orders double vegetable pizzas with no cheese, and they taste great. Your hard core "junkie" patients, however, will probably need some cheese on their pizzas. The best types of pizza topping are vegetables, with the exception of olives, which are high in fat. There will be some patients who insist on meat toppings. For people in this category, have them order ham or Canadian bacon instead of pepperoni, sausage, or pork bacon.

Even the hot dog can be improved by using whole grain buns instead of traditional white flour product.

Finally, most Americans do not drink enough pure water. Furthermore, telling "junkies" to have eight glasses of water a day is a joke; they just won't do it. However, there is a good chance you can sell them on consuming one large 12 to 16 ounce glass of pure water every morning as soon as they wake up. It doesn't sound like much, but over time that extra 16 ounce of fresh water a day will have a very positive effect on their health.

Did D.D. Palmer "Steal" the Manipulative Techniques of A.T. Still?

By Alana Ferguson

At the turn of the century the osteopathic profession bitterly denounced chiropractic as a "pure steal." In actuality, Palmer lived but a short distance from Still and several Missouri chiropractors reported seeing D.D.
Palmer's name in A.T. Still's guest book in the early 1890s. The historian, Booth, named Obie Stothers as the DO who taught Palmer the "old doctor's" (Still's) osteopathic techniques.

Palmer recognized this controversy as well as the similarities between chiropractic and osteopathy. Palmer stated that he was not "the fist person to replace subluxated vertebrae, for this art has been practiced for thousands of years. I do claim, however, to be the first to replace displaced vertebrae by using the spinous and transverse processes as levers." Palmer went on to devote much of his textbook, The Chiropractor's Adjustor, to refuting the osteopaths' claims that chiropractic was, in fact, osteopathy.

Nonetheless, the similarities remain striking. Both schools, "systems of health based on bone-setting," initially rejected integration of allopathic medicine; neither accepted the germ theory; both were against vaccination; both were against mixing "physical therapy" or "physical medicine" treatments with manipulation; and both were against expansions of their curricula to include "unnecessary" medical subjects.

Despite these claims of independence, in actuality early chiropractic and osteopathic philosophy were very similar. Both Palmer and Still originally described the body in mechanistic terms, both applied manipulation to all articulations of the bony framework and believed the manipulable lesion was a "surgical" subluxation, and both taught that man and his healing was the product of a supreme being. Given that these two professions began so similarly, why did osteopathy subsequently expand to an unlimited scope embracing allopathic drugs and surgery and chiropractic did not?

If you read this far, you should be a member of the Association for the History of Chiropractic. This is an excerpt from an article written by James W. Brantingham, D.C., that originally appeared in the 1986 edition of Chiropractic History. The association has devoted the last 12 years to recording the history of the chiropractic profession, but will not be able to continue its mission without continued support of that profession.

Donations to the association fell from $7,000 in 1990 to $1,375 in 1991. For an organization that operates on a break-even budget, this is disastrous. All of the board members, including the editor of the journal and the executive director, donate their time.

We believe that we are not only preserving chiropractic history, we are also selling a quality product. Included in the annual membership fee of $35 is a subscription to chiropractic history. This is a scholarly journal of the highest publishing standards. But don't let that scare you. The articles are readable and fascinating. And the journal looks good.

The association is made up of chiropractors and interested laypeople. Its membership cuts across political, philosophical, and geographical boundaries. The only common denominator is the desire to record accurate chiropractic history.

Eating Healthier -- Part I

By G. Douglas Andersen, DC, DACBSP, CCN

By far the most important aspect of nutrition is the quality and quantity of foods consumed. Take a day and ask your patients about their diet. You will find that most will answer that they eat a healthy diet, but could improve a little bit. 
Then ask them what they had for breakfast, lunch, and dinner the past two days. Most will quickly preface their answer by stating that what they consumed the last two days isn't normal, and that they usually don't eat bacon and eggs for breakfast, a cheeseburger and fries for lunch, and pot pies for dinner.

We clearly are a long way from fully understanding diet and all the ways it affects our physiology, psychology, and biochemistry. We do know that a low fat, moderate protein, high complex carbohydrate diet with minimal processing of the foods consumed seems to be the most healthy for the general population. We also know that the optimal diet for an individual will vary depending on many factors. In fact, we probably know more about what isn't the optimal diet than what is.

Chiropractic was the first Western health profession to stress a natural diet. In R.W. Stevenson's 1927 Chiropractic Textbook he quoted Palmer: "Foods, air and water, when they have been 'doctored' are poison."¹ Stevenson, himself, stated: "Sterilized air and water and artificially prepared foods are poisons, for they are not natural; innate evolutionary structures are unequated with them as foods."¹

When we counsel our patients on changing or improving their diets, we must remember that eating healthy is a lifestyle change. Like starting an exercise program, changing a person's food intake gradually increases the odds of lifetime compliance. One way to help the gradual change is to provide your patients some information in the form of handouts to post on their refrigerator to remind them of some healthier alternatives to the foods they normally consume. As doctors, we must remember that sometimes the first step in changing one's diet is just that, a first step. For example, low-fat milk is a healthier alternative to whole milk for the majority of the population. But for most people, it still contains too much milk fat, and thus is the first step in your long-term goal of non-fat milk consumption, or total abstinence from milk, depending on your patient's individual biochemical needs.

Below are some examples of food substitutions. These can be designed individually for each patient, or you can make a generic list. Either way, it keeps your name on their refrigerator and keeps them focused on the goal of improving their diet.

Food Substitution List
Food Consumed	Healthy Alternative
Whole dairy	Low-fat dairy (milk, yogurt, cottage cheese)
Processed sugared cereals	Processed unsugared cereals
Ice cream	Frozen yogurt
Sweetened applesauce	Unsweetened applesauce
Soft drinks	Sparkling water lightly sweetened with fruit juice concentrate
White bread, rolls, buns	Brown bread, rolls, buns
Iceberg lettuce	Red leaf lettuce
Bologna slices	Ham slices

Once your patients state that they are now eating off the "good list," you can then issue a new list that goes a step further:

Food Consumed	Health Alternative
Low-fat dairy	Non-fat dairy
Processed, unsugared cereals	Whole grain cereals
Frozen yogurt	Non-fat frozen yogurt
Unsweetened applesauce	Whole apples
Sparkling water with fruit	Sparkling water with fruit essence juice concentrate
Brown bread, rolls, buns	100% wheat or whole grain breads

Another type of list for those patients who are into the numbers game:

Food Consumed	Healthy Alternative	Benefit
1 croissant	1 bagel	30-60 fewer calories
1 oz. oil-roasted	1 oz. dry roasted	90-100 fewer calories
peanuts	peanuts	11-13 fewer grams of fat
2 oz. cooked white	2 oz. cooked oat	18 extra grams of fiber
pasta	bran pasta
1 oz. pork bacon	1 oz. canadian bacon	100 fewer calories
		10-12 fewer grams of fat
		6-8 extra grams of protein
7-1/2 oz. serving	7-1/2 oz. serving	70-100 fewer calories
beef chili & beans	turkey chili & beans	8-10 fewer grams of fat
1 regular order	1 baked potato	100-150 fewer calories
of french fries		10-12 fewer grams of fat
1 oz. cheddar cheese	1 oz. skim	30-40 fewer calories
	mozzarella cheese	3-6 fewer grams of fat
Canned vegetables	sugar free canned	10-30 fewer calories
	vegetables	per serving
3-5 oz. duck	3-5 oz. chicken	40-60 fewer calories
(skinless)	(skinless)	5-8 fewer grams of fat
1 tbsp. avocado or	1 tbsp. salsa dip	15-25 fewer calories
sour cream dip		3-5 fewer grams of fat

References 

1. Stevenson RW: Chiropractic Textbook. 1927
   
   
2. U.C. Berkeley Wellness Letter. 5(12): September 1989.

Anabolic Steroids, Part III

By G. Douglas Andersen, DC, DACBSP, CCN

When you have a patient who smokes cigarettes and will not quit, I feel it is unethical not to advise that patient to take antioxidants. The same is true for patients on anabolic steroids who will not quit. 
The first step in designing a program for the steroid user to minimize the side effects is to make it clear that taking supplements does not make the use of anabolic steroids safe.

Steroids do not produce desired muscular hypertrophy without a very high calorie, high protein diet. This is common knowledge to most steroid users. It is tempting to lower protein intake in those unaware of its importance. If anabolic steroids do not work, it will be easier to have a patient stop using them. However, what inevitably happens is that the patient discusses the lack of progress with the dealer or friends in the gym who will recognize the problem as inadequate protein intake. They would then strongly advise your patient not to seek your services anymore because you gave wrong information. The bottom line is deception usually comes back to haunt you. Therefore, what you can do with the rest of the diet is to make sure it is low in fat, high in complex carbohydrates, and low in the stressors -- sugar, salt, caffeine, and processed food.

I could not locate any studies in the literature concerning micronutrient support for the steroid user. We do know that the chances of side effects are increased when athletes consume higher doses of steroids. We also know that athletes who are on steroids longer also have greater chances of side effects. Finally, oral steroids are harder on the liver than parenterals and C-17 alkalinated parenterals cause more side effects than non-alkalinated types.

Unfortunately, there is no magic steroid support formula. I recommend a good, strong multi-vitamin, multi-mineral formula with the above diets. Added to this are additional micronutrients tailored to the patient's individual symptomatic requirements. The ranges I am listing are amounts that have been most commonly studies. The more nutrients you add to a multi-supplement for specific conditional support, the lower the dose you can use due to the synergistic effects of like nutrients.

We will now briefly review the types of micronutrients used for various conditions that have theoretical application for steroid induced symptoms.

1. The cardiovascular system.

A. Antioxidants. There are many types of antioxidant micronutrients. Below are some of the most common and best-studies substances:

Vitamin C: 1-5 gm
Vitamin E: 400-800 IU
Beta Carotene: 10-50 mg

Coenzyme Z10: 30-120 mg
Thiamine: 25-100 mg
Zinc: 30 mg*
Copper: 2 mg*
Manganese: 20 mg*
Selenium: 200-300 mcg

B. Antiplatelet aggregates

Fish oil (EPA and DHA): 3-6 gm
Gamma linolenic acid (GLA): 200-500 mg
Garlic oil: 25 mg 

• These minerals are precursors to superoxide dismutase. There remains controversy as to whether superoxide dismutase itself can be absorbed in people with a healthy intestinal mucosa.

C. Other cardiovascular protectors include:

Pantetheine: 900-1,200 mg per day (increases HDL, decreases LDL, decreases triglycerides)

Taurine: 1-3 gm per day (maintenance of myocardial electrolytes especially K+)

L-carnitine: 0.5-2.0 gm per day (decreases triglycerides)

Magnesium: 400-800 mg per day (only a matter of time before it is routinely used by cardiologists)

2. Hypertension:

Calcium: 1,000 to 1,500 mg per day

Magnesium: 800-1,200 mg per day

3. Hepatic Support: Lipotrophic factors:**

Glutathione: 250-1,000 mg (antioxidant which binds liver toxins)

Phosphatidylcholine: 2-5 gm (a component of lecithin; look for brands that contain 75%)

Silymarin: 50-150 mg (from the herb milk thistle if it has strong hepatic regenerating properties) 

• Most professional companies have lipothrophic formulas. You should look for a product that includes choline, inositol, betaine, and methionine.

4. Androgen-related side effects:

I came across a very interesting study that showed when females consumed dietary fiber in the form of wheat bran in the range of 30 or more grams per day, the amount of circulating estrogen in the blood stream was decreased. Although this has not yet been tried on males consuming anabolic steroids, consuming a diet high in insoluble wheat fiber certainly would do no harm and there is an excellent chance that if the wheat fiber drops estrogen levels in females, it may work the same in males. As we all know, when men consume pharmacologic amounts of testosterone, the body reacts by (1) slowing or stopping internal testosterone production, and (2) increasing estrogen production in an attempt to maintain a homeostatic environment. Unfortunately, high estrogen levels in males can result in unwanted side effects, the most common being gynecomastia.

Prostate enlargement and premature hair loss for males genetically susceptible to baldness can be helped by the herb Saw Palmetto (60-320 mg per day). It blocks enzymes that convert testosterone to dihydrotestosterone (DHT) and enzymes involved in DHT cellular uptake. Increased levels of DHT in steroid users have been implicated as a cause of these conditions. Alopecia in athletes without male pattern baldness may, in some cases, be retarded by Saw Palmetto and Ginseng. Testicular atrophy and azoospermia may be retarded by 50-100 mg zinc per day. I recommend a highly absorbable form such as picolinate. To make sure a copper deficiency is avoided, your athlete should consume plenty of legumes, whole grains and green leafys. When dosing with amounts approaching 100 mg of zinc, a copper supplement is a good idea. I recommend 4 mg in a well-absorbed form such as copper sebacate.

5. Aggressiveness

Valerian: (Non-toxic, non-addictive natural relaxants) Passiflora

6. Kidney Support.

Consume plenty of water

Zinc: 40-60 mg per day (for ammonia to urea conversion)

When looking at a patient's blood work, check the BUN.

When it is borderline high there is a good indication that the body is receiving protein in amounts it is unable to optimally metabolize.

In the years to come, it is my hope that strong, safe alternatives to steroids will be developed and research on natural protectants will commense.

References

DiPasquale: Anabolic Steroid Side Effects, Facts, Fiction, and Treatment. M.G.D. Press, Ontario, Canada.

Phillips: Anabolic Reference Guide, ed 6. Mile High Publishing Golden Color, 1991.

Rose: High fiber diet reduces serum estrogen concentration in premenopausal women. American Journal of Clinical Nutrition, 54: 1991.

Whitaker: Health and Healing. 2(3): March 1992.

Wright, G: Nutritional therapy for the 1990s. Seminar notes, Los Angeles, September 1991.

I would like to give my special thanks to Stewart Zweikoft, D.C. for providing resource materials.

Management of Asthma

By R. Vincent Davis, DC, PT, DNBPM

Asthma is a bronchial hypersensitivity disorder characterized by reversible airway obstruction produced by a combination of mucosal edema, constriction of bronchial muscularture, and excessive secretion of viscous mucus which results in mucous plugs which become progressively inspissated. 
Essential elements of diagnosis include recurrent, acute attacks of dyspnea, cough, and mucous sputum, usually accompanied by wheezing with prolonged expiration. There is generalized wheezing and musical rales.

Clinically, it is necessary to ensure that wheezing is not due to bronchitis, obstructive emphysema, or congestive heart failure. In these conditions, relaxation of the smooth muscle of the bronchial wall is not a component of the pathophysiology.

If patients are experiencing status asthmaticus at the time of examination, they should be hospitalized, especially if arterial blood gases dictate such care.

If the patient is not status asthmaticus, the initial modality of choice is interferential current. This modality selection is only acceptable in the absence of a history of cardiac disease, in which case it should not be used. In the absence of such a history the patient should be placed in a seated position. Two electrodes should be positioned over the upper limits of the trapezius bilaterally on the upper back, and the other two should be placed anteriorly over the lower ribs. In the event that the patient is experiencing respiratory difficulty while the treatment is being prepared, they should sit, leaning forward, with arms supported on a table. In this event, two electrodes should be placed anteriorly over the lung apices bilaterally, and the other two should be placed posteriorly over the lower ribs. This will cause the intersectional point of the interferring currents to be located at approximately the hilar region of the lungs.

Whether using a 4,000 Hz, 5,000 Hz, or 10,000 Hz base current, the interferential current range should be set from 10 to 150 Hz and initially applied for 10 minutes, being careful to monitor the patient's condition during the treatment period. If the patient presents any sign of distress during the course of treatment, the current must be turned off. In spite of this cautionary note, this is an effective method of aborting the severity of an asthmatic experience when properly applied. So long as the patient experiences no distress with IFC application, the treatment period should be increased by two minutes, with each application up to a total application time of 20 minutes.

During and following a course of treatment, the patient's breathing should become easier. Repeated treatments should result in a reduction in the frequency of acute attacks. Additionally, an acute attack is not a contraindication for this application. In fact, it is probable that the administration of IFC during an acute attack may negate the episode entirely.

When not in an acute episode, asthma patients may benefit by the performance of percussion chest postural drainage procedures. These procedures may be found in standard textbooks of physical medicine, or may be obtained by contacting this author.

Patients with much viscus bronchial mucus, especially when mucous plugs are undergoing inspissation, should be directed to force oral fluids. Increased daily oral fluids will help to liquefy bronchial secretions making them easier to discharge with postural drainage and expectoration by coughing.

References

Davis RV: Therapeutic Modalities for the clinical Health Sciences, ed 1. Copyright -- Library of Congress, TXU-389-661, 1983.

Griffin JE, Karselis TC: Physical Agents for Physical Therapists, ed 2. Springfield: Charles C. Thomas, 1982.

Krupp & Chatton: Current Medical Diagnosis & Treatment. Lange Publishers, 1983.

Krusen, Kottke, Elwood: Handbook of Physical Medicine & Rehabilitation, ed 2. Philadelphia: W.B. Saunders Company, 1971.

Schriber WA: A Manual of Electrotherapy, ed 4. Philadelphia: Lea & Feibiger, 1975

Anabolic Steroids -- Part II

By G. Douglas Andersen, DC, DACBSP, CCN

The earliest study I found of steroids and muscular hypertrophy was in 1938.¹ As I continued my literature review on steroids, I found that historians tend to disagree on exactly when anabolic steroids were used for athletics; however, most of the evidence points to the Russians using testosterone and its derivatives in the early 1950s, with the Americans starting either in the mid or late 1950s, depending on the source. 
Throughout the 1960s, steroids were generally used by strength athletes, such as power lifters, Olympic lifters, and body builders. Steroid use spread to field athletes in the mid and late 1960s. By the early 1970s, most world class track and field athletes that needed strength or explosiveness were using steroids. Strength athletes in other sports such as football also discovered steroids in the early 1970s. By the end of the decade, football players at all levels were using anabolic steroids and, as more and more coaches realized the importance of strength and explosiveness in their various sports, athletes in what would be considered non-traditional steroid sports begin to use steroids. Interestingly enough, the steroid use coincided with the decline of the myth that "muscle-bound" athletes were not able to perform well.

Graham and Kennedy estimate anabolic steroid use in the United States of at least one million.²

Side Effects of Steroids²

The following is a list of the major negative effects associated with the use of anabolic steroids:

1. Hepatic
Peliosis hepatitis*
Hepatoma*
Cholestatic jaundice
Elevated liver function tests

2. Cardiovascular
Hypertension
Decreased HDL cholesterol
Increased LDL cholesterol
Increased triglycerides
Atherosclerotic heart disease
Cardiomyopathy
Cerebrovascular accident

3. Skeletal
Premature epiphyseal closure*

4. Immune
Reduced immunoglobulin levels
Altered natural killer function

5. Endocrine
Male -- testicular atrophy, decreased sperm count, gynecomastia, decreased testosterone, decreased LH, decreased FSH, altered glucose tolerance, hyperinsulinism.

Women -- Hoarsening of the voice, enlarged clitoris*, menstrual irregularities, decreased breast size, male pattern baldness,* fetal abnormalities.

6. Dermatology⁴
Cystic acne
Comedones
Sebaceous cysts
Alopecia
Hirsutism*
Striae distensae
Seborrhea
Rosacea

7. Physiological
Euphoria
Aggressiveness
Marked libido changes
Mood swings

8. Subjective
Mood changes
Aggressiveness
Changes in libido
Muscle spasm
Muscle aches
Headaches
Nervousness
Tension
Dizziness
Nausea
Euphoria
Rashes
Urethritis
Scrotal pain
Increased urine output

*Considered an irreversible side effect⁵

The above list is both exhaustive and frightening. According to Dr. Phillips, the most common side effects of steroid use are the following:⁶

Sodium retention, high blood pressure, headaches
Acne
Gynecomastia
Aggression

Blood lipid changes (increased LDL, decreased HDL, and increase in total cholesterol) Palpitations

We will now discuss some of the side effects that receive the greatest amount of media attention.

Hepatic side Effects

Peliosis hepatitis is a disease of cattle caused by contaminated grass. There is not a single case of this occurring in an athlete taking anabolic steroids. There are cases of people contracting this disease who took anabolic steroids for hematological disorders.² Again, according to Drs. Graham and Kennedy,² steroid-induced hepatomas occur within those who have primary hematological disorders. They further state there have only been three cases in the literature of hepatoma in the athletes, and there was no record of the athletes hematological status. Furthermore, Dr. Phillips states that two of the athletes used high doses of oral steroids for four consecutive years. Even proponents of steroid use state that steroids should be used no more than 12 weeks at a time, and that athletes should refrain from using steroids for at least as long as they used them before they start another cycle.⁶ I found it interesting that jaundice and cholestasis are surprisingly uncommon and no specific clinical hepatic syndrome has ever been demonstrated in athletes abusing anabolic steroids.²

It is not uncommon for an athlete who is training heavily to have increases in SGOT and SGPT. To correctly monitor an athlete's liver function, one should order the isoenzymes of lactin dehydrogenase and alkaline phosphatase, which are liver specific.⁵

Teenage Use

Clearly, epiphyseal closure is a very serious side effect of anabolic steroids and all doctors should urge teenagers, especially young teens, to discontinue steroid use. This can be accomplished much easier than in adult athletes. Making coaches and parents aware of the problem increases your chances of attaining a complete and total cessation of teen steroid use.

Acne is another common side effect of anabolic steroids. Most teens have more than enough pilosebaceous gland activity. Administration of anabolic steroids increases already overactive structures. The bottom line is to emphasize to your teenagers that when they take steroids, they should expect to see a pronounced increase in acne.

Cardiovascular Side Effects

It is very clear that steroids have marked cardiovascular effects. Although cholesterol alterations are reversible with cessation, it is nevertheless clear from my literature review that this is a major risk factor of anabolic steroid ingestion and must be aggressively supported nutritionally in those athletes who continue to ingest anabolic steroids. When anabolic steroid use stops, the athletes must maintain a moderate aerobic exercise program coupled with a diet low in fat (20 percent of the calories) and maintain physician contact with follow-up laboratory analysis.

Females Steroid Use

Steroids in women is an area where I recommend you really emphasize to your patients the defeminizing effects that may occur with the use of male hormones. Make it clear that a high percentage of the irreversible side effects of steroid use occur in the female athlete.

Connective Tissue Side Effects

In my research, I was unable to come across what I feel is one of the most common negative effects of anabolic steroid use, and that is post cycle injury to connective tissue. I did find a few reviews on steroid-induced tendon and muscle rupture; however, these injuries are very rare. What is common are sprains, strains, bursitis, tendinitis, and capsulitis injuries in athletes who have recently discontinued steroid use. Anyone who has spent time in a serious lifting gym has heard, "I don't get injured when I'm on the juice," or "Every time I stop I get injured." Steroid users rationalize that they should just continue with anabolic steroids, adding additional types or changing types so they will not get injured. Therefore, in addition to nutritional support, when doctors do succeed in having athletes discontinue steroid use, they must emphasize that the athlete is at a higher risk for injury6 and implement a "safe" workout for six weeks following steroid cessation. Generally, two to four weeks after ingestion of steroids is discontinued, connective tissue injuries tend to occur. Steroids cause muscles to hypertrophy faster than supporting ligamentous and tendinous structures. When the steroid use stops, testosterone levels plummet because the body's negative feedback system shuts its own production down when steroid ingestion begins. Therefore, there is a rebound period with low testosterone levels. This equates to a decreased nitrogen balance, decreased protein synthesis, and decreased intramuscular fluid retention. Add to this heavy muscular loads to tissues that are no longer supercharged with pharmacological androgens, and the result is injury.

Safe Workout 

1. Lighten the amount of weight lifted.
   
   
2. Increase the amount of repetitions.
   
   
3. Emphasize the importance of strict form on every exercise, whether free weight or machine.
   
   
4. Decrease total sets.
   
   
5. Increase rest periods (that is, four instead of six lifting sessions per week).

By decreasing the amount of weight used and increasing repetitions, less load is placed on connective tissue that is susceptible to injury. At the same time, this workout provides greater circulation to these vulnerable areas, which will not only guard against injury, but will maintain the majority of the additional muscular tissue the athlete gains while on synthetic testosterone derivatives. Remember, although you have recommended lighter weights, higher repetitions, better form, and more rest, this does not mean that your athlete has to decrease intensity.

Nutritional Support for Steroid Cessation: 

1. Decrease the amount of dietary protein to l gm for each l.5 to 1.75 pounds of body weight (athletes who use anabolic steroids must ingest excessively high amounts of protein in order for the steroids to have the desired effect; however, when steroid ingestion stops, the high amount of protein then works as a disadvantage to the athlete by disrupting intramuscular osmotic balances, which will result in overtraining and increased injury.)
   
   
2. Add 32 ounces of additional fluid per day.
   
   
3. Increase vitamin C to a minimum of two grams per day.
   
   
4. Increase zinc to a minimum of 50 mg per day.
   
   
5. Manganese sulfate, chondroitin sulfate, perna canaliculus or mucopolysaccharides should be ingested at a level of 100-150 mg per day.
   
   
6. A strong multivitamin, multimineral formula.

I recommend the athlete ingest these levels of micronutrients for six weeks. After that they should continue with a good strong multivitamin, multimineral formula.

References 

1. Panicolaou HN, and Falk GA: General muscular hypertrophy induced by androgenic hormones. Science, 87:238-239, 1938.
   
   
2. Graham S, Kennedy M: Recent developments in the toxicology of anabolic steroids. Drug Safety, 5(6):458-476, 1990.
   
   
3. Kibble WM, Ross MB: Adverse affects of anabolic steroids in athletes. Clinical Pharmacology, 6:686-692, 1987.
   
   
4. Scott MJ Jr., Scott MJ III: Dermatology and anabolic androgenic drug. Reprint request to 533 Medical Dental Building, Seattle WA., 98101.
   
   
5. Hough. Anabolic steroids and ergogenic aids. American Family Practice, 1157-1164, April 1990.
   
   
6. Phillips WN: The Anabolic Reference Guide, ed 16. Mile High Publishing, Golden Colorado. 1991.

The Carotenoid Gap

By Jerry Shefts, DC and Carla Rudolph, DC

Chiropractors, nutrition professionals, and government agencies have long urged the American public to include more fruits and vegetables in their diet. The National Academy of Science and the U.S. 
Surgeon General currently recommend eating 2-3 servings of fruits and 3-5 servings of vegetables every day for optimum health benefit. Recent research now points to certain types of fruit and vegetables which, in fact, may be more important for the health of the individual than other types. This group of foods is classified as carotenoids. Carotenoids are the naturally occurring colors seen in certain fruits and vegetables. For example, the red in tomatoes, the yellow in squash, and the orange in carrots are obvious, but many green plants such as spinich, contain high levels of carotenoids as well. The chlorophyll in these plants masks the color indicator.

The first correlation between high intake of carotenoids and health benefits started appearing in literature in the 1970s. Researchers observing populations around the world found that where diets were high in fruits and vegetables the rates for certain types of cancers were statistically lower. The converse was also found to be true. Lower intake of fruits and vegetables resulted in higher levels of cancer, as well as increases in cardiovascular disease.

Beta-carotene became the focus of the scientific literature and the media, as the superstar in the fight against cancer. The data pointed to definite favorable physiological changes from consuming higher quantities of foods rich in beta-carotene. Currently research has identified 600 carotenoids, including alpha-carotene, gamma-carotene, luetin, lycopene, and cryptoxanthin. It is now believed that a complete complement is necessary in order to combat serious health disorders such as cancer and cardiovascular disease. It also may play an integral part in the longevity of the individual.

Basically, carotenoids protect our bodies from the negative effects of oxidation reactions in the body. Oxidation has a damaging effect on the cells, and this may be the precursor for the development of disease. The antioxidant effect of the carotenoids and their ability to neutralize free radicals and singlet oxygen make them vital to life itself. Studies conducted at the National Institute on aging reveal that higher carotenoid consumption lowers the incidence of cardiovascular disease, enhances antimicrobial immune functions, and may possibly contribute to longevity. There has been a correlation established which shows that high levels of plasma carotenoids may contribute to increased life span. Oxidative stress plays a role in aging and an individual's life span is governed by a number of different mechanisms acting to lower oxidative stress in cells.

Some experts are now recommending eating at least six milligrams of carotenoids a day, and yet it is estimated that the majority of Americans are actually consuming 1.5 milligrams per day. This "carotenoid gap" could be completely eliminated if Americans ate 5-8 servings of fruits and vegetables every day. However, given the American dietary track record this may not be a realistic expectation. The U.S. Department of Agriculture's recent survey showed that nearly half of all Americans eat no fruit daily, nearly one-quarter eat no vegetables daily, and only nine percent actually eat five servings of fruit and vegetables daily. The evidence is overwhelming that if people add more carotenoids to their diet, it could help protect them against many diseases associated with aging. The patients that entrust their health to us must be made aware of this fact.

References 

1. U.S. Department of Agriculture, U.S. Department of Health and Human Services: Nutrition and Your Health: Dietary Guidelines for Americans. Home and Garden Bulletin No. 232, Washington, D.C., Government Printing Office, 1980.
   
   
2. Patterson BH: Fruits and vegetables in the American diet: Data from the NHANES II Survey. Am J. Public Health, 80:1443-1449, 1990.
   
   
3. Colditz GA, et al: Increased green and yellow vegetable intake and lowered cancer deaths in an elderly population. Am. J. Clin. Nutr., 41:32-36, 1985.
   
   
4. Hennekens CH, et al: Vitamin A, carotenoids and retinoids. Cancer, 58:1837-1841, 1986.
   
   
5. Krinsky NI: Antioxidant function of carotenoids. Free Radical Biol. Med., 7:617-635, 1989.
   
   
6. Cutler RG: Antioxidants and aging. Am. J. Clin. Nutri., 53:373S-380S, 1991.
   
   
7. Krinsky, N: The evidence for the role of carotenes in preventative health. Clin. Nutr., 7:107-112, 1988.
   
   
8. Bendich A: Carotenoids and the immune response. Am. J. Clin. Nutr., 119:112-115, 1989.

Anabolic Steroids -- Part I

By G. Douglas Andersen, DC, DACBSP, CCN

This month we begin a multipart series on anabolic steroids. In this series we will address the ethics and controversies of steroids, a brief history of their use, steroid side effects, nutritional support for the steroid user, and nutritional alternatives to steroids.

This author would like to make three statements concerning steroids: 

1. I do not condone steroid use.
2. I do not advise any athlete to take steroids.
3. In this steroid series I will try to address this issue fairly and unbiasedly, without the hype that I feel exacerbates the problem.

This author began lifting weights for fitness in the 1970s. It was clearly obvious to everyone who spent time in gyms lifting weights that steroid users (when coupled with hard workouts and high protein, high calorie diets) achieved amazing results. Medical doctors repeatedly stated that steroids did not work, based on research. The average man-in-the-gym's opinion was either they were lying to the athletic community or they were incredibly inept at their studies and analysis. The result was the same. They lost a lot of credibility on many statements they made about anabolic steroids.

In the late 1980s and early 1990s the media began to get involved with the steroid problem. It was almost like a "reefer madness" all over again. The problem, again, was that the man in the gym simply didn't see anything approaching the horrible stories of steroid-related illness that the media publicized. Furthermore those athletes who followed the sport of weight lifting were not seeing the stars of the 1960s, 1970s, and 1980s who took anabolic steroids for years in various bodybuilding, power lifting, and Olympic lifting competitions die. All these people were still around. In fact, some of them had become movie stars. That's right, take huge amounts of steroids for 15 years, then retire and become a movie star. Sadly, the bottom line was that athletes did not get the full truth from the media and, thus, credibility was lost and any factual statements the media now make are simply discounted and not believed by the average weight lifter.

Facts about steroids that DCs must deal with: 1) Using steroids is against the law. Possession and use of steroids is, in most states, now a felony. 2) The use of anabolic steroids is not healthy. 3) For a great majority of people the use of anabolic steroids is not life threatening. As an example, anyone can go out and drink themselves to death and, sadly, a few people every year do. However, most people who use alcohol do not kill themselves. The same is true of anabolic steroids. 4) Anabolic steroids help build strength and muscle much better than any natural product.

Doctors' Ethics

When an athlete presents in the office on steroids, doctors have the following choices:

1. They can call the authorities and turn in the patient. 2. They can demand the patient stop using steroids immediately or advise them to seek health care elsewhere. 3. They can work with the patient, explaining the legal and medical problems of anabolic steroid use. 4. The doctor can plead ignorance with an attitude, "I don't want to get involved. I'm going to adjust or do therapy."

Of the four ethical choices, this author feels that the fourth choice is by far the worst. I feel that most doctors would probably choose the third, and work with the patient, not against them. chiropractors are known for being able to adapt and work with people synergistically, as opposed to some of the other health care providers, who tend to have an antagonistic relationship with their patients.

Establishing Credibility

To establish credibility with athletes who are consuming anabolic steroids, the doctor must:

1. Freely admit they work and work well. You will be amazed at the credibility this one sentence will give you. 2. Honestly, without hype, educate the patient on the realistic risks and side effects of anabolic steroid use. 3. If you choose to work with an athlete, your goals should be to decrease the amount of steroids that the athlete consumes, increase the amount of time between the athlete's steroid cycles, and instruct the athlete how to safely train both during steroid use and between cycles. With this approach you will be in an excellent position to influence the patient athletes to permanently discontinue steroid use and begin to educate them in non-toxic ergogenic alternatives.

Human Nature

One of the lures to using anabolic steroids is the improvement or perceived improvement of one's looks. Our knee-jerk reaction is "what an unhealthy way to improve your looks." You'll get no argument from this author. But, I would like to remind you of some of the other unhealthy things we do as a society to look good. Go to any beauty salon and take a deep breath in. Toxic? You bet, and it's in our hair and scalps. Nasal surgery on a healthy nose that works perfectly? Sunbathing and face lifts are other unhealthy things Americans do to look good. Finally, let's not forget all those "silicone inserts." Who knows, maybe someday silicone will replace steroids for those who use them cosmetically. instead of going to the gym, people will go to their plastic surgeons. As for people who use steroids for enhanced performance, imagine if we had a "smart" pill with similar side effects. Think back to your training in chiropractic school for your tests and boards. What if "C" students suddenly began to break the curves, win the scholarships, graduate with honors, and get the best jobs without changing their study habits? What would you do? Better still, how would you convince someone not to use these so-called "smart" pills. This author feels that the use and abuse of anabolic steroids is a bit more complex than first glance indicates. A carefully constructed doctor-patient relationship based on the facts and trust is the position we must put ourselves in, in order to correctly influence our patients and athletes.