A recent study snappily called:

Dose response and efficacy of spinal manipulation for chronic cervicogenic headache: a pilot randomized controlled trial

By Haas and co-workers was published in the uber serious Spine (The Spine Journal 2010; 10:117-128) which said that chiropractic was good at sorting out headaches.

As we all know, headaches are very common (with up to 16% of the population having one at any one time) and can very disabling (leading to work-days-lost, absenteeism costs and increased medical benefits spend).

Headaches are broken down into primary and secondary. The primary group is made up of:
• migraine,
• tension-type
and
• cervicogenic headache (CGH).

This last lot, CGH, account for a significant proportion of the 16% point estimate of those suffering primary headaches (but Nilson and Sjaastad have estimated the point to range from 0.4%-4.6%). Whatever. They are linked to neck pain and mechanical dysfunction and so, it is theorized, treating neck pain and mechanical dysfunction through manual therapies will help reduce headache symptoms.

Systematic reviews have been conducted on the usefulness of spinal manipulative therapy (SMT) in the treatment of CGH, however the treatment plans offer great variability: from once per week for three weeks to twice per week for 8 weeks. This, clearly, demonstrates a lack of clinical understanding and consensus in the research. This prevents us from being able to confidently set out the prognosis and expectations with respect to SMT.

The purpose of the study was to determine the efficacy of spinal manipulation in CGH and compare a high-dose and low-dose SMT application to a light massage.

One group received low-dose SMT (8 treatments), high-dose SMT (16 treatments), low-dose light massage (8 treatments) and high-dose light massage (16 treatments). The study showed some interesting things:

• While treatment dose had no effect on the use of medication, those receiving SMT used 1/3 less medication at 24 weeks.

• With respect to the number of cervicogenic headaches experienced, those receiving SMT experienced 2.6 fewer headaches per week compared to those receiving light massage.

• At the end of 24 weeks, those receiving SMT experienced 2.1 fewer ‘other’ headaches per week compared to those receiving light massage.

• While dose effects were small, those who received high-dose SMT experienced a greater improvement in neck pain (-5.9 at 12 wks; -10.6 at 24 wks)

• CGH pain, the number of headaches experienced per week and the amount of medication intake all reduced, with sustained reductions, favouring the SMT group.

• Lastly, by eight weeks, the number of weekly headaches was reduced 50% in those patients receiving SMT and on secondary analysis, a 50% reduction in symptoms (obtained via the outcome measures) was achieved in 80% of those receiving SMT.

The authors point out several key limitations to this study:
• The study design was highly complex and multifactorial.
• There was a small number of patients within each subgroup.
• Multiple headache classifications were present within many patients.

Interestingly, for us as chiros, there was no difference between the two dosages of SMT (though SMT proved to be more effective than light massage, irrespective of dosage.). And, as we’d expect, the differences between the SMT and the light massage group were not only statistically significant, but clinically significant as well.

This study is highly relevant and helpful to clinical practice as it strengthens the use of cervical spine manipulation in the treatment of CGH. It is also helpful as it demonstrates that patients do not tend to be cured by this intervention alone, indicating that CGH may require a combined intervention approach which includes exercise, soft-tissue therapy, spinal manipulation and education.

Have a read and then see why we tell people to get some early care and so avoid this stuff as it just can’t be good for you!

“For Facet Joint Pain, Minimally Invasive Surgery A Good Fit
In pilot study, 30-minute surgery reduces pain, opioid use; multicenter trial to follow

Gabriel Miller

A minimally invasive approach for facet arthrodesis (artificial induction of joint ossification between two bones via surgery – my note) reduces pain as well as chronic opioid use in back pain patients, according to a new study. The procedure — originally developed and used by orthopaedic surgeons and neurosurgeons — also may be performed safely by interventional pain physicians, the study demonstrated.

Although arthrodesis of the facet joints is not a new procedure, experts say a minimally invasive approach — which can be performed by a number of specialties — is novel.

…Like an open surgical approach, the concept behind the minimally invasive arthrodesis is to fuse the facet joint by drilling a hole between the joint walls and tamping an allograft bone dowel into the joint, separating the joint surfaces, locking the facet joint into place and providing a minimal amount of stability. Facet joint disease most often results from degeneration of the cartilage within the facet joint; the joint then becomes unstable and shifts around loosely, causing painful bone-to-bone contact.“ The premise is if you can eliminate the motion that you have between these facet joints, then you can take away the pain,” said Dr. Guiot.

Daniel Bennett, MD, medical director of Integrative Treatment Centers in Denver, and the lead investigator of the pilot study presented at the AAPM meeting [said]: “Because the No. 1 cause of sustained low back pain is joint-related, this procedure is a new tool in the interventional pain specialists’ tool belt.”
The study included 28 prospectively enrolled patients with facet-mediated low back pain, (so, PFS in other words) that was confirmed by intraarticular facet injection. Patients also were required to have previous radiofrequency ablation (RFA) with a return of pain. “We wanted to start with a population that had experienced the current gold standard of care and [had] at least gone through all of the invasive treatments short of surgery,” Dr. Bennett said.

During the procedure, a minimally invasive (!), stab-wound incision is made and Steinman pins are placed between the facet walls. A drill guide is inserted using a spatula and the pins are removed; using the guide, a cortical reamer then bores a Morse taper-shaped canal of bleeding bone, into which the bone allograft is placed. (Minimally invasive, mind!)

The primary end points in the study were pain measured on a 100-point visual analog scale and function measured with the Oswestry Disability Index (ODI), each of which was measured at four, 12 and 52 weeks postoperatively. After complete follow-up, average pain scores decreased from 79 to 23 and functional disability, as measured by the ODI, improved from 33.46 to 8.32 (SD, 5.17).

Narcotic use also was measured before and after surgery, with morphine equivalents as high as 510 mg per day among patients. However, after 12 months, only four patients remained on opioids,

Dr. Bennett said:
“There was a big difference [in opioid use] and at the end of the day, when you look at that with the ODI data, there is a significant improvement in function,” he said.

“Pain management specialists inject facet joints all day long, so they are extremely accustomed to getting into that joint—in fact, much more accustomed than any surgeon would be,” said Dr. Guiot. “Once you are in the joint and you can access that space, that’s the toughest part of the procedure [and] the remaining portion is actually very simple.”

An additional key benefit, Dr. Guiot said, is that a minimally invasive (!) approach, which doesn’t damage or significantly alter surrounding tissue, doesn’t preclude any larger reconstruction procedures at a later date. “The most beneficial aspect is that this really doesn’t burn any bridges,” he said.

Dr. Bennett believes that the diagnostic approach used prior to minimally invasive (!) arthrodesis represents a shift toward treating pain at the source, rather than blunting nerves through ablation or opioids.

“One important thing to point out: This technique only treats the joint,” Dr. Bennett said. Arthodesis may prove more durable than RFA, but in order for it to work effectively physicians have to know precisely where the pain is originating.

“What I’m advocating based on the data is intraarticular facet injections that confirm the pain generator as the joints, not ligament or muscular structures,” he said. “Then you know what you should expect as an outcome when you fuse those painful joints.”

So stapling the joints together reduces the pain. Now this is laudable but no one should get to the point that they need their joints, which are designed to move, to be clamped together. Please get some care into those joints before you need ablating (!), opiods which I’m sure my mother warned me about or a minimally invasive (!) arthrodesis.

Initially, it appears a great and heart-warming article of surgical success – but read between the lines a bit and you’ll see a damming example of all that’s wrong with the current system of medical care for the low-back.

Look for these key points:
1. 10 years of pain!
2. Constant pain.
3. GP and painkillers – sure to work, them!
4. Didn’t, so back to the GP.
5. Referred to surgeon for a life-threatening three-hour operation (though I’d have thought the risk of paralysis that she mentions, the MRSA, anaesthetic induced death and, well, just death was not likely or serious enough to stop her having this operation as she had been in constant pain for 10 years!)
6. “The beauty of this operation is that it doesn’t constitute major spinal surgery”!
7. £10,000!

So, here it is:
“Around eight in ten Britons are affected by back pain at some time in their lives. Anne Baker, 65, a retired shopkeeper living in Sheffield, had a pioneering procedure to cure her debilitating back ache. She tells ANGELA EPSTEIN her story.

Pioneering surgery: Anne Baker can now enjoy life after having spinal fusion
THE PATIENT
My back has always been a problem, particularly after playing golf or lifting things. But over the past decade, it slowly worsened until I was in constant pain.

I went to my GP, who said it was wear and tear in my spine and gave me painkillers. Unfortunately, the benefit was only short term — I had a constant nagging pain in the centre of my back, which made me stoop, and I couldn’t hold my head up properly without being in immense pain. I was forced to give up golf and increasingly relied on my husband to do jobs around the house. He even had to fasten buttons on the back of my clothes.

It reached a point, five years ago, where even lying in bed was uncomfortable and the only way I could get a moment’s sleep was by half-sitting up on the sofa. As well as being in awful pain, I was exhausted all the time, which made me miserable.

I went back to my GP — after several appointments in previous months — in desperation, thinking there must be something that could be done. The painkillers were now having little effect so he referred me to a specialist, Lee Breakwell.

Although I was afraid of surgery — I’d heard stories of people coming out even worse after very invasive operations — there seemed to be no alternative. It was either an operation or a wheelchair and I was already practically housebound, so what was there to lose? A scan revealed one of the discs in my spine had degenerated so badly over the years that it had slipped out of place, causing the vertebra on top to tilt downwards by 30 degrees. Without the cushioning effect of the disc, two of my vertebrae were resting on each other, which was causing the dreadful pain.

So I was amazed when Mr Breakwell said that he could cure me using a new technique which was much less invasive than the conventional procedure. First I would need the disc removed — usually the vertebrae on either side would then be ‘fused’ together using screws: this stops the movement and the pain. But, instead, Mr Breakwell said he would use a bone graft, which helped the vertebrae to fuse better together, with fewer complications. I was a bit nervous about having a general anaesthetic and couldn’t help worrying that if something went wrong, that would mean being paralysed.

Although I was very sore from the stitches when I came round, incredibly, the constant nagging pain in my back was gone. The feeling was indescribable. The day after the operation, I could stand up straight without that terrible pain. The nurses helped me with exercises which I continued to do at home after being discharged, five days later.

Within three weeks, I could stand up straight without any pain. It was astonishing to see myself in the mirror after so long stooping — I seemed to have grown an inch-and-a-half.

Progress was slow, and I had to walk using crutches for seven weeks. But I could sit up properly and lie down flat without any discomfort after a couple of weeks — a milestone after sleeping on a sofa for two years. About six months later, I was able to play golf for the first time in four years. I’m constantly aware of my good fortune — even little things such as fastening the buttons on my dress.

Before the surgery, I felt like an old woman and thought my future was a wheelchair and pain for the rest of my life. Now, I can wear nice clothes and high heels and play golf. I even have a perfect swing, as the metal rod in my back helps keep my hips straight! It’s like being given a whole new lease of life.

THE SURGEON
…[To begin the three-hour operation, I made a 10cm vertical incision in the small of the back along the spine, and peeled back the spinal muscles to reveal the base and bones of the spine. I then drilled into the vertebrae on either side of the damaged disc and stabilised them with small screws in order to remove the disc (a disc is around 10mm high and four cm in diameter). I packed a teaspoon of bone graft — grated bone, which is better absorbed by the body than solid bone, taken from Anne’s pelvis during the operation — into a banana-shaped piece of plastic (a ‘spacer’) about 10mm high with a hole through it. The plastic is then placed into the space where the disc used to be, so that the bone from the graft can grow and fuse with the joints on either side. The bone graft doesn’t need any treatment to prompt it to grow. However, the adjacent joints need still to be in order, to keep the space open for the new bone to grow in. I do this by locking little screws into the joints. The bone graft takes between six and 12 weeks before it gets taken up by the body and turned into proper bone.

While the bone graft doesn’t act as a new disc, it makes that part of the spine solid and puts an end to the pain previously being caused by a jarring damaged disc.

We need discs in our back to provide shock absorbency for the spine. However, missing one disc shouldn’t matter too much, as we have other discs to compensate. The beauty of this operation is that it doesn’t constitute major spinal surgery [!]. The procedure is quite localised, yet it can cure a disabling disc problem. It relieves pain and enables the patient to function normally again.
Anne’s return to the golf course is a wonderful example of this. And it should solve her problem for life.

The operation is available on the NHS. It costs £10,000 privately.”

Good grief, why didn’t they spend a little time and money (I’d estimate about 1/33th of what they paid for the operation alone) on some early care in the first few years and maybe, just maybe, none of this madness would have had to happen.

Now, I am really glad that Anne is functioning well and that the surgery was a success but I am appalled at the loss of a decade of her life due to medical mismanagement.

1. The comercially available ice pack – like the James Barton ones we sell;

2. A load of smashed up ice from the freezer in a freezer bag;

3. Some good old frozen peas.

And here is the best way to apply it.

We advise that you use it for no more than 20 minutes on and 40 off in any one hour so that you don’t ice burn your back (to add to your woes). Locate the centre of your pain and place the pack against it – simple, really.

If you are using the pack through clothing have a layer of thin cloth (handkerchief not T-shirt) between you and the ice pack. If you are applying it without clothes then a thin layer of warm cloth can be applied first this will make the whole experience less terrifying as the cooling effect will slowly chill the warm cloth and then start its work.

It has been shown that patients icing within the first 24 hours of an acute injury have an approximate 6-day recovery time with grade 2 injuries and 13-day recovery time with grade 3 injuries. By waiting 48 hours to begin icing the recovery time almost doubles for grade 2 and 3 injuries! The application of heat can triple the recovery times for both grade 2 and 3 injuries.

So, go with ice first of all and fast unless told otherwise by someone who knows better – so, not your mate int he pub!

Overview
LLD is typically divided into two broad categories:

1. Structural discrepancies. These occur when either the thigh (femur) or shin (tibia) bone or both bones in one leg are different lengths to the corresponding bones in the other leg. Small discrepancies between the length of bones on each side of the body are common; the problem occurs when the difference in length is more pronounced (usually .5 to 1 inch difference is considered within normal limits). A structural LLD also is called a true leg length discrepancy and is considered a true discrepancy because the cause is an actual physical length difference in the lower extremity bones. Structural LLD is usually as a result of genetic conditions, nutritional deficiency or traumatic cause such as fracture or disease loss of bone. A fuller guide is shown below:

a. Previous injury to bone. A broken bone can cause an LLD if the bone heals in a shortened position. This typically occurs if the bone fractures into several shards and is more likely in an open fracture. Remarkably, broken bones in children can lead to overgrowth of bone few years after healing, resulting in a longer than normal bone. Overgrowth commonly occurs in young children with femoral fractures. However, if the break runs through the growth centre near the end of a bone and damages the cells responsible for growth of the bone, this may cause slower growth, resulting in a shorter leg.

b. Bone diseases. Bone disease such as osteomyelitis, can also injure the growth plate, where growth in length occurs, so that a discrepancy occurs gradually over time. Others include neurofibromatosis, multiple hereditary exostoses and Ollier disease. Bone tumours and the treatments designed to eradicate them can also be related to leg length discrepancy. Tumours, like an infection, can invade the growth plate and treatments, like chemotherapy, can also damage the plate.

c. Bone infection. Bone can occur in children while they are growing can cause significant LLD, especially if the infection happens in infancy. Inflammation of joints during growth, such as juvenile arthritis, can cause LLD.

d. Hemihypertrophy (one side too big) or hemiatrophy (one side too small) are rare limb length discrepancy conditions. In these conditions, the arm and leg on one side of the body are either longer or shorter than the arm and leg on the other side of the body. There may also be a difference between the two sides of the face.

e. Other causes. Other causes include inflammation (arthritis) and neurologic conditions.

f. Idiopathic difference. Sometimes the cause of limb length discrepancy is unknown. These conditions are usually present at birth, but the leg length difference may be too small to be detected. As the child grows, the limb length discrepancy increases and becomes more noticeable.

2. Functional discrepancies. These occur when the leg lengths are equal but the symmetry is altered usually somewhere above the hip which in turn disrupts the symmetry of the legs. Functional LLD is more common than the structural form, however the causes can be harder to determine. In functional LLD it appears that one leg may be longer than the other, but there is no significant difference in the length of the lower extremity bones. Instead, a postural distortion above the hip joints has caused one lower extremity to appear longer or shorter than the other.

The causes of functional LLD are numerous with the most common set out below:

a. Sacroiliac joint dysfunctions leading to pelvic obliquity – and I think the most common, at least in my clinic. This is one of the key findings from a massive study carried out by one of our co-authors, Augusto Manganiello was that just a small LLD can lead to significant pelvic torsion and further sine biomechanical problems.

b. Hip joint dysfunction causing compensatory alterations by the joint and muscles that move the joint. Congenital (present at birth) problems that alter alignment of the hips, such as coxa vara and developmental dislocation of the hip fall into this category.

c. Neuromuscular problems, such as cerebral palsy, which causes problems with alignment and posture can also lead to a functional discrepancy.

d. I am told that a growth in muscle mass itself may lead to LLD. Apparently, the Vastus lateralis muscle seems to push the iliotibial band (ITB) laterally leading to femoral angle compensations to maintain a line of progression during the gait cycle. This is bound to be misdiagnosed as ITB syndrome and subsequently treated incorrectly.

e. And the internal rotators of the lower limb being chronically short or in a state of contracture though I hate this sort of diagnosis as there’s never a decent answer to the why?

f. And apparently, failure or incorrect loading of the Back Force Transmission System (the longitudinal-muscle-tendon-fascia sling and the oblique dorsal muscle-fascia-tendon sling). See the proceedings of the first and second Interdisciplinary World Congress on Low Back Pain.

g. And one I found last week with a patient who has uber lax ligaments and has developed one hyperflexed knee leading to a subsequent low hip on that side.

It is important to distinguish between the two as they are treated differently.

Incidence
One study reported that 32% of 600 military recruits had a 1/5 inch to a 3/5 inch difference between the lengths of their legs. In a study by a bloke called Knutson, who is no slouch, he concluded:

“Using data on leg-length inequality obtained by accurate and reliable x-ray methods, the prevalence of anatomic inequality was found to be 90%, the mean magnitude of anatomic inequality was 5.2 mm (SD 4.1). The evidence suggests that, for most people, anatomic leg-length inequality does not appear to be clinically significant until the magnitude reaches ~ 20 mm (~3/4″).
Conclusion
Anatomic leg-length inequality is near universal, but the average magnitude is small and not likely to be clinically significant.”

The most accurate way to identify a structural LLD is with a lower extremity radiograph that allows a comparison of bone measurement with the other limb. If this is not an option, a comparison of the measurement between bony landmarks on each side with a tape measure is another option, although it is somewhat less accurate.

Treatment
Structural discrepancies
For structural LLD the therapeutic goal must be to flatten the pelvis. Treatment of structural LLDs depends on the severity of discrepancy and the requirements of the patient. Treatment is done in the following ways:

1. Orthotics: A shoe lift can be used to treat discrepancies up to 2 cm. The lift should be large enough to allow the patient to walk normally.

2. Shortening procedures: The following procedures, used to shorten the longer leg, may be recommended for some children, in cases where the leg length discrepancy is expected to be between 2 and 6 cm at maturity. Shortening is considered safer and results in less complications than lengthening procedures:

a. Epiphysiodesis – This procedure slows the rate of growth of the long leg, allowing the short leg to catch up. The operation involves the creation of bony ridge, usually by repositioning a block of bone in the region, that tethers the growth plate, preventing future growth. The disadvantages of this procedure include shortened stature, surgery on the unaffected extremity, and the irreversibility of the procedure.

b. Epiphyseal stapling – This operation is performed to slow the rate of the growth temporarily. Staples are surgically inserted on each side of the growth plate. Once equalization has been achieved, the staples are removed.

c. Bone resection – This operation, removal of a section of bone to equal out the discrepancy, can be performed in adults or adolescents who are no longer growing.

3. Lengthening procedures are usually reserved for discrepancies that are more than 4 cm. While one of the obvious advantages of lengthening is the achievement of height, it is not always the method of choice because the process used is technically difficult and has a significant rate of complications, discussed further below.

For this procedure, a customized apparatus that encircles the leg is surgically attached to the limb that will be lengthened by pins. Limb lengthening correction works on the principle of bone regeneration (osteogenesis) as segments of the bone are pulled apart (distracted). To achieve this, a bone is first cut in two during surgery. Days after surgery, the two ends of the bone are very gradually pulled apart through continual adjustments that are made to the apparatus, usually at a rate of 1 mm per day. This gradual distraction leads to formation of new bone between the two ends, at the site of lengthening. After the process is complete, and the bone is given a chance to harden, the apparatus is surgically removed. A cast or brace may be required for some time for further protection. Common complications associated with lengthening procedures include pin tract infection, wound infection, hypertension, partial dislocation of the hip and knee, a delayed union of the bone and fatigue fractures after removal of the lengthening apparatus.

4. Prosthetics: These devices, which are typically used to treat a child who has had to have an amputation, may be satisfactory for some patients with very large discrepancies, who would not benefit from other lengthening or shortening procedures

But, any structural LLD <20 mm and LLD caused by supra-pelvic muscle hypertonicity may interact in a standing posture, but not in an prone or supine posture as they are unloaded postures. So, any LLD due to suprapelvic muscular hypertonicity should be eliminated before any necessary treatment of structural LLD starts.

The lateral flexion of the lumbar spine was assessed in a group of subjects 10 years after structural LLD caused by femoral fracture that occurred after they were skeletally mature. Despite the compensatory lumbar scoliosis, these subjects had symmetrical lumbar lateral flexion, prompting the authors to comment that the “…acquired leg-length discrepancy produced little permanent structural abnormality in the lumbar spine…”. So, significant anatomic LLD acquired after skeletal maturity does not result in adaptive structural changes within a 10-year period.

However, another study from the same orthopaedic centre looked at the effects of significant (so about 3 cm) structural LLD acquired prior to skeletal maturity in mature subjects (so between 17–38 years old). In this group, there was considerable asymmetry of lumbar lateral flexion after placing a lift under the short leg to level the pelvis. This indicates that the body had permanently compensated to the structural changes in the spine/pelvis.

This type of permanent compensation in preskeletal maturity LLD was also found in subjects with pelvic obliquity. Young et al. found that placing a lift under the foot of a subject with no pelvic obliquity resulted in greater lumbar lateral flexion towards the now high iliac crest side. In subjects with pelvic obliquity, when the lift was put under the foot on the side of the low iliac crest in order to level the crest, lateral flexion was increased towards the formerly low crest side. If the body remodels and adapts to the pelvic obliquity or torsion caused by anatomic LLI, then by putting a lift under the side of the “low” iliac crest, one is actually raising what the body has adapted to as level. In other words, the unlevel pelvis of those with anatomic LLI has been adapted to and is now “normal”, and putting a lift under the low side has the same effect as putting a lift under the leg of an even pelvis!

“Glastonbury Spring Water appreciates the need in reducing / off setting our carbon footprint where at all possible. When taking on our new build at Park Corner Farm, Glastonbury, the environment & climate change heavily influenced the way we carried out the design.
We developed a run down council farm into a state of the art production facility with every aspect of the design encompassing recyclable or renewable materials wherever possible. All bricks in the build were reclaimed from the previous farm buildings. Sheep’s wool was used as insulation for the roof. Under floor heating installed with a ground source heat pump to warm the offices & production areas & solar panels introduced to provide hot water for our bottling plant.

A reed bed sewerage waste system completed the installation. Now the plant is fully operational all plastics, bottles & wrapping are recycled locally as well as cardboard.

Our water is bottled at source onsite from our own borehole, no tankering is involved at any stage

“Other Recycling Initiatives”
As from December 07 all our drivers will carry PDA’s to eliminate the use of paper.
We are continually tree planting to expand our orchards at Park Corner.
If you are interested in our build or any of the schemes running at Park Corner including our higher level stewardship we would be more than happy for you to pay us a visit.”

Cool, eh? I might set up a visit.

Rowing is up there amongst the most demanding of sports to train for if you are going to do well and to succeed you need to be able to train hard – and we mean well beyond mere mortal levels of a run round the Downs once a week.

CoBRC winners

I am really pleased that we are involved in keeping these lot working well and will even risk putting a fiver on them to come good at Henley.

How do you calculate your daily energy requirements in calories?
Basic energy requirements (BER) includes your basal metabolic rate (BMR) + extra energy requirements (EER).
To calculate BMR:
For every Kg of body weight 1.3 Calories is required every hour.
1.3 x 24 x bodyweight KG = BMR
(e.g A person weighing 50Kg would require 1.3 × 24hrs × 50Kg = 1560 Calories/day to maintain their current weight.)

To calculate EER:
For each hours training you require an additional 8.5 Calories for each Kg of body weight.
8.5 x training hours x bodyweight KG = EER
(e.g. For a two hour training session our 50Kg person would require 8.5 × 2hrs × 50Kg = 850 calories extra.)

BMR + EER = BER
Basic energy requirements MAINTAIN your current weight.
Calculate Daily Calorie Deficit For Fat Loss
The following are guidelines and tips to get your nutrition plan assembled for effective fat reduction to improve your PWR (power to weight ratio).

Determine your total caloric intake for (fat) mass reduction

Method one: multiply your weight in pounds by 11 and 12 and subtract 300 to 500 calories to obtain goal daily calorie intake range to promote healthy weight loss.

Example: 200 lbs times 11 (= 2200) minus 500 = 1700 200 lbs times 12 (= 2400) minus 500 = 1900 Calorie range = 1700 to 1900 calories

Method two: Reduce your BER figure by 10 – 20%

Both of these methods introduce a calorie deficit of up to 3000-4000 calories per week to lose between 1-2 lbs of weight. Should your activity level increase, you create a larger calories deficit. Adjust energy intake accordingly to avoid fatigue or excessive hunger.

Calories = Energy/Fuel
Like fuel for a car, the energy we need has to be blended. The blend that most people require is as follows:
40 – 70% Carbohydrates (sugar, sweets, bread, cakes)
15 – 25% Fats (dairy products, oil)
15 – 40% Protein (eggs, milk, meat, poultry, fish)

The energy yield per gram is as follows: Carbohydrate – 4 Calories, Fats – 9 Calories and Protein – 4 Calories.
What does a 50 kg athlete require in terms of carbohydrates, fats and protein?
Carbohydrates – 57% of 2410 = 1374 Calories – at 4 Calories/gram = 1374 ÷ 4 = 343 grams

Fats – 30% of 2410 = 723 Calories – at 9 Calories/gram = 723 ÷ 9 = 80 grams

Protein – 13% of 2410 = 313 Calories – at 4 Calories/gram = 313 ÷ 4 = 78 grams

Our 50kg athlete requires 343 grams of Carbohydrates, 80 grams of Fat and 78 grams of Protein

Consider these easy ways to cut calories

Keep a food record (for at least 3 days) to evaluate and monitor your current eating habits. Calculate your average daily calorie intake. It is a very effective self-monitoring tool. It will identify hidden calorie sources; it is a remedy for “food amnesia”!

Limit animal protein (beef, pork, poultry and seafood) to 8 ounces or less daily. Reduce or use very small amounts of added fats like cooking oils spreads and dressings. Drink zero calorie or low calorie beverages (water, diet drinks)
Eat three meals with one or two snacks daily. Spread your calories throughout the day. Your body operates best when it has a steady supply of fuel. Let fruits and vegetables dominate your plate. Choose mainly whole grain starches; avoid processed grains (sugar, white flour).

Consider taking a standard multivitamin
Meeting vitamin and mineral needs while following a calorie-controlled eating plan coupled with exercise should be easy if you are eating responsibly. A standard multivitamin will help you meet your daily vitamin and mineral needs if you feel unable to do this.

Maintain good hydration
Aim for 2-3 liters water daily. Carry a water bottle and drink from it throughout the day. Avoid alcohol and caffeine.

Stay focused during the holidays
Limit or avoid alcoholic beverages (they’re high in calories!) Avoid being too restrictive yet regulate your food portions.

Monitor your weight and body composition
Take measurements and trend these parameters over time.

Get most of your fats from EFA’s. Flax powder or cold pressed oil is an excellent source of EFA’s. Walnuts also have high levels of omega 6 & 9. These essential fatty acids are not manufactured by our own body’s therefore we must make sure we intake adequate amounts. EFA’s have been shown to improve muscle repair, aid anti-inflammatory response and also fats help aid satiety by slowing down gastric emptying. Limiting fats to lower than 20% will only leave you depleted, hungry and grumpy so don’t avoid them completly, just get them from intelligent sources.

“Back pain relief in just five minutes a day

If you suffer from back pain and have received professional help, the chances are that you have been told that you need to strengthen your ‘core’. Studies into the causes of back pain have identified weak musculature of the low back and ‘core’ as a common factor in many cases of chronic back pain. So, what is this term ‘core stability’ which is being bandied about and where is this elusive core?

The core muscles are located around the abdominal region, back, pelvic floor and hips. These muscles are responsible for balance, posture, trunk stability and are the foundation for movement. If they are weak, other muscles have to compensate, which is where poor posture and back pain come in.

Core stability isn’t about having a six-pack. Your six-pack muscle (the Rectus Abdominis) is a superficial muscle and, although it does form part of the core, we are more concerned with strengthening the smaller, deeper muscles for maximum stability.

So, now you know where the muscles are, we can work on identifying them in your own body in order to effectively strengthen them.
Below are four core strengthening exercises. During each exercise, you need to employ these muscles and maintain the contraction throughout. If you’ve done Pilates before, you may have heard this referred to as ‘zipping and hollowing’ or ‘pulling in’. Once you’ve mastered this technique, apply it to everyday life. Contract your core when lifting, running, even getting out of bed to keep your spine protected.

Here’s how to do it…
Lie face up on the floor with your legs bent and feet flat on the floor. Locate the top of your pelvis [on each side directly above where your pockets are] and walk your fingers diagonally down to[wards the top of your zip at] the front [each hand] by about 5cm.
Keep your fingers there, now cough. As you cough you’ll feel a contraction in the muscles under your finger. This is your core ‘firing up’.
This is the contraction you want to establish and maintain throughout the exercises so practice doing this by coughing again and trying to hold the contraction for at least 30 seconds.
If you find you’re holding your breath, try counting out loud.
It does take a bit of practice to get the hang of this but once you’ve got it you’ll have no problem holding the contraction while exercising and breathing at the same time!

So, to the exercises…

Roll down
This will mobilise your spine and provide a good stretch down your back. Stand with your feet hip width apart and your knees slightly bent. With your core contracted, put your chin on your chest and slowly roll down through your spine. Keep your knees slightly bent.
Think about articulating one vertebrae at a time, feeling the stretch down your back until you’re bent over with your neck relaxed and your arms hanging down, like a rag doll. Then roll back up, stacking one vertebrae on top of the other. Bring your head up at the very end to finish the exercise.

Leg raises part one
Lie face up with knees bent and feet flat on the floor hip distance apart. Contract your core and raise one leg off the floor until the knee is above your hip-joint, keeping your knee bent.
Be careful not to lose the natural curve of your spine. If your back starts to ache, chances are your back is arching and your pelvis is tilting away from you.
Avoid this by holding the contraction thigh and tilting your pelvis towards you by pushing your spine toward the floor.
Note I said pushing ‘towards’ the floor, not ‘into’ the floor. You don’t want to lose the natural curve by pushing the spine into the floor.

Leg raises part two
In the same starting position as the previous exercise, contract your core and raise one leg then straighten it out in front of you, keeping a bend in the knee. Raise as high as you can without losing the natural curve in your spine, then, making sure you’re still holding in your core, press your low back into the floor and tilt your pelvis in towards you. This time you want to lose the curve. Hold, then return to your starting position and repeat the other side.

Front support hold
Often referred to as ‘the plank’ this is a great one for your core. On your front, with your core contracted, prop yourself up on your elbows and raise onto your toes so your entire body is off the floor (apart from your elbows and toes, obviously – if you learn how to do it otherwise, please let me know).
You’re aiming for a ‘dish’ position, so rather than having your back dead straight, you want to tilt your pelvis forwards to achieve a slight upward curve, like a bridge. This takes pressure off your back and works the core harder.
See for illustrations and further guidance. If you can spare five minutes each day to do these four exercises, you’ll be giving yourself a good start to achieving core stability and reducing back pain. ”

Not at all bad advice and if you look at our web site:
www.c1healthcentre.co.uk
you’ll see these shown on our page to boot.

http://www.telegraph.co.uk/health/expathealth/7718976/Back-pain-relief-in-just-five-minutes-a-day.html

For years, employees who suffer from chronic low back pain have been treated with a transcutaneous electric nerve stimulation (TENS), a portable device that applies a mild electrical current to the nerves through electrodes. The theory behind the treatment was that nerves can only carry one signal at a time. Physicians believed that transcutaneous electric nerve stimulation confused the brain and blocked the real pain signal. However, according to a guideline issued by the American Academy of Neurology, this method is not recommended.

Research on TENS transcutaneous electric nerve stimulation for chronic low back pain has produced conflicting results. For the guideline, the authors reviewed studies for low back pain lasting three months or longer. Acute low back pain was not studied. The report concluded that transcutaneous electric nerve stimulation does not help chronic low back pain.

Researchers noted that all but one of the studies excluded people with known causes of low back pain, such as a pinched nerve, severe scoliosis (curving of the spine), severe spondylolisthesis (displacement of a backbone or vertebra), or obesity. In the study that looked at low back pain associated with known conditions, transcutaneous electric nerve stimulation was not shown to be effective.

“The strongest evidence showed that there is no benefit for people using transcutaneous electric nerve stimulation for chronic low back pain,” said Richard M. Dubinsky, lead author of the guideline and a fellow of the AAN.

“Doctors should use clinical judgment regarding transcutaneous electric nerve stimulation use for chronic low back pain. People who are currently using transcutaneous electric nerve stimulation for their low back pain should discuss these findings with their doctors.”

The guideline determined that transcutaneous electric nerve stimulation can be effective in treating diabetic nerve pain, also called diabetic neuropathy. However, researchers said more and better research is needed to compare transcutaneous electric nerve stimulation to other treatments for this type of pain.