Anterior Cruciate Ligament Injuries

Intrinsic Risk Factors– Structural differences– Quadriceps Femoris

angle– Femoral Notch– Joint Laxity and Flexibility– Hormonal Influence

Extrinsic Risk Factors– Muscular Strength and

muscular activation patterns

– Knee Stiffness– Jumping and Landing

Characteristics

Structural Differences

Pelvic Width

Tibiofemoral angle

Magnitude of the Q angle

Width of the femoral notch

Quadriceps Femoris Angle(Q Angle)

Average male and female = 8-17 degrees Women avg. at high end; contributes to wide pelvic base and

shorter femoral length resulting in more lateral proximal reference point

Q angles greater than 20 degrees for women are abnormal Inc. lateral pull on quadriceps femoris muscle on the patella and

put medial stress on the knee Lower extremity alignment cannot be altered, but the dynamic

position of the tibia can be improved with internal rotation exercise of the tibia(medial hamstring)

Femoral Notch

Early as 1938, postulated that the dimensions of the intercondylar notch (height, width, ratio of height to width, and overall shape) contribute to anterior cruciate injuries

A narrowed anterior or posterior notch width increases the risk

CT testing necessary A-shaped notch

Joint Laxity and Flexibility

Inherent in the individual

Support by strengthening the quadriceps, hamstrings, gastrocnemius

Caution in attempt to increase flexibility Nutritional support

Hormonal Influence

Estrogen affects soft tissue strength, muscle function, CNS Relaxin can drastically diminish collagen tension Estrogen and progesterone receptor sites have been found in

the ACL More non-contact ACL injuries during the ovulatory phase of

menstrual cycle(day 10-14) During this time there is an estrogen surge and relaxin peak at

day 14 and again midway through the luteal phase PMS influence BCP: hormonal stability

Muscular Strength and Activation Patterns

In response to anterior tibial translation females prefer to recruit the quadriceps whereas the male athlete first contract the hamstrings

Adequate strength and reaction time of the hamstrings is critical in knee stability

Coactivation of the hamstrings with quadriceps is necessary to aid the dynamic component of joint stability, to equalize articular surface pressure distribution, and to regulate the joint’s mechanical impedance.

Plyometrics and agility-type exercises, running through cones, tires, and figure eights to improve muscle reaction time

Knee Stiffness

Intrinsic component is the number of active actin-myosin cross-bridges in the muscles at a specified point(1st point of protection)

Extrinsic component is dependent on the excitation provided by the alpha and gamma motoneurons (potential of protection is greater)

Varus and Valgus stiffness Functional training program that emphasizes the hamstring and

gastrocnemius muscle groups

Jumping and Landing

High percentage of ACL injuries occur when athlete is landing from a jump

More knee extension on landing produces greater maximum impact force

Women perform with less knee flexion, more knee valgus, and less hop flexion.(Orthopedic Society for Sports Medicine Specialty Day, 1999)

Specific Jump and Landing training program is recommended for women who participate in sports that require jumping and pivoting (Hewett 1996)

Rehabilitation of ACL injuries

Early Phase– Weight-bearing and proprioceptive exercises to provide

neuromuscular reeducation and improve functional knee stability

Return-to-Activity Phase– Dynamic exercises involving jumping and pivoting to retrain

the athlete for high impact loading of the knee joint

Follow-through Phase– Continuation of the thrusting leg into a position of full hip and

knee extension. This position causes a valgus force at the knee and tibial external rotation

Back Injuries in the Young Athlete

Acute Injuries

Fractures– T/L spine compression fx occur with axial loading

in a flexed or vertical posture Acute Disc Herniation

– Usually without sciatica– May present with back spasm, neurogenic

scoliosis, hamstring tightness, buttock pain Contusions, Strains, and Subluxations

– Adolescent growth spurt may predispose to an acute apophyseal avulsion of at the lumbodorsal fascia to the apophysis of the iliac crest or spinous process

Overuse Injuries

Risk Factors– Growth Cartilage- immature ossification

centers are often the weakest link of force transfer

– Biomechanics• Kinematics: body motion• Kinetics: force to mass and its motion

– Intrinsic-musculo tendinous inflexibility– Extrinsic-collision and ground reactive forces

– Nutrition- may result in irreversible osteopenia and stress fractures such as spondylolysis

Extension Injuries

Spondylolysis and spondylolisthesis

Lordotic Low Back Pain

Transitional Vertebrae

Facet Syndrome and Sacroilitis

Spondylolysis

Stress fracture of the pars interarticularis Repetitive flexion and extension AP/Lat films Symptomatic fracture treated with anti-

lordotic lumbosacral orthosis(Boston brace), PT modalities, restricted activities

Return to sport after there is demonstrated union, pain-free and manifests a full range of motion

Spondylolisthesis

A forward slippage that occurs with one vertebral body over the inferior vertebral body.

The isthmic type is concern for athlete. Graded by degree of slippage(0-25% grade 1). Athletes are at low risk for progression Progression is associated with rapid growth and

is symptomatic Above Grade 3(>50% slippage); risk for

progression and surgical candidate

Lordotic Low Back Pain

Tight thoracolumbar fascia is a consequence of rapid growth.

Presents as hyperlordosis with a flat mid-back and thoracic kyphosis

Several pain syndromes may ensue– Traction apophysitis at the iliac crest, spinous process,

anterior vertebral ring– Pseudarthrosis (Baastrup’s syndrome)

Transitional Vertebrae

Incomplete segmentation of the lower lumbar and upper sacral vertebrae

Pseudarthrosis may form b/t a bony lumbar extension to the sacral ala or iliac wing

Rapid flexion/extension may cause severe inflammation(Bertolotti’s syndrome) which may mimic a spondylolysis

Treatment to quiet inflammation and stabilize surrounding structures

Facet Syndrome and Sacroiliitis

Flexion Injuries

Scheuermann’s Kyphosis Disc degeneration Internal disc derangement Non traumatic Causes of Back Pain

Scheuermann’s Kyphosis

Three consecutive anterior vertebral bodies wedged at least 5% each

Vertebral end plate changes Schmorl’s nodes Apophyseal ring fractures Upper trunk and postural exercises Atypical Scheuermann’s is associated with the lower

T/L spine due to rapid flexion/extension Aggressive thoracolumbar fascia stretching and

spinal stability

Disc Degeneration

In the young athlete it is usually due to microtraumatic overuse.

Internal Disc Derangement

Radial tear of the inner anulus. The nucleus pulposus is irritating to the outer annulus. The tear is contained and pressure increases with any lumbar flexion. Notably sitting.

Non-traumatic Causes of Back Pain

Consideration must be given from the beginning. Rule out infections with discitis and osteomyelitis, tumors , juvenile RA, and other collagen vascular diseases

Breast Conditions

Breast Cancer Lymph edema Fibro adenoma Fibrocystic Breast Changes Breast Augmentation Mastitis

Breast Cancer

Malignant neoplasm– Classified: in situ (contained) invasive (infiltrated

surrounding tissue)

Several types: – Two most common:

• ductal carcinoma (epithelial cells lining the ducts)

• lobular carcinoma (milk-secreting glands of the breast)

Ductal Carcinoma

Most common of all breast cancers “Ductal carcinoma in situ” has the

highest cure rate of all the cancers Growth Patterns:

– Micropapillary– Cribriform– Solid– Comedo (most aggressive)

Who Gets It?

20-20y/o… 1:2000 30-40y/o… 1:250 40-50y/o… 1:67 50-60y/o… 1:35 60-70y/o… 1:28 Lifetime…. 1:8

Etiology and Risk Factors

Personal and family history of Breast cancer Hormonal influences:

– high/sustained estrogen levels – HRT – BCP(high estrogen)

Exposure: – Foods treated with hormones

• Xeno estrogens

Genes: BRCA 1 BRCA 2 – 50-85% lifetime risk of breast ca, ovarian ca, both.

Signs and Symptoms

Silent Mass-typically not movable “orange-peel” appearance of breast Dilated venous pattern Mass in armpit Nipple discharge Non-healing sore on breast or nipple Swelling in arm or hand Back (bone) pain

Stages of Breast Cancer

Stage O: In situ ductal carcinoma in situ (DCIS)

Stage I: Tumor < 2cm, no spread Stage II(A,B): Tumor 2-5cm, with/without

spread to axillary lymphnodes Stage III(A,B): Tumor >5, spread to axillary

lymphnodes or penetrated the wall to the skin or chest wall

Stage IV: Metastasized

Dietary Support

Indole 3-carbinol: liver metabolism of estrogen to 2-hydroxy estrogen derivative cruciferous vegetables broccoli, kale, cauliflower, cabbage, bok choy

Lignans Green tea catecins Lycopene (tomatoes, red peppers,

grapefruit) Eliminate xenoestrogens (eat organic)

Nutritional Supplementation

Calcium D-glucarate: aid in elimination of xenoestrogens, assist intestinal flora

Coenzyme Q10 300mg/day Selenium 60 mcg/day Vitamin C 5000 mg/day Vitamin E 400 IU/day Folate Vitamin B6 50-100mg/day

Lymphedema

Complication of procedures to treat breast cancer

Accumulation of lymph fluid that accumulates in the arm resulting in swelling.

Etiology– Removal of lymph channels– Compromised immune system

Management

Avoid excessive heat to arm, lifting heavy objects, restrictive clothing, strenuous activity

Compression sleeves Pneumatic pumps Lymphatic drainage massage Mild range of motion exercise

Fibroadenoma What is it?

– Benign tumor of the breast Who gets it?

– Women in their menstruating years, most common breast tumor in adolescent girls

What causes it? – Unknown

Signs and Symptoms: – Movable tumor – Non-tender – Not attached to skin – Clearly delineated

How is it diagnosed? – Signs and symptoms, biopsy, mammography, ultrasound

Fibrocystic Breast Changes

Aka: Cyclic Mastalgia: An exaggerated response of the breast tissue to hormonal changes.

Etiology: Unknown Signs and Symptoms:

– Lumpy breasts– Breast pain and tenderness– Swelling of breasts (feeling of fullness)– Soft, movable lumps– Symptoms progressively worsen after ovulation

and improve after menses

Management

Decrease caffeine Trans fats excess salt hormonal treated foods

Exercise

Breast Augmentation: Risks and Complications

Anesthesia Rxn Asymmetry Bleeding Breast droop Capsular

Contracture Deflation(7%) Displacement Hematoma(3-4%) Impact leak

Infection Nerve damage Pain Permanent

numbness(15%) Rupture of implant Skin irregularities Slow healing Symmastia(merge

into one) Visable scar

Sensation Loss/Change

15% risk of having permanently numb nipples

Implants placed above the muscle have greater risk.

All incisions have a risk of diminished sensation

Capsular Contracture

Scar tissue hardens around the implant Less common and less severe with

saline implants vs. silicone implants Baker Grade I - IV Studies suggest 17% saline implants

have some lasting problem

Rupture or Leak

Rupture of Saline Implants: deflates and the salt water is absorbed by the body.

Rupture of Silicone-Gel implants: pain, tingling, swelling, burning. According to FDA, 69% have at least one rupture.

Mastitis What is it?

– Inflammation/Infection of the milk ducts in the breast Who gets it?

– Women who are breast-feeding. If non-breast feeding, look for CA.

Etiology? – Improper drainage of the milk ducts.

Signs and Symptoms:– Triangular flush: redness on the underside of breast– Swelling, Pain, Tenderness of breast– Flulike symptoms– Fever– Sensation of heat on breast

Prevention/Management

Nurse infant on demand Adequate rest Frequent nursing Support bra Hot packs/massage Drink fluids ** Chaste berry (cyclic mastalgia)

contraindicated b/c prolactin-lowering abilities

Cardiovascular Disease

Any disease of the heart and blood vessels, including CAD, atherosclerosis, DVT, varicose veins, strokes, aneurysms, stenosis

Women affected after age 55. Men-45 y/o

Leading cause of death in women, regardless of race.

Cholesterol(a fat) plays a major role– LDL: bad– HDL: good

Cholesterol

Necessary for variety of functions, primarily the production of hormones

It is not soluble in the blood, must bind to a protein that forms a lipoprotein– LDL: not good because it moves away from the

liver to target tissues, such as the heart– HDL: the protein removes cholesterol from the

target tissue and blood vessels and returns to the liver, for preparation for excretion.

The role of Estrogen

Estrogen raises HDL and lowers LDL Prevents oxidation, making the LDL’

less harmful in the blood vessels. Decreases at menopause

– Women in perimenopause typically have total cholesterol 200-240 with desirable HDL and LDL levels.

Lifestyle changes

Smoking cessation– 4800 chemical substances: many can

damage heart and blood vessels• Nicotine-constricts blood vessels, increase HR

and blood pressure

• Carbon monoxide in smoke- replaces oxygen in the blood, increasing blood pressure, heart has to work harder to get oxygen to tissue

• Women who smoke and take birthcontrol pills are 20-30x greater risk of having stroke or heart attack

Exercise alone reduces CVD by 30-50% Diet: decrease saturated fats Vitamin C: 2000mg/day Folate, B12, B6: decreases homocysteine

levels Homocysteine: Amino acid that, in excess,

damage coronary arteries and make it easier for platelet aggregation, predisposing to heart attack and stroke

Omega-3 fatty acids Manage weight

Female Organ Conditions

Fibroids Polycystic Ovary Syndrome(PCOS) Pelvic Inflammatory Disease(PID) Reproductive Tract Malignancies

Fibroids What is it?

– Noncancerous tumors of the uterus. Who Gets it?

– Women during their reproductive years. Silent in 20’s, symptomatic mid-30’s.

Etiology: – Heredity– Estrogen/Progesterone Imbalance:

• growth is dependent on high estrogen. – Grow during high estrogen times-pregnancy, use of BCP,

insulin resistance. – Shrink with low estrogen times-menopause, progesterone

only BCP

Signs and Symptoms

Feeling of hardness in lower abdomen

Frequent urination Menorrhagia Anemia Blood clots Asymptomatic

Dysmenorrhea Dyspareurnia Mittelschmerz Reproductive

problems-miscarriage and infertility

Low Back Pain

Uterine Fibroids

Attach to muscle wall

Pre-menopausal #1 reason for

hysterectomy

Diagnosis

Uterus appears lumpy on pelvic exam Pelvic ultrasound MRI CT Laparoscopy Hysterosalpingogram Dilation and curettage

Management

Manage insulin resistance: – Can increase estrogen and occurs in times of

prolonged stress. Eliminate Caffeine Increase Phyto estrogens: cruciferous vegetables

Anti-inflammatory Diet Calcium, magnesium, potassium

– decrease muscle/menstrual cramps

Fiber: – Food types provide B vitamins that help body’s

synthesis anti-inflammatory prostaglandins

Psycosocial factors: – Stress causes a rise in cortisol, affects other hormones

Acupressure/Acupuncture Spinal manipulation:

– Uterus and Ovaries T12-L5

Pain control: massage

Vaginal depletion packs-suppositories containing vitamins, minerals, herbs– Improve circulation of the pelvic organs– Draw fluid and infectious exudates out– Inhibit local bacteria growth– Stimulate slough off abnormal cervical cells– Promote lymphatic drainage

Surgery

Myomectomy or Hysterectomy Uterine artery Embolization

– Excessive bleeding– Risk of hemorrhage– Inability to tell if tumor is benign– Familial hx of reproductive tract cancer

Polycystic Ovary Syndrome(PCOS)

Umbrella term used to label a group of symptoms that all appear to be connected to the menstrual cycle and to have a strong correlation with insulin sensitivity

PCOS

Most common hormonal disorder in women of reproductive age in US (5-10%)

Commonly diagnosed in 20’s but begins during adolescence.

Etiology of PCOS

Ovarian Failure: Follicles mature but do not release an egg, resulting in cyst formation on and around the ovaries, which subsequently cause infertility and amenorrhea

Insulin Resistance: Direct relationship

Insulin Resistance

Cells do not respond to stimulus from insulin…

Blood sugar levels rise, pancreas accelerates insulin production…

Blood sugar floods into cells… Blood sugar levels fall… Hypoglycemic state DIABETES

INSULIN RESISTANCE IS MARKED BY ELEVATED BLOOD SUGAR LEVELS AND BLOOD INSULIN!

Glucose from sugars is converted to energy in cells; in the absence of this critical source of energy, fatigue and food cravings result

The liver responds to elevated Blood sugar levels by rapidly converting excess sugar to fat.

The excess fat results in increased hormone load; more estrogen is stored in fatty tissue and synthesized by the aromatase enzyme.

Aromatase enzyme synthesizes estrogen via the androstenedione pathway…excess testosterone

Signs and Symptoms

Amenorrhea Obesity Infertility Acne Hirsutism Polycystic ovaries Pelvic pain Thinning Hair

Signs and Symptoms

Hair loss • Cardiovascular disease Insulin resistance • Elevated blood pressure Type 2 Diabetes • Elevated cholesterol

Diagnosis

Gynecologic history Vaginal/abdominal ultrasound Blood chemistries

– Elevated LH– Low FSH– Elevated glucose– Hyperandrogenism– Elevated blood lipids

Management

Dietary: Ingesting simple carbohydrates and high glycemic index foods can compound the problem b/c

they cause a rapid rise in blood sugars. Exercise: Mild to moderate aerobic activity;

intense activity may increase symptoms.

Restore monthly Bleeding:– Progesterone cream during luteal phase– Spinal manipulation to ovaries innervations– Muscle stripping: adductors

Pelvic Inflammatory Disease (PID)

Infection of the uterus, fallopian tubes, or other reproductive organs

Common complication of STD: Chlamydia and gonorrhea Organisms migrate from vagina and cervix into uterus and

pelvis 10% PID are iatrogenically induced: abortion, IUD, D&C Diagnosis:

– Signs & Symptoms

– Differential Diagnosis

– Ectopic pregnancy

– Appendicitis tests immediately following menstruation

Acute PID– Presenting complaint is dull lower abdominal pain;

exacerbated by movement or sexual intercourse– Fever or chills– Rebound tenderness– Procedures that involve dilation of the cervical canal:

miscarriage, abortion, IUD

• Subacute PID• Low back pain• Acute PID

• Chronic PID• Constant/intermittent low back pain• Low grade fever/infection

Reproductive Organ Malignancies

Vulvar cancer: rare form that primarily affects the labia Vaginal cancer:vaginal bleeding in 60% cases Cervical cancer:arises from unmanaged cervical

dysplasia Ovarian cancer: BRCA1 & BRCA 2 Fallopian tube cancer: mild but chronic lower

abdominal or pelvic pain Uterine cancer(endometrial ca):75% post-

menopause; primary cause is unopposed or excess estrogen.

Physiology of the female reproductive system

1. Different periods of Female

Neonatal period : 4 weeks childhood: 4 weeks to age of 12 adolescence: menarche, age of 12-17 sexual maturity: begain 18, maintains for 30

years peri-menopausal period:begain 40,

maintains for 10-20 years pre-menopause, menopause(last time of

menorrhae), post-menopause senility

2.The definition of menstruationMenarche: the onset of the first

menses

occurs about two years after the onset of pubert

occurs between 13 and 15 years of age

anovulatory for first two years

The first day of menstrual bleeding is considered day 1 of the menstrual cycle

The length of menstrual cycle is 28 –30 days

The duration of flow is 2-7 daysThe volume of menstrual blood loss

is 30ml-50mL(<80mL),darkness and nonclotting.

The Founction of ovary

Produce oocyte Endocrine: produce female

hormone

3.Reproductive cycleDevided into 3 phasesMenstruation: 1-4days the follicular phase:5-14 days a number of follicles developing, only one dominant follicle others become atretic ovulation:14th, releasing oocyte luteal phase: 15-28 days unless pregnancy

occurs

1) Development of ovaryOvarian cycle is divided into four phases

Development of follicles primitive folliclesprimary follicles secondary follicles antrun/ developing follicles maturity follicles ovulation corpus luteum corpus albican

2)Ovarian steroid hormones

Estrogens rise in plasma by 4th day of cycle from granulosa cells and theca

cellsnegative feedback to FSHpositve feedback to LH

Progesterone: from corpus luteum maximal production occurs 3-4 days

after ovulation and maintained for 11 days

negative feedback on FSH and LH

4.Clinical manifestations of hormone changes

1)Endometrium be sloughed to a basal level in menstruation proliferative phase: 5-14 days (stroma thickens,gland elongated) in follicular

phase, a maximal thickness in ovulation Secretory phase :15-28 days (stroma loose, edematous, vesseltwisted, gland tortous) in corpus

luteum

Menstrual phase:1-4 days Endomitrium is sloughed and bleeding

onset

2)endocervix

Cervical also changes in response to the reproductive cycle

Cervical gland secrete thin,clear,watery,mucus in follicular phase

maximal in ovulation

Mucus becomes thick,opaque,tenacious in corpus luteum phase

3)vaginaThickening and maturation of the

surface epithelial cells responed to E2 in follicular phase

thickening and secretory changes of vaginal epithelium in corpus luteum phase

4)Hypothalamic thermoregulating centerProgesterone shifts the Basal body

temperature upward(BBT)

BBT record is a useful tool to evaluate the reproductive cycle

5.H-P-O axis The control of menstruation is

based on a feedback loop of H-P-O axis

Hypothalamus Producing GnRH(gonadotropin-releasing

hormone) be secreted in a pulsatile manner be a pulse generator of cycle be influenced by E and neurotransmitters

PituitaryProducing Gonadotropins follicle-stimulating hormone(FSH) luteinizing hormone(LH)be protein hormones secreted by the

anterior pituitary glandbe pulsatile mannerbe influenced by E,P, and other factors

Ovaries ovarian sex steroid hormones

estradiol (E), progesterone(P)

Feedback of H-P-O axis

Concept of feedback

the magnitude and the rate of GnRH, FSH, LH are determined by E, P,

negative feedback : resulting in decreased secretion ofGnRH FSH,LH

positive feedback: resulting in increased secretion of LH,which triggers ovulation

Key words

reproductive cycle menstruation ovarian cycle H-P-O axis feedback

Fibromyalgia

Aka fibrositis or fibromyositis Most common cause of widespread

muscular pain Affects 2% of all Americans Women 10:1 20-60 y/o; peak at 35 y/o

Etiologies

Sleep disturbances

Lack of exercise

Micro-trauma

Emotional State

Viral Infection

Chemical Imbalance– GH, Serotonin– Low cortisol levels– Elevated substance

P

Autoimmune(RA)

Clinical Diagnosis of Fibromyalgia: American College of Rheumatology 1990

History of Widespread pain– Left side of body– Right side of body– Above waist– Below waist– Axial skeletal(C-T-L)

Pain in 11/18 tender point sites on digital palpation

– Occiput– Lower cervical– Trapezium– Supraspinatus– Second rib– Lateral epicondyle– Gluteal Greater

trochanter– Knee

In addition:The following must be present

Diffuse musculoskeletal pain for at least three months

Stiffness that is worse in the morning

Tenderness to digital palpation:11/18

Modulation of symptoms by physical activity, weather or stress

Poor or non restorative sleep

Fatigue

Anxiety Headaches Irritable bowel syndrome

Subjective swelling and numbness

CBC/Thyroid/Anemia/Antibody negative

Fibromyalgia vs. Myofascial Pain

Metabolic Causes vs. Musculoskeletal Injury

Mitochondria damage in muscle cells Disruption of glycolysis: Energy crisis Small blood vessel distortion in muscle during

contraction: tissue hypoxia Decrease cortisol/DHEA: anxiety Leaky gut syndrome: bacteria, fungi, parasites, toxins,

undigested protein, fat and waste

Underactive Liver: free radicals not eliminated-inflammation

Prognosis

Prognosis if favorable with Integrated/supportive treatment

Treatment Protocol

Manipulation/gentle distraction Exercise regime Physical Modalities Sleep Homeopathy/medicine Nutrition Bio behavioral therapies

Liver Detoxification Normalizing intestinal flora Boost immune system Decrease

– Fat consumption– Refined carbohydrates– High protein-increase uric acid levels

Weather Sensitivity

Increase Humidity Decrease barometric pressure +temperature Women 67% ; Men 37% Fibromyalgia 80%(cold,damp) Migraines not affected Ligamentous type of pain syndrome assoc.

with DJD Reactive Depression

Chronic Fatigue Syndrome

Sudden onset of flu-like illness Post-exertional malaise: pain and

weakness of muscles or exacerbation of “systemic” symptoms

Night sweats- 50% patients– Dramatic-associated with chronic infection

CFS vs. Fibromyalgia

Persistant fatigue that does not resolve with bed rest and severe enough to decrease ADL 50% for 6 months

R/O chronic clinical conditions Epstein-Barr antibodies History of viral infection

CFS symptoms

Achy muscles/joints Anxiety Depression Cognitive changes Fever Headaches Intestinal problems Irritability

Muscle spasms URI Sensitivity to

light/heat Sleep disturbances Sore throat Swollen lymph

glands

Treatment

Liver Detoxification Normalizing intestinal flora Boost immune system Decrease

– Fat consumption– Refined carbohydrates– High protein-increase uric acid levels

Iliotibial Band Syndrome

ITB is continuation of the tendinous portion of the TFL Indirectly attaches to the gluteus medius, maximus, and

vastus lateralis muscles The inter-muscular septum connects the ITB to the linea

aspera femoris until just proximal to the lateral epicondyle of the femur

Distally, the ITB spans out and inserts on the lateral border of the patella, lateral patellar retinaculum, and tubercle of the tibia

Assists the TFL in abduction of the thigh and controls and decelerates adduction of the thigh

Anterolateral stabilizer of the knee by moving anterior to the epicondyle as the knee extends and slides posteriorly as the knee flexes, remaining tense in both positions

What Causes ITBS?

Runners mileage Knee Flexion/extension weakness Excessive pronation Hip abductor weakness

The Female Athlete

Title IX: Prohibites sexual discrimination in any federally funded educational institution 1972

Health Concerns Unique to the Female Athlete

Musculoskeletal

Gynecological

Psychological

Nutritional

Musculoskeletal Issues

Osteoarthritis

Spinal injuries

Anterior Cruciate ligament

Stress Fractures

Ilio-tibial Band friction syndrome

Patellar Tracking disorders

Sport Specific Injuries

Female Athlete Triad

Disordered eating: 15-62% female college athletes have self-reported eating disorders. – Anorexia/ Bulimia

Amenorrhea: 66% – Primary, Secondary, Oligomenorrhea

Osteoporosis

Decrease in performance may not be seen for some time, thinking the habits are harmless

Complications include depression, fluid/electrolyte imbalances and changes in endocrine/thermoregulatory systems

Factors contributing include enviromental, mood, performance pressures

Disordered Eating

Amenorrhoea

Altered rhythemic secretions of (GnRH) leads to decreased levels of FSH and LH leads to decreased levels of Estrogen and progesterone

Results in Amenorrhea

Amenorrhea

Primary: Absence of spontaneous uterine bleeding by 14 Y/O; w/o secondary sexual characteristics or by 16y/o with normal development

Secondary: Six-month absence of menstrual bleeding with

Oligomenorrhea Infrequent menses

Osteoporosis

BMD loss is a silent process 95% peak BMD by 18 y/o Puberty accompanied by deposition of 60% of final bone

mass: any nutritional inadequacy and high exercise intensities may more severely alter bone formation

Moderate exercise is beneficial, extreme loads may be detrimental to bone health

Primary function of estrogen is to inhibit osteoclastic activity.

– Hypoestrogenic state, osteoclast-mediated bone resorption in uninhibited, resulting in osteoporosis

Etiology of Female Athlete Triad

Sports or Activities that emphasis lean physique or a specific body weight such as gymnastics, ballet, distant running, diving, swimming

Mental and psychosocial issues: low self-esteem Parents and coaches who place undue

expectations on the athlete Misinformation about nutrition Societal pressure to be thin Physical, sexual, or substance abuse

Signs and Symptoms

Recurrent stress fractures Amenorrhea/

Oligomenorrhea(<9 cycles/yr) Erosion of the tooth enamel

from gastric acids: recurrent vomiting

Very thin Recurring muscle injury Parotid swelling as a result

form frequent stimulation of salivary glands: vomiting

Tooth marks on hand from induced vomiting

Fatigue/decreased ability to concentrate

Sensitivity to cold Heart irregularities Chest pain Endothelial dysfunction Reduced cardiovascular

dilation response to exercise

Eating alone Frequent trips to bathroom

after meals

Diagnosis

History– Menstrual history

• Delayed onset of menarche• Hormonal therapy use

– Diet history• Diet diary• List forbidden foods• Questions about weight• Diet pills/laxatives

– Exercise history• Patterns• Training intensity• Fractures• Overuse injuries

Examination Height/weight/BMI Sexual maturity rating Scoliosis Neglect/abuse screening Blood pressure BMD Labs

– Anemia

– Serum electrolytes

– Enzymes: amylase lipase

Treatment

Diet– Decrease High-phosphate substances (diet soda)– High protein diets cause increase calcium excretion,

potential for bone loss– Decrease red meat: uric acid from protein synthesis

Vitamin and Mineral Supplementation– Calcium– Vitamin D– Vitamin C– Folic Acid

Peri-Menopause Treatment Protocols

Vasomotor(hot flashes, night sweats)

Spinal adjustments: L1/2 ovarian function C0/1 and L5/S1 parasympathetic function

Acupuncture/pressure Bioidentical hormones: Estrogen, testosterone,

progesterone and DHEA. Black cohosh: 500-1000mg dry (20-40mg

extract)/day. Isoflavones (45-50mg/day) Vitamin E (400-800 IU/day) HRT: estrogen; progesterone; est. + prog.

Genitourinary Atrophy/Prolapse

Correcting leg length deficiencies Avoid medication that cause mucosal dryness:

antihistamines and decongestants Chaste berry 150-500mg/day, Black cohosh Zinc 15 mg/day, magnesium, vitamin C Exercises

– Kegal– Knee-chest pulls on slant board– Gluteal contractions– Pelvic rock with pillow between knees

Psychosocial/Psychological

Sleep: aids the function of pineal gland that is responsible for melatonin synthesis.

Melatonin is needed for sleep Diet: omega-3, isoflavones, lignans Exercise St. John’s Wort: inhibit serotonin uptake in brain and

inhibit the enzyme catechol-O-methyltransferase, which degrades the neurotransmitter dopamine.

Manage adrenal fatigue– DHEA: CAREFUL(testosterone-estrogen)– Licorice root

Management of Pregnant Patients

Established patients that become pregnantNew Patients for management of pregnancyNew patients with conditions associated with pregnancy

Activities of Daily Living

Biomechanics: neuro-musculo-skeleton Balance: center of gravity Nutrition Sleep Exercise Stress Ergonomics

Established patients

Treatment schedule – 1st trimester: 12 weeks

• Regular schedule– Fatigue, nausea and vomiting, general malaise– Headaches– Constipation– Hemorroids– Varicosities of legs and vulva– Breast changes– Menstrual like cramping

2nd trimester No more than bimonthly

– Weight gain, greater fatigue, fluid retention– Backache– Indigestion– Food cravings– Light headedness(syncope)– Muscle cramps– Ligament pain– Excessive salivation, Pica, change taste and smell

3rd Trimester 1-2x/wk

– Braxton-Hicks contractions, indigestion– Difficulty breathing, sleeping– Low back pain, groin pain, symphysis pubis pain– Edema– Anxiety, depression, emotional– Joint ache and pain– Dyspepsia

New Pts-pregnancy management

1st trimester: 1x/wk– Establish good alignment and repore

• 2nd trimester: 1x/2wksLess osseous adjusting

• 3rd trimester: 1x/wk Decrease symptoms Prepare for delivery

• Post-partumligamentus stabilityalignmentNutritionbehaviors

NP’s w/ Assoc. Conditions

No xrays Treat with normal protocols Modify technique for comfort Understand that the condition will likely

resolve at end of pregnancy

1st Trimester

Nausea/Vomiting: Ginger, carbonated beverages, acupressure(seabands), cold compress(throat,gastric sphincter)

Fatigue/general malaise: Nutritional counseling, food diary, prenatal vitamin, decrease stress, sleep, readjust to a new schedule

Headaches: Vascular-inc. circulatory volume & vasodilation responding to high progesterone, caffiene-withdrawl, stress, low blood sugar, muscle spasm.

– They may resolve in second trimester. Introduce stress-reduction activities, massage, heat/cold, adjustments

– Fatigue: Educate that she may have to alter daily activities such as• Move away from aerobic activity to isometric activity• Stress reduction technique• Nutritional balance

2nd Trimester

Backache: Center of gravity change resulting in muscle strain. High levels of circulating progesterone softens cartilage and loosens once-stable joints

Upper back pain: Increase breast size– Pelvic tilt exercises, core muscle strengthening,

balance exercises(theraball)– Decrease walking, girdle– Sleeping postures– Heat/cold– Massage/relaxation

Muscles cramp: phosphorus/calcium ratio, pressure on pelvic nerves and blood vessels

– R/O DVT, dehydration

– Ligament Pain: Stretching of pelvic ligaments

• Avoid twisting

• Upper Extremity discomfort: May report pain,

numbness, tingling due to postural changes and fluid retention. CTS symptoms are frequent

– Exercises: balance, core stabilizers, – Wrist splint if necessary– Educate on sleeping postures

Constipation: large amounts of progesterone cause dec. contractibility of GI tract & large intestine compressed by uterus. Bulk forming, nonnutritive laxatives, water, exercise, food suggestions, prenatal vitamins( every 2days)

Cramping: increases vascular congestion in pelvis, stretching of round ligaments, pressure from presenting fetal part.

R/O: ectopic pregnancy, miscarriage, GI problems, UTI

Varicose veins: Legs and Vulva- vasodilation from hormones

– Support hose, legs up for venous drainage-2x/day, girdle, decrease prolong standing and sitting, crossing legs

– R/O: Deep vein thrombosis

Third Trimester

Braxton-Hicks contractions: differentiate from labor contractions-grow longer, stronger, closer together at regular intervals

Edema: Sleeping on left side, Rest 2-3x/day, isometric contractions, do not wear constrictive clothing, TAKE BP EVERY VISIT

R/O: pregnancy induced hypertension

Joint aches/pains: Hormonal changes increase mobility of all joints

– SI, Sacrococcygeal, pubic, increase size of pelvis for delivery– More prone to injury

Childbirth Preparation

Three philosophies:– Grantly Dick-Read: education and relaxation

techniques to reduce fear-tension-pain cycle– Bradley: exercise to prepare muscles, relaxation

techniques, inward focusing with deep abdominal breathing to achieve labor and delivery w/o medications

– Lamaze: relaxation techniques and breathing, outward focusing, and conditioned response to relax during labor.

Postpartum

Period from delivery of the placenta and membranes to the return of the woman’s reproductive organs to their non-pregnant state.

Approx. 6 weeks Assessment: 4-6 weeks

Assessment

Ligament stability and joint alignment – Until hormones are stable– Neuro-musculo-skeletal systems are pre-pregnancy state

• Behavior• ADL: eating, sleeping, grooming• Interaction with baby

• Complications: Gestational diabetes, mastitis, thyroiditis, postpartum eclampsia or hemorrhage

Exercise guidelines

Regular routine: not sporatically Hydration: 2x normal amount Avoid high impact, excessive spinal

curve, stretch adductors Do not lie on back for more than 5 min. Toning and stretching exercises

recommended

Prohibited sports

Snow or water skiing Scuba diving Horseback riding surfing High altitude, oxygen deprivation

Exercises:– Stretching: cat/cow, side bow, standing-triangle, cow face, etc.

– Core: one arm/leg, tree, theraball

– Breathing: belly breathing, alternate nostril, legs up the wall

Adjustment options

Sleeping options

Reflexology

Vibrational therapy

Heat/ice

massage

Specific Sport-related Injury

Soccer

Most frequently added women’s sport among intercollegiate institutions

Heading– Avg six times a game– 5250 headers over a 15yr career– This repetitive impact to the skull accounts

for 4-22% all soccer injuries– Clinical manifestations range from

headache to brain damage

Types of Headers

Clearing : ball is to be projected high into the air over a long distance

Shooting: sufficient speed to elude the goalkeeper

Passing: advances the ball over a small distance

Jumping: approach by running and great accelerated force into the neck musculature

Cervical Spine Musculature

Just before impact, the muscles of the neck must stabilize the head to dissipate the effects of the contact with the ball

During execution, the head is accelerated forward by the neck musculature to generate momentum that can be transferred to the ball

Sternocleidomastoids become active before contact with the ball to generate the forward velocity of the head

Trapezius muscles remain active following impact to stabilize the head and neck system

Figure Skating

50% traumatic injuries 50% overuse injuries

– Women more frequently to the lower extremities

– Causes include inflexibility, inadequate or asymmetric strength, inappropriate warm-up or cool-down, poor diet, fatigue, overuse

Basketball(netball)

Women have 25-60% more ankle and knee injuries

Lumbar spine injuries are usually causes by contact with another player

Achilles tendon injuries due to inappropiate landing techniques

Field Hockey

One of the most common team sports in the world next to soccer

Swimming

Shoulder Impingement Syndrome Lumbar Hyperextension Injuires Cervical overuse syndromes Breaststroke: Medial collateral ligament

Specific Sport-related Injury

Soccer

Most frequently added women’s sport among intercollegiate institutions

Heading– Avg six times a game– 5250 headers over a 15yr career– This repetitive impact to the skull accounts

for 4-22% all soccer injuries– Clinical manifestations range from

headache to brain damage

Types of Headers

Clearing : ball is to be projected high into the air over a long distance

Shooting: sufficient speed to elude the goalkeeper

Passing: advances the ball over a small distance

Jumping: approach by running and great accelerated force into the neck musculature

Cervical Spine Musculature

Just before impact, the muscles of the neck must stabilize the head to dissipate the effects of the contact with the ball

During execution, the head is accelerated forward by the neck musculature to generate momentum that can be transferred to the ball

Sternocleidomastoids become active before contact with the ball to generate the forward velocity of the head

Trapezius muscles remain active following impact to stabilize the head and neck system

Figure Skating

50% traumatic injuries 50% overuse injuries

– Women more frequently to the lower extremities

– Causes include inflexibility, inadequate or asymmetric strength, inappropriate warm-up or cool-down, poor diet, fatigue, overuse

Basketball(netball)

Women have 25-60% more ankle and knee injuries

Lumbar spine injuries are usually causes by contact with another player

Achilles tendon injuries due to inappropiate landing techniques

Field Hockey

One of the most common team sports in the world next to soccer

Swimming

Shoulder Impingement Syndrome Lumbar Hyperextension Injuries Cervical overuse syndromes Breaststroke: Medial collateral ligament

Adolescence and Puberty

Adolescence: the time period from puberty to adulthood: physical, psychological, social, cognitive and emotional changes

Puberty: phase of physical development of sexual maturation and child is capable of reproduction

Puberty (Pubescence)

Physical Transformation– Breast development– Pubic hair growth– Growth spurt– Menarche– Achievement of fertility

Phases of Puberty

1. Adrenarche• Begins about 8 y/o and continues

until appox. 16 y/o.• Increased adrenal activity• DHEA/DHEAS• Secondary sexual characteristics:

responsible for pubic and axillary hair

2. Gonadarche• Begins approx. 8 y/o• Hypothalamus-Pituitary-Ovarian Axis• Primary sexual characteristics: Increased

gonadal stimulation

3. MenarcheThe first menstrual period

17% body fat necessary

22% body fat needed for ovulation

2-21/2 years after breast development

HPO Axis: Biphasic feedback system(a positive feedback mechanism)

Hypothalamus: synthesis and release of gonadotropin releasing hormone(GnRH); – Aka: luteinizing hormone releasing hormone(LHRH)

• Pituitary: GnRH(LHRH) stimulates the Pituitary to synthesize and release gonadotropins, FSH and LH

• Ovaries: FSH and LH stimulate the ovary • Results in germ cell maturation and hormone synthesis

Normal Pubertal Growth

Principal factor:

Insulin-like growth factor-I (IGF-I)GH exerts its action through this mediator.

Concerted action between GH, IGF-I, Estrogen, progesterone, and other sex hormones

** GH directly stimulates epiphyseal cartilage growth

Puberty (Pubescence)

Physical Transformation– Breast development– Pubic/Axillary hair growth– Growth spurt– Menarche– Achievement of fertility

Breast development

Budding occurs with rising levels of estrogen

1st sign of sexual development May be unilateral, often tender < 8 y/o: precocious > 13 y/o: delayed

Pubic/Axillary hair growth

Lags breast development by about 6 mths Appears late in puberty

– If first sign of puberty, may cause Hirsutism and menstrual irregularities

Growth spurts

Starts with breast development Average growth: 2-5 in/yr Sex steroids and GH contribute Increase weight: 8-20 lbs. Higher percentage of fat

Tanner Developmental Scale Sexual maturity rating, Tanner staging Pediatrics A system for objectively determining sexual maturity, which correlates chronologic age with a group of anatomic parameters, determining the degree of adolescent maturation; the most commonly used system was delineated by Tanner; in ♀, 5 stages of maturation are recorded for pubic hair and breast development; in ♂, 5 stages are recorded for pubic hair, growth of penis and testicles.

McGraw-Hill Concise Dictionary of Modern Medicine. ｩ 2002 by The McGraw-Hill Companies, Inc.

Menarche

Single most emblematic event in the transition to womanhood

Lack of menses by 16-17 y/o merits evaluation– Primary Amenorrhea– Hypothalamic immaturity (20%)– HPO axis

Achievement of fertility

Occur approx. 2-21/2 years after menses Anovulatory cycles until HPO axis matures. Secretions of GnRH are pulsatile; every 90 min FSH and LH are augmented in peaks As puberty progresses, the ovaries amplify the message

from the gonadotropins and release a greater amount of estrogen.

This cycle begins only during sleep. As the HPO axis becomes regulated, adds in the uterus in the communication link, the young adolescent will begin ovulating healthy follicles.

Ovarian Follicles

Birth: 600,000 Puberty: 300,000 Menopause: 30,000

Full maturation of one dominant follicle depends on development of support follicles, which secrete hormones such as estradiol, inhibin, and androgens, necessary for healthy HPO-U axis

Common Female Adolescence Problems

• Musculoskeletal

nutritional

Endocrine system• Dysmenorrhea

• Dysfunctional Uterine Bleeding• Eating Disorders

• Psychosocial Issues

Musculoskeletal

Rapid Growth demands– Scoliosis evaluation– “growing pains”: joint instability– Nutritional

• 2200 kcal/day(11-14y/o), 2400 kcal/day(15-18)• Protein/Calcium/Potassium/Zinc• Iron: Increased Blood volume• 1:10 overweight

Endocrine influence on musculoskeletal system– Thyroxine, insulin, corticosteroid=promote

skeletal growth– Parathyroid hormone, calcitonin, Vitamin D

• Skeletal mineralization

Parasympathetic/Sympathetic

Parasympathetic– Uterus via inferior mesenteric plexus:

sacral plexus– None to ovaries

Sympathetic– Uterus and ovaries via thoraco-lumbar

spine– Breasts via Upper - mid thoracic spine

Common Referred Pain Patterns

Viscerosomatic pain from the May refer to

Ovaries T12 and the medial thigh

Fallopian Tubes T11-T12

Uterus T10-L1 and the lower abdomen

Cervix S2-S4

uterine ligaments Across the lumbosacral area

Vagina Low back and buttocks

Cervix Sacral base

Rectum and trigone of the bladder

Sacral apex

Green’s gynecology: essentials of Clinical practice, 1990

Dysmenorrhea

Severe pain or cramps in the lower abdomen during menstruation– Primary: painful menses that is not related to any

definable pelvic lesion. Primary dysmenorrhea begins with the first ovulatory cycles in women under 20

– Secondary: Painful menses that is related to the presence of pelvic lesions or pelvic disease(ie: endometriosis, fibroids, PID)

Who Gets it?

Most female adolescents and young adults

Most common reason for absences from school or work

Causes of Primary Dysmenorrhea

Increased uterine activity/forceful contractions Excessive production of vaspression Overproduction of prostaglandins(E) Cervical Stenosis Misalignment of pelvic girdle(sacrum and ilium) Ligament imbalance: Broad, Round, Uterosacral T12-L4, S2-S4 nerve intervention Other factors: diabetes, anemia, stress, low pain

threshold, increase sensitivity to pain

Causes of Secondary Dysmenorrhea Post-surgical adhesions: C-section,

episiotomy, or tears with birth Cervical stenosis due to surgery on cervix IUD cause irritation Endometriosis Fibroids PID IBS

Signs and Symptoms- Primary

Dull, midline, cramping or spasmodic lower abdominal pain

Shortly before of at the onset of menses Radiate to the lower back and inner

thighs Ancillary symptoms: nausea, diarrhea,

vomiting, headache, anxiety, fatigue

Risk Factors

Earlier age at menarche Long menstrual periods Smoking Obesity Alcohol consumption High simple-sugar diet

Treatment/Therapies for Dysmenorrhea Manipulation Massage Exercise: Stretching Rest Acupuncture Herbs: Bromelain, tumeric, cumin TENS/ IST Heat NSAIDS Dietary changes

Dietary

Omega-3 fatty acids Thiamine (vitamin B1) Calcium: 1200-1800 mg/day

– leafy veg, broccoli, sardines

Magnesium: 500 mg/day– Leafy veg, molasses, soybeans, nuts, seeds

Red Raspberry tea, chamomile

Decrease consumption:– Red meat and dairy: precursors to the

inflammatory prostaglandins via arachidonic acid

– Alcohol: liver stressor and interfere with detoxification pathways

– Caffeine: a sympathetic NS stimulator that can intensify smooth muscle contraction

– Sugar: depletes body of Ca, K, Mg, Mn

Abnormal Uterine Bleeding

Menorrhagia- abnormally heavy or prolonged bleeding during menstruation; longer than 7 days

Metorrhagia- irregular bleeding or bleeding in between cycles

Amenorrhea-absence of menses for at least 6 months

Oligomenorrhea- Infrequent menses; > 35 days Polymenorrhea- Menses occurring with abnormal

frequency

Causes of DUB: Adolescence

Immature HPO axis Anemia Eating Disorders Pregnancy

Eating Disorders

Epidemic proportions in Western Countries

9:10 are women 1.2 million women in America affected

by eating disorders The end point of social, biologic, and

individual factors Mortality rate of anorexia 8-18%

Anorexia Nervosa

Refusal to maintain body weight Body weight less than 85% of expected for

height and weight Intense fear of gaining weight Self evaluation of one’s body altered Two main clinical forms:

– Food restriction: 50% OCD– Binge/Purge: worse addictive behaviors– BOTH EXERCISE EXCESSIVELY– Peak age 14-18: stressful life event

Bulimia Nervosa

Recurrence of Binge eating– 2x/wk for 3 months = diagnosis

Purging/Non-purging Recurring compensatory behavior to prevent

weight gain– Laxatives, diuretics, excessive exercise, fasting,

vomiting Peak age 18 y/o: after diet

Etiology of Eating Disorders

Psychological factors that cause addiction to food as source of comfort

Family difficulties Irregularity in neurohormonal systems

– Serotonin Struggle with body image and sense of

identity

Anorexia, Bulimia, Obesity and Gynecological Health

Nutrition plays a key role in the growth and development of adolescents

Growth spurts: achieve 25% of adult height and 50% of adult weight

Achievement of fertility Menstrual abnormalities reflect abnormal nutrition Anorexia: hypothalamic suppression and amenorrhea;

high risk of osteoporosis Bulimia: 50% hypothalamic dysfunction and irregular

menses; less risk of osteoporosis Obesity: Anovulation and hyperandrogenism(Polycystic

ovary disease)

Pathophysiology of Eating Disorders

Anorexia– Severe caloric restriction suppresses the HPO

axis– Risk of osteopenia and osteoporosis is high

Bulimia– 50% lose their menstrual cycle– Oligomenorrhea does not appear to impact bone

density

The Adolescent Partnership

Communication– Listening skills: open “psychological” ears– Repetition and patience– Non-judgmental, motivate and inspire– Be a good role-model

Evaluation– Keep in mind the adolescent’s perspective on her health

within the context of her developmental state– At 12 y/o: adult brain is only 5% developed– Cultural issues of race, ethnicity, class, community and past

experiences

Meet the Parents

Balance the needs of the adolescent and needs of the parents

Begin Hx with parent and adolescent Find an opportunity for the parents to present

concerns away from the adolescent. Do patient education and treatment programs with

the parent and child together Find many opportunities to discuss treatment and

education with adolescent alone. At the end of every session, ask the adolescent if

there are any unanswered questions or concerns

EndometriosisEstimate 20 million women

Complications:

Pelvic Pain

Cramps

Bladder Disorders

Infertility

“Retrograde Menstrual Bleeding”

John A. Sampson, Albany NY

named disease in 1927

explained how, not why

HYSTERIAGreek for hystero = uterus

Complaints from menstrual cramps were once considered a form of hysteria

Seven Early Warning Symptoms of Endometriosis Menstrual cramps that increase in severity

over time. Intermenstrual pain, or mittelschmerz. Dyspareunia, or painful intercourse Infertility of unknown origin Bladder infections Pelvic pain History of ovarian cysts

Prostaglandins

1935. First discovered by Dr. U.S. von Euler at the Karvlinska Institute in Stockholm originally thought produced solely by prostate gland in males. Hence their name.

1957. Dr. V.R. Pickles, British physiologist at University of Sheffield studied the function of these amino-acid like hormones. He found them in uterine tissue which was a medical milestone in menstrual cramps.

F2 or (F2 Alpha)Usually kept in control by the pregnancy hormone, progesterone. If conception occurred progesterone continues to be produced and F2 is not released.

COMPLAINTS

Dysmenorrhea: painful menstruation

Dyspareunia: Painful intercourse ‘cul de sac’

Rectal bleeding: Urinate frequently, blood in urine during menstruation

FOUR BASIC CAUSES OF ENDOMETRIOSIS

Hereditary factorsImmune system stress

Hormone levelsThe embryonic theory

Before prostaglandin inhibitors were developed, it was not unusual to hear of women who became addicted to Laudanum -

tincture of opium- to relieve their pain.

Others tried Sweat baths with massage “Salt glow” rubdown of the abdominal cavity to

stimulate blood flow. ‘Galvanism’ less fearsome cousin to shock treatment Liniments, douches, decorations, poultice, brews Hemlock tea “tones uterus” (leaves and inner bark.

Now use everything from TENS unit to acupuncture.

Alternative Therapies

AcupunctureHerbs

Chinese MedicineYoga

Magnesium

100:1 with calcium in bone 3x magnesium in muscle Insomnia, nervousness, rapid heartbeat,

mm cramping Regulate body temp-last through

perspiration Cramping-Ca2+ and Mg 2+ 2:1

Potassium and Iron

RBC and muscle tissue contraction of mm,

heartbeat, nerve impulse, and body fluids

electrolyte minimum daily required

40eg kidney or cardiovascular

disorders

RBC and hemoglobin RBC lives 100 days women store=250mg men store=830 mg Ferrus gluconate ferrus sulfate

Comparison of Diagnostic Techniques for Endometriosis

PROCEDURE INDICATIONFOR TEST

TYPE PROCEDUREREVEALS

Laparoscopy Pelvic tumorsPelvic massClinical symptoms ofendometriosis

Invasive surgery Pelvic endometriosisPelvic adhesionsTubal pregnancyUterine tumorsPelvic cysts

Culdoscopy Pelvic tumorsPelvic massClinical symptoms ofendometriosis

Invasive surgery Pelvic endometriosisPelvic adhesionsTubal patencyUterine tumorsPelvic cysts

Pelvic sonogram TumorsCysts

Noninvasive procedure Pelvic tumorsPelvic cysts

Side Effects of Danocrine

Weight gain Fatigue DizzinessHeadaches Acne Mild

HirsutismDepression Rash Inc. AllergiesOily skin Bleeding Pelvic painBreasttenderness

Vaginitis Dec. Breastsize

Back pain Breast lumps Neck achesHot flashes

INFERTILITY

•After a couple has been trying to conceive over one year. (over 35 years old - 6 months). •$1 billion a year market

CAUSES OF FEMALE INFERTILITY

Pre-existing endometriosis Underactive thyroid gland Nutritional deficiencies Inappropriate body fat ratio Hormonal Imbalances Use of addictive substances Depression and stress

PREEXISTING ENDOMETRIOSIS

Alfa - v/beta 3 protein Blocks fallopian tubes or ovaries w/scar tissue Tissue produces prostaglandins , the

hormone that interferes with the release of eggs

Affects mechanism between fimbriae and the ovary

Inadequate luteal phase

HYPOTHYROIDISM

Excess Estrogen

Autoimmune processIncrease risk of

miscarriage

NUTRITIONAL SUPPORT OF THYROID

Iodine rich foods: 25 - 1,000 mcg(fish, kelp, seaweed)

Zinc: 20-60 mg(beef, oatmeal, nuts, chicken, seafood, liver, dried beans)

Copper: 2 -3 mg(liver, eggs, yeast, legumes, nuts, raisins)

Tyrosine: 300-1000mg(soy,beef, chicken, fish) B complex: 25-50mg Magnesium: up to 400mg

The Big Picture

Under weight or obesitychronic anemiaLow energy intakelow immunity

Inappropriate Body Fat Ratio

85% < or equal to ideal weight > to 120%

athleteseating disordersamenorrhea

Diet & SupplementsWomen with fertility problems should eat a whole foods diet, avoid highly processed and refined foods, and eliminate excess caffeine which can contribute to infertility.

•Vitamin C: 1,000 mg three times daily•Zinc: 20-60 mg three times daily•Magnesium: at least 400 mg daily•Vitamin B complex: 25-50 mg daily•Beta Carotene: 6mg daily•Omega 3 EFA: 3000 mg•Borage oil: 200-300 mg of gamma linolenic acid daily•Vitamin B6: 50 mg daily•Vitamin E: 400 IU daily•Folic Acid: 500mg

Hormonal Imbalances

Xenoestrogen - laden pesticides “greenhouse gases”

Detoxification protocols (liver channel flows through reproductive organs)

Birth control pills

OTHERS

Use of addictive substances

Depression & stress

Infertility Workup Barnes Basal temp test pelvic exam pap smear laparoscopy (if indicated) hysterosalpingogram progesterone test antisperm antibody test

HERBAL REMEDIES

Chastetree Berry (vitex angus - castus)

Dong quai (Angelica Sinensis)

Licorice (Glycyrrhiza glabra)

Siberian ginseng (Eleutherococcus senticosus)

PREMENSTRUAL SYNDROME (PMS)

PREMENSTRUAL DYSPHORIC DISORDER(PMDD)

Premenstrual Syndrome(PMS)

Umbrella term for a broad range of symptoms that begin after ovulation, peak before menstruation, and diminish after menses.

Premenstrual Dysphoric Disorder(PMDD)Classified in the Diagnostic and Statistical Manual of Mental Disordersas a psychiatric disorder.

Classification of SymptomsClassification of Symptoms

Somatic: water retention, pimples, intestinal disturbance, low back pain, migraines,TMJ, cold soresCognitive: lack of motor coordination, social impairment, dysphoriaEmotional: anxiety, irritability, depression, fatigue, eating habits, mood swings

CAUSES OF PMS

poor diet estrogen dominance

Under active thyroid gland exhausted adrenal glands

Food sensitivities or allergies Stress: sleep disorders nutritional deficiencies

Altered serotonin and dopamine levels

POOR DIET

•low levels of magnesium •higher percentage of total dietary calories derived from fat•Imbalance of Blood sugar

ESTROGEN DOMINANCE

bloating, weight gain, headaches, backache

diet high in estrogenic foodschronic stressPeri menopauseUnder active thyroid

UNDERACTIVE THYROID GLAND ‘HYPOTHYROIDISM’

low production of progesteroneTRH (Thyrotrophin-releasing

hormone)TSH (thyroid-stimulating

hormone) produced by pituitary gland

EXHAUSTED ADRENAL GLANDS

Chronic stress or hypothyroidism

Produce adrenaline & nor-adrenaline

Progesterone used to produce adrenal hormones

NUTRITIONAL DEFICIENCIES B6 hinders liver’s ability to metabolize

Estrogen Magnesium - chronic stress promotes

magnesium excretion, which in turn leads to fluid and sodium retention

Fiber, protein & fat

Food Sensitivities

Environmental sensitivities

stress

sleep disorders

caffeine

lack of sunlight

lack of exercise

DIETARY RECOMMENDATIONS Consume a high-complex carbohydrate diet Limit sugar to less than 10% total calories Limit protein to 15% of total calories & limit or

avoid protein from animal sources For chocolate cravers, choose moderate amounts

of low-fat chocolate foods such as cocoa made with nonfat milk & chocolate cake with no frosting

Reduce fat intake to no more than 30% of calories

DIETARY RECOMMENDATIONS (CON’T) REDUCE SATURATED FAT TO LESS THAN 10% OF

CALORIES INCLUDE ONE TO TWO TBS OF SAFFLOWER OIL IN

THE DAILY DIET. LIMIT SALT TO MINIMIZE FLUID RETENTION AND

SWELLING CONSUME SEVERAL SERVINGS DAILY OF FIBER-

RICH FOODS TO ENSURE A FIBER INTAKE RANGING BETWEEN 20 - 40 g.

AVOID CAFFEINE, ESPECIALLY WHEN ANXIETY AND BREAST TENDERNESS ARE PROBLEMS

DIETARY RECOMMENDATIONS (CON’T) Vitamin B6 supplementation (50-150mg/day)

started on day ten of the menstrual cycle and continued through day three of the next cycle has produced positive results in some women. The RDA for Vitamin B6 is 1.6 mg per day. Vitamin B6 in doses greater than 100 mg a day should be taken only with the supervision of a physician.

DIETARY RECOMMENDATIONS (CON’T) Consume at least RDA levels of

Magnesium, Iron, and the B-Complex Vitamins, and no more than 300 IU of Vitamin E (RDA is 12 IU).

Vitamin D (700 IU/day)and Calcium(1200mg/day)

L-tryptophan

WHAT YOU CAN DO TO GET RELIEF

learn stress reduction techniquesget natural lightantidepressants- st. john’s wortExerciseVitamin E (400-800 IU)Magnesium “anti stress mineral”

ALTERNATIVE MEDICINE THERAPIES FOR PMS

acupressure aromatherapy

ayurvedic medicine Yoga/stretching detoxification

Herbal remedies

PMT-Cator

Clincial measurements of symptoms

The Guy Abrahams PMS classification chart identifies four subgroups of Premenstrual Tension

PREMENSTRUAL SYNDROME CLUSTERS

CLUSTER SYMPTOMS INCIDENCE(PRECENT)

PMT-A Nervous tension, irritability, 66mood swings, anxiety

PMT-H Weight gain, swelling of 65extremities, breast tendernessabdominal bloating

PMT-C Headache, sweets cravings, 24increased appetite, heart pounding, fainting, fatigue, dizziness

PMT-D Depression, forgetfulness, 23confusion, crying, insomnia

PMT-A

Anxiety Irritability Insomnia Hormonal Imbalance

– Estrogen is CNS stimulant– Progesterone is CNS depressant

PMT-A

Basic Dietary guidelinesB6(pyridoxine):50-100mg

Fiber: 20-40G

Reduce caffeine

Lower dairy and refined sugar

PMT - H

Hyper hydration

Breast tenderness

Abdominal bloating

Edema of face and hands

PMT-HDietary Guidelines Ginkgo Biloba 40 mg(3 times a day) Vitamin A and B6 Magnesium 200mg/day Vitamin E 150-400IU/day Decrease Sodium

PMT - C

Cravings for sweets Increased appetite Headaches Fatigue Glucose Intolerance

PMT-CMagnesium: 430 mg

B6: 100 mg lower salt and simple

carbohydratesDecrease salts and simple

carbohydratesVitamin A 200,000 - 300,000 IU

PMT - D

Depression Forgetfulness Confusion Lethargy Possible excess progesterone

PMS-D

Amino Acid L - Typtophan: 6gTyrosine 3 - 6 g

B6 Magnesium

Treatment Protocol

Adjustments Nutrition Exercise

Acupuncture Lifestyle

Homeopathic

Chiropractic Adjustments

T11 – S3: sympathetic/parasympathetic L2 produced marked decrease in

symptoms(Hubbs 1986) ROM of femur at hip joint. Adductor

and psoas major muscle hypertonic SI joints

Mosby’s Recommendation

Cramps/LBP: L2-L4 Breast tenderness: T5-T7 Fluid Retention and weight gain: T12-L1 Anxiety: T3-T7

Nutrition-Dietary Changes

• Reduce hypoglycemia: small, frequent meals

• Decrease serotonin synthesis: Eat protein

with carbohydrates

• Limit Arachidonic acid: precursor to

Prostaglandin E

• Eliminate caffeine• Limit high sugar foods

• Screen for excessive yeast• Limit salt

• Increase dietary fiber• Increase water consumption

• Limit alcohol • Increase fish oils

Supplemental Support

B complex

Vitamin B6

Magnesium

Calcium

Vitamin E

Vitamin C

Lecithin

Zinc

Flaxseed or Fish oil

Exercise

Regular Aerobic: Endorphin release

Yoga: Especially inversions and sacral region

Specific strengthening: Keigel

Homeopathic

Evening Primrose oil: lessens uterine contractions & pain, 500-1000mg/3x day

Black Cohosh: regulates hormone production, can delay onset,1-2 capsules/ 3-4hrs

Valerian: reduce anxiety, mild sedative, 1-2 capsules/ 3-4 hrs Chaste Tree Berry: helps balance estrogen/progesterone, 40

drops/day for PMS or amenorrhea Cramp bark: eases cramps,useful in cases of excessive

bleeding, 1 capsule/3-4 hrs for cramping

(dosage recommendations from Women’s Encyclopedia of Natural Health by Tori Hudson)

Lifestyle changes

Stress reduction: “relaxation response”, yoga, biofeedback

Adequate rest Schedule activities with PMS in mind No Smoking Get natural light

AYURVEDIC MEDICINEBALANCE THE DOSHAS : bodily humors (energies)

Vata - blood flow and the endometrial lining (movement)

Pitta - menstruation for hormonal changes (metabolism)

Kapha - contents of menstrual flow (structure)

•On the first day of menstruation, have a liquid diet (blended soups, juices) to aid digestion.•Avoid eggs and fermented, spicy, or sour foods.•Eat foods that are warm and easy to digest.•Eat less than usual, especially in the evening.•Avoid cheese, yogurt, red meat, fried foods, and chocolate.•Avoid carbonated beverages and cold drinks.•If you crave salt, satisfy the desire minimally, but try to resist the sugar craving or find natural substitutes such as whipped cream with honey rather than ice cream.•Take a hot shower rather than a bath.•Budget time for resting.•Reduce your exercise schedule.•Spend some time turning inward.

TRY FISH OILS FOR RELIEF OF CRAMPS

Taking as little as 6g of fish oil daily during the time of menstrual cramping can significantly reduce the pain. When 42 young women, 15 to 18 years old, took 6g of fish oil (omega-3 essential fatty acid) daily for two months for relief of menstrual pain, pain reduction was rated at 37%. The women also managed on 53% less conventional pain medication (ibuprofen) for their cramps.

AcupunctureReflexology

Pregnancy

Important Factors

Mechanical stress variations Hormonal Considerations

– Relaxin, pregnanediol and estriol Patient comfort Boundary Issues Nutritional Support

Musculoskeletal Conditions

Low back pain Tension cephalgia Altered gait Chronic neck and back

fatigue Intercostal neuralgia Groin Pain Thoracic Outlet

Syndrome Symphasis Pubis Pain

Sciatic neuralgia Coccygodynia Herniated IVD Carpal tunnel syndrome DeQuervian

tenosynovitis Osteonecrosis of

femoral head

Common Complaints

Bleeding Gums Dehydration Breathing Difficulties Diastasis Recti Abdominis Dizziness/Light-headedness Fluid Retention Symptom Heartburn In Utero Constraint (Webster technique) Morning Sickness Tipped Uterus (Buckled Sacrum Maneuver) Snoring

Serious Issues

Gestational Diabetes Pre-eclampsia/Toxemia Premature Contractions Rhesus Factor Spontaneous Abortion(Miscarriage)

Etiologies

Sleep disturbances

Lack of Exercise

Microtrauma

Emotional State

Viral infection

Chemical Imbalance (GH, Serotonin)

Autoimmune(RA)

Nutrition for the Childbearing Years

A women’s nutritional status before and during pregnancy and during lactation helps determine the outcome of her pregnancy and the long term health of herself and her child.

Maternal nutrition during pregnancy & lactation influence:

development of braincomposition and size of the

bodyinfant’s metabolic competence

to handle nutrientsmother’s future health

Recommended Weight Gain for Pregnant Women

RecommendedPrepregnancy Weight Total Gain classification (BMI) lb kg

Underweight (<19.8) 28-40 12.5 - 18Normal (19.8 to 26) 25-35 11.5 - 16Overweight (26.1 to 29) 15-25 7.0 - 11.5Obese (>29) > or = 15 > or = 7

Energy Requirements

1st trimester 96 k cal/day (2115)

2nd trimester 265 k cal/day (2275)

3rd trimester 430 k cal/day (2356)

Macronutrients & Micronutrients

The quality of the maternal diet is as

important as its quantity.

ProteinRequirements= 60 g/day

20% increase over nonpregnant level

Greatest concerns are low levels of:•iron•calcium•zinc•folic acid

IronIron deficiency anemia is a serious condition during pregnancy. It is

associated with preterm delivery and increased maternal mortality.

RDA pregnant (30 mg)non pregnant (15 mg)

• rapid expansion of maternal blood volume

•deposition of iron in fetal tissues

Heme Iron•found in food of animal origin•absorbed at a rate of 15 -30%

Non-Heme Iron•found in food of plant origin•absorbed at a rate of 5%

Vegetarian

Avoidance of red meat but consumption of fish and/or chicken

lacto - ovo: no meat consumption but intake of dairy products

vegans: no consumption of food of animal origin.

(Macrobiotic diet included)

Foods High in Calcium(Recommended Intake 1, 000 mg/day)

Milk & Dairy Products Calcium (mg)yogurt, plain, nonfat (1 cup) 452yogurt, fruit flavored, low fat (1 cup) 345chocolate milkshake (1 cup) 256skim milk (1 cup) 302whole milk (1 cup) 285cheddar cheese (1 oz) 204American cheese (1 oz) 174ice cream, soft serve (1 cup) 206ice cream, hard serve (1 cup) 170cottage cheese (1 cup) 154

Foods High in Calcium (Con’t)(Recommended Intake 1,000 mg/day)

Protein calcium (mg)tofu w/calcium sulfate (1/2 cup) 434sardines, canned, w/bones (1/2 cup) 428tofu w/o calcium sulfate (1/2 cup) 130almonds (1/2 cup) 165Fruits & Vegetablesspinach, fresh, cooked (1/2 cup) 122broccoli, cooked (1/2 cup) 85okra, cooked (1/2 cup) 88orange (1 medium) 54

ZINC

crucial for tissue growth deficiency can cause poor fetal growth deficiency common because Zinc is

found in the same foods as Iron & Calcium

RDA pregnant 20 mg

non pregnant 15 mg

Plant Sources of Zinc

wheat germnuts

dried beans

Folic Acid

most important vitamin during pregnancy

all cell divisionDNA synthesis

Recommended Daily Allowances

adults 230 mgchildbearing years 400 mg

pregnancy 800 mg

Folic Acid

5-10 mg fruitsvegetablescheesemilkeggs

100-150 mg liverorange juicespinach

DeficiencyNeural tube defects in the fetus

megaloblastic anemia in mother

Vitamin A

excess is teratogenicretinol

Beta Carotene is not

Smoking Highest % of Low Birth Weight Babies

#1 obese smokers who gained

< or = 15 lbs

#2 normal weight smokers who gained

< or = 25 lbs

Hellerstedt, Hines, Story,

Altm & Edwards (1997)

Caffiene

does cross the placentabreast milkhalf life higher in pregnancy -

11 hoursinfants (100 hrs)

Pregnancy Test

Urine• HCG: hormone called human chronic Gonadotropin

• 26 -36 days after last menstrual period

• 8 -10 days after conception

A positive result usually indicates pregnancy. Only two-thirds of women with ectopic pregnancies will have positive pregnancy tests.Positive results also occur in :

(a) choriocarcinoma(b) hydatidiform mole(c) testicular tumors(d) chorioepithelioma(e) chorioadenoma destruens(f) conditions w/a high ESR such as

acute salpingitis(g) cancer of lung, stomach, colon, pancreas,

and breast

Interfering Factors

1.False-negative tests and falsely low levels of HCG may be due to a dilute urine (low specific gravity) or a specimen obtained too early in pregnancy.

2. False-positive tests are associated with(a) proteinuria(b) hematuria(c ) presence of excess pituitary

gonadotropin (HLH) as in menopausal women

(d) drugs1. Anticonvulsants2. Antiparkinsons3. Hypnotics4. Tranquilizers

Obstetric Sonogram Confirming pregnancy facilitating amniocentesis determine fetal age multiple pregnancy fetal development is normal fetal viability localizing placenta masses postmature pregnancy

Major Uses of Obstetric Sonography

First Trimester Second Trimester Third Trimester

confirm pregnancy establish/confirm dates if no fetal heart tonesconfirm viability if no fetal heart tones clarify dates/size discrepancyrule out ectopic pregnancy clarify dates/size discrepancy large for dates--rule outconfirm gestational age large for dates--rule out Macrosomia (Diabetes) birth control pill use poor estimate of dates multiple gestation irregular menses molar pregnancy Polyhydramnios no dates multiple gestation congenital anomalies postpartum pregnancy Leiomyomata poor estimate of datesprevious complicated pregnancy Polyhydramnios small for dates-- rule out caesarean delivery congenital anomalies fetal growth retardation RH incompatibility small for dates--rule out Oligohydramnios diabetes mellitus poor estimate of dates congenital anomalies fetal growth retardation fetal growth retardation poor estimate of dates

congenital anomalies Oligohydramnios

Major Uses of Obstetric Sonography (Con’t

First Trimester Second Trimester Third Trimester

clarity dates/size discrepancy determine fetal position--rule out large for dates--rule out breech Leiomyomata If history of bleeding--rule out transverse lie Bicornuate uterus total placenta previa If history of bleeding --rule out Adnexal mass If RH incompatibilty--rule out placenta previa multiple gestation fetal hydrops abruptio placentae poor dates Determine fetal lung maturity molar pregnancy Amniocentesis for Small for dates--rule out lecithin/sphingomyelin ratio poor dates Placental maturity (grade 0-3) missed abortion If RH incompatibility--rule out blighted ovum fetal hydrops

RUBELLA ANTIBODY TEST

Induce IgG IgM antibody formation infection in 1st trimester associated with

congenital abnormalities, miscarriage or stillbirth Elisa Test (enzyme immunoassay or enzyme linked immunoassay)

TESTS DONE TO PREDICT NORMAL FETAL OUTCOME AND IDENTIFY FETUS AT RISK

FOR INTRAUTERINE ASPHYXIA

Name of Test & Normal Values

Breast Stimulation Test (BST)Normal values: reactive; negativeImplies that placental support is adequate and that the fetus is probably able to tolerate the stress of labor should it begin within a week. There should be a low risk of intrauterine death due to hypoxia.

Reason for Performing Test

After 26 weeks’ gestation, the nipples are stimulated to release oxytocin that causes uterine contractions similar to labor contractions.

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TESTS DONE TO PREDICT NORMAL FETAL OUTCOME AND IDENTIFY FETUS AT RISK

FOR INTRAUTERINE ASPHYXIA

Name of Test & Normal Values

Oxytoxic Challenge Test (OCT)Normal Values: Reactive; negativeImplies that placental support is sufficient should labor begin within one week.

Reason for performing test

Intravenous oxytocin is administered to produce three (3) good quality contractions of at least 45 seconds each in 10 minutes, and the FHR is monitored for reaction to this stress. It is performed when a nonstress test is nonreactive or a BST is either positive or unsatisfactory.

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TESTS DONE TO PREDICT NORMAL FETAL OUTCOME AND IDENTIFY FETUS AT RISK

FOR INTRAUTERINE ASPHYXIA

Name of Test & Normal Values

Acoustic StimulationNormal Values: Reactive

Reason for performing test

Using an electronic fetal monitor and sound source on the maternal abdomen, an evaluation of fetal movement in response to stimulation is done.

Nonstress testNormal Values: Reactive; at least two (2) episodes of fetal movement associated with a rise in FHRProvides a baseline status & implies an intact CNS and autonomic N-S that are not being affected by intrauterine hypoxia

It determines fetus’ ability to respond to environment by an increase in FHR associated with movement where not under the stress of labor.

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Amniocentesis

hematologic disorders fetal infections

inborn errors of metabolism sex linked disorders

identification of chromosomal abnormalities neural tube defects such as:

-anencephaly -encephalocele -spina bifida

-myelomeningocele

estimation of fetal age wellbeing of fetus

pulmonary maturity

HIGH-RISK PARENTS WHO SHOULD BE OFFERED PRENATAL DIAGNOSIS

1. Women of advanced maternal age (35 or over). 90% fall in this category; at risk for children with chromosome abnormality, especially trisomy 21 (at age 35 to 40, the risk for Down’s is 1% to 3%; at age 40 to 45, there is a 4% to 12% risk; and over age 45, the risk is 12% or greater.2. Women who have previously borne a trisomic child, or clients who previously had a child with any kind of chromosome abnormality.3. Parents of previous child with spina bifida or anencephaly or family history of neural tube disorders.4. Couples in which either parent is a known carrier of a

balanced translocation chromosome for Down syndrome.

HIGH-RISK PARENTS WHO SHOULD BE OFFEREDPRENATAL DIAGNOSIS (CON’T)

5. Couples, of which both partners are carriers for a diagnosable metabolic or structural autosomal recessive disorder. Presently, over 70 inherited metabolic disorders can be diagnosed by amniotic fluid analysis.6. Couples, of which either partner or a previous child is affected with a diagnosable metabolic or structural dominant disorder.7. Women who are presumed carriers of a serious x-linked disorder.8. Couples and families whose medical history reveals mental retardation, ambiguous genitalia, parental exposure to environmental agents (drugs, irradiation, infections).9. Couples and families whose medical history reveals multiple miscarriage or stillbirths, infertility.10. Anxiety about potential offspring.

CLINICAL IMPLICATIONS

1. Elevated level of alpha-fetoprotein is an indicator of possible neural tube defects.2. Creatinine levels are reduced in prematurity.3. Increased and decreased total volume of amniotic fluid is associated with certain developmental arrests.4. Increased bilirubin levels are associated with impending fetal death.5. Color changes of fluid are associated with fetal distress and other disorders.6. Sickle cell anemia and thalassemia can be detected by examination of fibroblast DNA obtained by amniocentesis.

CLINICAL IMPLICATIONS (Con’t)

7. X-linked disorders are not routinely diagnosable in utero. However, because they affect only males, the sex of the fetus may be determined in a woman who is a carrier of a deleterous x-linked gene, as in hemophilia or Duchenne’s muscular dystrophy.8. Cystic fibrosis.9. The presence of some of the over 100 detectable metabolic disorders.10. For disorders in which an abnormal protein is not expressed in amniotic fluid cells, other test procedures are necessary, such as DNA restriction endonuclease analysis.

HERPES

Natrum Mutriaticum (Chloride of Sodium)

Pica

Calcarea Carbonica (Carbonate of lime)

Nitricun Acidum (Nitric Acid)

LACTATION:

The greatest physiologicalstress of the

life cycle

Fatty acid composition of human milk is influenced by the

maternal diet.

Fatty acids are responsible for nerve & brain development

in the infant.

• Protein Requirements = Pregnancy (60 g/day)• Iron Requirements drop (15 mg/day)• Mineral content of Milk (Ca 2+, Mg 2+, K +2, Na 2+ ) are not affected by maternal diet• Vitamin Content is dependent on maternal dietary intake. (esp. B6, thiamine, folic acid)• Weight loss is experienced by 80% lactating women• Aerobic exercise does not affect breast milk volume or composition

BEST-ODDS NURSING DIET

Increase the caloric intake to about 500 calories per day over the pregregnancy requirements.

Increase calcium requirement to five servings per day.

Reduce protein intake to three servings per day Drink at least eight glasses of fluids (milk, water,

broths or soups, and juices); take more during hot weather and if perspiring a lot.

Splurge occasionally.

Lactation

Protein requirements: 60g/day Iron: 15 mg/day Mineral content of milk not affected by maternal

diet Vitamin content is dependent on maternal

dietary intake Weight loss experienced by 80% lactating

women Aerobic activity does not affect breast milk

volume or composition

Benefits of physical fitness

Good muscle tone Sense of well-being

Sense of body control Best physical shape for labor and delivery

Reduced anxiety an dfrustration

Improved sleep

Weight control Body fat deposition to a minimum

Improve chances for easier labor

Improved self image

Treatment Protocol

Manipulation: decrease 2nd tri, inc. 3rd tri Massage(caution in severe edema-

toxemia) Heat/ice (no modalities) Foot reflexology/cranial sacral Peppermint, ginger, papaya Meridian stimulation

Stress Injury to Bone: Interactive model

Mechanical factor

Hormonal Influence

Nutritional environment

Genetic Predisposition

Definition of Stress Injury

Stress injury to a bone occurs on a continuum, ranging from normal bone remodeling/repair to frank cortical fractures. Terms such as bone strain and stress reaction are used to reflect this progression of bone injury toward a frank cortical stress fracture, which is defined as a partial or complete fracture of a bone resulting from its inability to withstand nonviolent stress that is applied in a rhythmic, repeated, sub threshold manner

Bone Biology overview

Extrinsic Mechanical Factors

Acute change in training regimen– Duration, intensity, frequency)

Footwear age Fitness level: early fatigue of muscles Running Surface/terrain

– Uneven: hills, roads– Hard/soft

Intrinsic Mechanical Factors

Tibial Bone width– Large compression and

tension forces – The external forces

exceed the tibia’s intrinsic resistance strength

– Narrow mediolateral tibial width have less resistance to these forces(area moment of inertia)

Foot Structure– Pes cavus(high arch)

absorbs less stress and transmits greater force to the tibia and femur

– Pes Planus(flexible, low arch) absorbs greater metatarsal force

Hormonal Factors

Delayed Menarche Hypothalamic hypoestrogenic Amenorrhea Ovulatory Disturbances Oral Contraceptive Pills Testosterone

Nutritional Factors

Low Calcium Intake

Vitamin D Genetics

Inadequate Calories

Anorexia Nervosa

Common Sites for Fractures

Pubic Ramus Femoral Neck Femoral Shaft

Patella Tibia Medial Malleolus

Tarsal Navicular

Fifth Metatarsal

Sacrum

Topics in Women’s Health

Chiropractors are ‘Port of Entry’Women account for nearly twice as many outpatient visits as menNIA, office of research on Women’s Health 1990’sNCCAM: National Center for Complementary and Alternative medicine(COGME) Fifth Report on Women and Medicine The Council on Graduate Medical Education

What is Port of Entry Care

Provide evaluation of comprehensive health needs and coordinate care

Involves integrated, accessible health services that addresses most of an individual’s needs, regardless of problem type or organ system

PCP’s are assumed to be competent in initial evaluation of all problems with which patients present.

What are the needs?

POE’s: internists, general practitioners– Pap smear– Preventative tests– Evaluation of symptoms, DDX, ROF, Refer• Chiropractors:

• Preventative tests• Evaluation of symptoms, DDX, ROF, Refer• Port of Entry for non-allopathic therapy

Women’s Education

Mass media: print, television, radio– One study: 90% women reported the media as

main source of information about mammography• How do they report in compared to :

• Medical journal articles• Women’s greatest health risks• Most commonly expressed health concerns

http://www.nlm.nih.gov/medlineplus/womenshealth.html

Resources

http://www.cdc.gov/women/index.htm

http://womenshealth.gov/topics.cfmwww.shirleys-wellness-cafe.com/women.htm

http://www.healthy.net/www.cogme.gov/rpt5_4.htm

Paradigm shift

Historical, medical research has been based on the 70-kg man. Efforts to acknowledge the biological differences.

Women’s participation in the medical profession has risen dramatically. Female Osteopathic physicans increased 36% between 1989-1992. The trend has been on a continuous rise.

Demand by consumers and policy makers for increased attention to women’s health issues.