Sleep Hygiene

I spent the day in the Oral-facial pain clinic and, among other things, learned about sleep hygiene from Dr. Mazzeo. He gave these tips to a patient who has trouble falling asleep on a couple nights each week. Since we live in a time where work is extremely portable (computers, phones, and the internet) our nightly routines can be busy and stressful and our bedrooms are used for much more than dressing and sleeping. Quality sleep is important because it allows our body to heal itself and recover from the stessors of our lives. Since we are creatures of habit, these tips make sense if we expect our body to calm down and sleep well when we go to bed.

Sleep Hygiene Information

1) Lie down to sleep only when you are sleepy.

2) Use your bed primarily for sleep. Do not read, watch TV, surf the internet, talk on the phone, drink, or eat in bed.

3) If you find yourself unable to fall asleep after 15-20 min, get up and go to another room, and then return to the bed when you are sleepy. Avoid thinking while in bed. The goal is to associate your bed with rest and falling asleep quickly.

4) Set your alarm and get up at the same time regularly regardless of the amount of sleep you got during the night. Try to get the same number of hours of sleep each night and arise at the same time each morning. This will help your body acquire a consistent rhythm.

5) DO NOT...

a. Nap during the day.

b. Routinely use products (caffeine, nicotine, alcohol, or stimulant drugs {decongestants}) that interfere with sleep in the evening.

c. Exercise or engage in exciting or emotionally upsetting activities close to bedtime.

6) Try to make the bedroom a quiet, comfortable, and secure place.

Breast Cancer Symposium - 16 Sept 2009

Breast Cancer Symposium For Primary Care Providers – 16 Sept 2009

Presenters: CDR Henry, MC, USN & Anne Forsha, RN

Basics

Value of early detection

90% survival rate (5 yrs) if caught in a localized state

59% survival rate (5 yrs) if spread to regional lymph nodes

Tamoxifen

If taken for 5 yrs, a 49-88% reduction in risk of estrogen receptor-positive tumors

Fisher B, et al. Tamoxifen for prevention of breast cancer: report of the P-1 study. J Natl Cancer Inst 90:1271, 1998

Raloxifene has lower incidence rates for uterine hyperplasia but this can only be taken by post-menopausal women

6 Dangerous Lies About Breast Cancer

You’re too young to have breast cancer

Cancer dosen’t hurt

Cancer presents as pain in 5% of patients

Negative Mammograms rule out breast cancer

False negatives ~20%

~ 20% of breast cancers are ONLY detected by clinical breast exam

No family history means you are safe

80% of breast cancer patients have NO RISK FACTORS (besides gender)

Men can’t get breast cancer

1% of breast cancers are in men

It’s just mastitis

Diagnostic Imaging

Resolution for MRI ~ 5mm & mammogram ~ 1cm

No evidence to suggest difference in care between these two

Hormone Receptors

Estrogen & Progesterone are primary players

~ 80% of breast cancers are + for hormone receptors

This determines treatment, prevention, & prognosis

Clinical Breast Exam

Start with patient seated and observe for change in size, shape, dimpling, erythema, nipple discharge, nipple retraction

Acronym: B.R.E.A.S.T. – Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, Tender breast

Have pt raise arms over head and observe for skin retraction

Have pt supine with ipsilateral arm over her head & palpate with pads of first 3 fingers

Be sure to include entire area from clavicle to inframammary ridge and from the latissimus dorsi to the sternum

Best time for the exam is just after menses before the spike in progesterone mid cycle when breast gets firmer

Should be performed every 3 yrs from age 25 – 39 and annually from age 40 on

Nipple Discharge

Seen with 3% of breast cancers

Green = OK (probably fibrocystic dz)

Watery/Serous = Bad

Bloody/Serosang = Bad

Spontaneous = Bad

Only one duct = Bad

Estrogen

Study with Prempro (conjugated estrogen & progesterone used to treat symptoms of menopause) Jama 289(24):3304, 2003

16,608 women ages 58-79

Prempro vs placebo

Prempro group

26% increase in breast cancer

22% increase in cardiovascular events

24% decrease in hip fractures

37% decrease in colorectal cancer

Hormone replacement therapy risks are far greater than benefits

Risk Assessment

Hereditary susceptibility

BRCA1 gene: 20% - 40% contribution to hereditary breast cancer

BRCA2 gene: 10% - 30% contribution to hereditary breast cancer

Features indicating increased likelihood of BRCA mutation

Multiple cases of early onset breast cancer

Ovarian cancer (with family history of breast or ovarian cancer)

Breast and ovarian cancer in the same woman

Bilateral breast cancer

Ashkenazi Jewish heritage

Male breast cancer

Risk of breast cancer

General population: by age 50 – 2%, by age 80 – 10%

In mutation carriers: by age 50 – 73% by age 80 – 87%

Who should get genetic testing

Pt with breast or ovarian cancer that was diagnosed at a young age or has a strong family history of breast or ovarian cancer

Lifestyle & Risk

Weight – no clear association

Exercise – no clear association

Alcohol – >2 drinks per day is associated with an increased risk of breast cancer

Tobacco – no clear association

Stress – no clear association

Oral Contraceptives – very little risk for women under 40 yrs

Navy Football

Dr. Morgan and I have started working with the Naval Academy’s football team and it has been quite an educational experience. Similar to working with the Palmer West sports council, chiropractic care for high end athletes needs to be tweaked to address a barrage of acute conditions potentially masking underlying chronic complaints. Unlike chronic care patients, the serious athlete primarily wants to be able to continue to compete at a high level. While it is important to keep the athlete in top condition, equally important is the practitioner’s responsibility to protect the athlete’s body from their own drive to push through the pain and possibly toward injury. Working with the football team has presented these challenges as well as others.

As an intern providing chiropractic care, I fall on the low end of the navy athletic medical “food chain.” Everyone works under a head team doctor who guides a team of various doctors and trainers. All of these providers know the players and their conditions much better than I do since I only see the team one to two days each week. The medical staff has been extremely welcoming and helpful pointing out the players who need my services the most. My “office” consists of a portable table in an isolated spare space whether it is a small locker room or office, so being resourceful and creative with space is a must. I only get one hour with the team between practice and dinner so I have to be ready to treat as efficiently and effectively as possible.

Not only has my time with the football team been rewarding and enjoyable, but I have learned more about myself and technique when working with athletes. These patients are not only much more muscular than the average patient, but many have associated soft tissue problems compounding any segmental dysfunction. Myofascial release, PNF stretching, and trigger point therapies are not only extremely effective, but also make adjusting much easier. I have needed to learn to generate more power from my core to adjust some patients and doing this in a safe way is crucial.

I would strongly recommend young chiropractors to get involved with any sports team whether it is a high school team or professional. The experience is not necessarily about the love of sports but learning how to care for a unique group of patients. Not only is this a way to get more experience but being able to modify chiropractic techniques is a vital skill to succeed in a diverse practice.

Core Stabilization

Core stabilization is a concept discussed commonly in chiropractic, but until recently I had not come across one source that compiled research and presented conclusions, based on logical and quantatative studies, in a clear and precise manner. There are two general theories on core stabilization; core stiffening and hollowing. I will not go into detail about these theories so as not to influence you in one direction, but I recommend reading up on both. Recently, I finished a book Dr. Morgan recommended and I would STRONGLY SUGGEST every chiropractic student read at least the last few chapters. Stuart McGill’s “Low Back Disorders: Evidence Based Prevention and Rehabilitation” gives a nice review of back anatomy and biomechanics as well as discussing common injuries found in a sedentary lifestyle. Current research on the biomechanics of the low back is presented and interpreted eliminating hours of tedious research. McGill explains how to analyze patients’ physical characteristics in order to more effectively help patients learn preventative measures. Most importantly, you will learn rehabilitation techniques, including core stabilization exercises, and treatments specific to the various stages of rehabilitation: corrective exercise, stability, endurance, and strength. This text is relatively inexpensive ($40 at half.com) and I have already seen significant improvement in many of my patients, and noticed a difference in my own core strength, from using techniques learned from this book.

Cluneal Nerve

I saw a 33 yo male patient recently who presented with left hip pain which he has had since Nov of 2007. The patient also reported a leg length discrepancy which was confirmed to be 2.5 cm short on the right. He had been to various other doctors and had multiple imaging studies and was diagnosed with trochanteric bursitis. The ortho surgeons wanted to operate but the patient wanted to investigate conservative treatment options.

After taking the history I found a couple of factors which made explore other options besides the bursitis diagnosis.  First, the patient has stopped running, the major provocative action, and although the pain has decreased, he is still having constant 3/10 pain. Second, point tenderness was found at the middle portion of the iliac crest and, even though pain extended about ten inches down the lateral thigh which is consistent with trochanteric bursitis, side lying on the both the left and right sides did not provoke pain.

While trochanteric bursitis was a viable option I wanted to explore other possible causative factors. After initially thinking of lateral femoral cutaneous nerve involvement due to the pain distribution down the lateral thigh Dr. Morgan, suggested investigating the cluneal nerve.  After some research, the superior cluneal nerve, as seen in the image below, passes over the exact portion of the iliac crest where the patient reported point tenderness.  The superior cluneal nerves are more commonly associated with lower lumbar and sacroiliac pain since the distribution pattern normally involves the superior buttock. This classic entrapment occurs when a branch of the superior cluneal nerve becomes restricted in the tunnel of thoracolumbar fascia through which it crosses over the iliac crest. 

Picture from www.thebarrow.org

Although it is uncertain whether cluneal nerve involvement is a part of this patient’s condition, a treatment plan involving myofascial release of the tissue surrounding the its passage over the iliac crest will be utilized. For more information on how cluneal nerve entrapment is related to low back pain check out Dr. Warren Hammer’s article from Dynamic Chiropractic in 1998 which can be found at the following link (http://www.chiroweb.com/mpacms/dc/article.php?id=37220).

Introductory Post

Welcome to my new blog documenting experiences from my internship at the National Naval Medical Center (NNMC) in Bethesda, MD. The purpose of this blog is to provide insight for chiropractic students, professors and administrators into the experiences I have had during my six months at the NNMC. As chiropractic continues to become more integrated into multidisciplinary health care settings, the demand for chiropractors who can operate professionally and effectively in this environment will increase. Therefore, it is my goal to help chiropractic students become excited to participate in similar internships to prepare for this challenge. This blog will consist of reflections on the administrative challenges present in a large hospital setting, presentations of interesting cases, discussions of various radiologic studies, and so on. Without further delay, I would like to give you a quick summary of my first two months.
For those of you who do not know, the NNMC treats active servicemen and women, as well as their dependent family members, and retirees. Going into this position I thought I was prepared to step into a completely different world of a military setting as well as a large hospital. However, the NNMC is not only a military hospital, but also a military base. In addition to the hospital, there are buildings specifically for housing active duty servicemen and women, a child development center for the children, and even the navy’s version of a Walmart. I quickly realized I had a lot to learn about the military culture if I was going to have a comprehensive understanding of my patients.
My first week was spent walking between various departments and buildings getting various ID tags, clearances, sensitive document training, and other administrative headaches. Although these protocols are necessary to ensure the safety of those on the base, due to the enormity of the grounds and the endless number of medical departments in the hospital, it is easy for these measures to become laborious. After working my way through the initial administrative check-in process, I spent a couple days shadowing the intern from Davenport and before I knew it I was treating patients.
I have been treating patients on Monday, Wednesday and Friday while on Tuesday and Thursday I have been doing rounds with various groups in the hospital. These rounds are determined by Dr. Morgan’s advice and my interests. My first rotation was with the in-patient physical therapists. We worked with blast victims who were just coming out of amputation surgery, sniper victims with traumatic brain injuries, as well as patients who had total joint replacements within the last 36 hours. Working with the physical therapists was extremely educational. I realized I did not fully understand what physical therapy consisted of and the scope of their practice. I appreciated talking with Dr. Morgan after this experience because he told me these rotations are not only intended to increase my clinical skills but also to establish relationships with other professions and learn about what my patients go through in the various stages of healthcare.
Most recently I have been working in radiology reading musculoskeletal x-rays, CT-Scans, and MRIs. Sitting for eight hours a day in a dark room reading imaging studies can be a bit monotonous, but my ability to read MRI studies to my patients and explain what they are seeing is well worth the effort. Interestingly, most patients that I treat who have had an imaging study have never seen their films and nobody has ever explained what the results mean. I think this presents an opportunity for chiropractors to develop excellent relationships and gain confidence of patients by taking a little extra time to explain to them the anatomy seen on their film and what the results entail for their future.
The most enjoyable part of my experience at the NNMC so far has been the patients. The military patients are different from civilian patients in many ways, but the most noticeable include excellent compliance (for the most part) and a strong commitment to physical fitness. I have had the opportunity to examine patients with complex cases including IED blast victims, multiple disc herniations, healing sternal fractures and I am happy to inform you that chiropractic care is bringing amazing benefits to these servicemen and women. Also, Dr. Morgan is an excellent mentor because he is receptive to questions concerning treatment plans and adjusting techniques, but more importantly, he encourages me to be confident in my abilities and the effects of chiropractic care. This confidence is not only built on the improvement seen clinically in my patients, but also supported by current research which Dr. Morgan encourages me to study. This brings up a significant difference I have noticed about working in a hospital setting; being knowledgeable about current research is not only helpful to the patients and provider, but expected by colleagues throughout the hospital. Although this experience has been challenging, time consuming, and financially stressful on my family, I could not have imagined a better environment to improve as a clinician as well as member of the general healthcare community.
If you are interested in this internship, working in a hospital, or VA, I strongly suggest a day at the hospital to learn more about working in this setting. You can contact me at kyle.alexander@med.navy.mil.