Transcript Anterior Cruciate Ligament Injuries

Anterior Cruciate Ligament Injuries
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Intrinsic Risk Factors
– Structural differences
– Quadriceps Femoris
angle
– Femoral Notch
– Joint Laxity and Flexibility
– Hormonal Influence
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Extrinsic Risk Factors
– Muscular Strength and
muscular activation
patterns
– Knee Stiffness
– Jumping and Landing
Characteristics
Structural Differences
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Pelvic Width
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Tibiofemoral angle
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Magnitude of the Q angle
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Width of the femoral notch
Quadriceps Femoris Angle(Q Angle)
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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
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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
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Inherent in the individual
Support by strengthening the
quadriceps, hamstrings, gastrocnemius
 Caution in attempt to increase flexibility
 Nutritional support
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Hormonal Influence
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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
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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
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Intrinsic component is the number of active actin-myosin crossbridges 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
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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
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Early Phase
–
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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
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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
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Fractures
– T/L spine compression fx occur with axial loading in a
flexed or vertical posture
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Acute Disc Herniation
– Usually without sciatica
– May present with back spasm, neurogenic scoliosis,
hamstring tightness, buttock pain
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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
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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
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Spondylolysis and spondylolisthesis
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Lordotic Low Back Pain
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Transitional Vertebrae
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Facet Syndrome and Sacroilitis
Spondylolysis
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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
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Lordotic Low Back Pain
Tight thoracolumbar fascia is a
consequence of rapid growth.
 Presents as hyperlordosis with a flat midback and thoracic kyphosis
 Several pain syndromes may ensue
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– 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
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Facet Syndrome and Sacroiliitis
Flexion Injuries
Scheuermann’s Kyphosis
 Disc degeneration
 Internal disc derangement
 Non traumatic Causes of Back Pain
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Scheuermann’s Kyphosis
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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
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
Breast Conditions
Breast Cancer
 Lymph edema
 Fibro adenoma
 Fibrocystic Breast Changes
 Breast Augmentation
 Mastitis
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Breast Cancer
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Malignant neoplasm
– Classified:
in situ (contained) invasive (infiltrated
surrounding tissue)
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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:
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– 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
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Etiology and Risk Factors
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Personal and family history of Breast cancer
 Hormonal influences:
– high/sustained estrogen levels
– HRT
– BCP(high estrogen)
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Exposure:
– Foods treated with hormones
• Xeno estrogens
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Genes: BRCA 1 BRCA 2
– 50-85% lifetime risk of breast ca, ovarian ca, both.
Signs and Symptoms
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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
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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
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Indole 3-carbinol: liver metabolism of estrogen to 2hydroxy estrogen derivative cruciferous vegetables broccoli,
kale, cauliflower, cabbage, bok choy
Lignans
 Green tea catecins
 Lycopene (tomatoes, red peppers,
grapefruit)
 Eliminate xenoestrogens (eat organic)
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Nutritional Supplementation
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Calcium D-glucarate: aid in elimination of
xenoestrogens, assist intestinal flora
Coenzyme Q 300mg/day
Selenium 60 mcg/day
Vitamin C 5000 mg/day
Vitamin E 400 IU/day
Folate
Vitamin B6 50-100mg/day
10
Lymphedema
Complication of procedures to treat
breast cancer
 Accumulation of lymph fluid that
accumulates in the arm resulting in
swelling.
 Etiology
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– 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
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Fibroadenoma
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What is it?
– Benign tumor of the breast
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Who gets it?
– Women in their menstruating years, most common
breast tumor in adolescent girls
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What causes it?
– Unknown
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Signs and Symptoms:
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Movable tumor
Non-tender
Not attached to skin
Clearly delineated
How is it diagnosed?
– Signs and symptoms, biopsy, mammography,
Fibrocystic Breast Changes
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Aka: Cyclic Mastalgia: An exaggerated response
of the breast tissue to hormonal changes.
 Etiology: Unknown
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Signs and Symptoms:
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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
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Decrease caffeine
Trans fats excess
salt hormonal
treated foods
 Exercise
Breast Augmentation: Risks and Complications
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Anesthesia Rxn
Asymmetry
Bleeding
Breast droop
Capsular
Contracture
Deflation(7%)
Displacement
Hematoma(3-4%)
Impact leak
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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
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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
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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.
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Mastitis
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What is it?
– Inflammation/Infection of the milk ducts in the
breast
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Who gets it?
– Women who are breast-feeding. If non-breast
feeding, look for CA.
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Etiology?
– Improper drainage of the milk ducts.
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Signs and Symptoms:
– Triangular flush: redness on the underside of
breast
– Swelling, Pain, Tenderness of breast
– Flulike symptoms
– Fever
Prevention/Management
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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
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– 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
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– 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
The role of Estrogen
Estrogen raises HDL and lowers LDL
 Prevents oxidation, making the LDL’
less harmful in the blood vessels.
 Decreases at menopause
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– Women in perimenopause typically have
total cholesterol 200-240 with desirable
HDL and LDL levels.
Lifestyle changes
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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
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Female Organ Conditions
Fibroids
 Polycystic Ovary Syndrome(PCOS)
 Pelvic Inflammatory Disease(PID)
 Reproductive Tract Malignancies
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Fibroids
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What is it?
– Noncancerous tumors of the uterus.
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Who Gets it?
– Women during their reproductive years. Silent in
20’s, symptomatic mid-30’s.
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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
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Feeling of hardness
in lower abdomen
Frequent urination
Menorrhagia
Anemia
Blood clots
Asymptomatic
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Dysmenorrhea
Dyspareurnia
Mittelschmerz
Reproductive
problemsmiscarriage and
infertility
Low Back Pain
Uterine Fibroids
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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
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Management
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Manage insulin resistance:
– Can increase estrogen and occurs in times of
prolonged stress.
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Eliminate Caffeine
 Increase Phyto estrogens: cruciferous vegetables
 Anti-inflammatory Diet
 Calcium, magnesium, potassium
– decrease muscle/menstrual cramps
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Fiber:
– Food types provide B vitamins that help body’s
synthesis anti-inflammatory prostaglandins
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Psycosocial factors:
– Stress causes a rise in cortisol, affects other hormones
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Acupressure/Acupuncture
Spinal manipulation:
– Uterus and Ovaries T12-L5
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Pain control: massage
 Vaginal depletion packs-suppositories containing
vitamins, minerals, herbs
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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
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– Excessive bleeding
– Risk of hemorrhage
– Inability to tell if tumor is benign
– Familial hx of reproductive tract cancer
Polycystic Ovary Syndrome(PCOS)
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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
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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
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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
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Amenorrhea
Obesity
Infertility
Acne
Hirsutism
Polycystic ovaries
Pelvic pain
Thinning Hair
Signs and Symptoms
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Hair loss
Insulin resistance
Type 2 Diabetes
• Cardiovascular disease
• Elevated blood pressure
• Elevated cholesterol
Diagnosis
Gynecologic history
 Vaginal/abdominal ultrasound
 Blood chemistries
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– Elevated LH
– Low FSH
– Elevated glucose
– Hyperandrogenism
– Elevated blood lipids
Management
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Dietary:
Ingesting simple carbohydrates and high
glycemic index foods can compound the problem b/c
they cause a rapid rise in blood sugars.
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Exercise:
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Restore monthly Bleeding:
Mild to moderate aerobic activity;
intense activity may increase symptoms.
– Progesterone cream during luteal phase
– Spinal manipulation to ovaries innervations
– Muscle stripping: adductors
Pelvic Inflammatory Disease (PID)
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Infection of the uterus, fallopian tubes, or other
reproductive organs
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Common complication of STD: Chlamydia and gonorrhea
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Organisms migrate from vagina and cervix into uterus and pelvis
10% PID are iatrogenically induced: abortion, IUD, D&C
Diagnosis:
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Signs & Symptoms
Differential Diagnosis
Ectopic pregnancy
Appendicitis tests immediately following menstruation
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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
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Vulvar cancer: rare form that primarily affects the labia
Vaginal cancer:vaginal bleeding in 60% cases
Cervical cancer:arises from unmanaged cervical
dysplasia
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Ovarian cancer: BRCA1 & BRCA 2
Fallopian tube cancer: mild but chronic lower
abdominal or pelvic pain
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Uterine cancer(endometrial ca):75% postmenopause; 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
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pre-menopause, menopause(last time of
menorrhae), post-menopause

senility
2.The definition of
menstruation
 Menarche:
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 days
 The volume of menstrual blood loss
is 30ml-50mL(<80mL),darkness and
nonclotting.
The Founction of ovary

Produce oocyte
 Endocrine: produce female
hormone
3.Reproductive cycle
Devided into 3 phases
 Menstruation:
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 ovary
Ovarian cycle is divided into four
phases

Development of follicles
primitive folliclesprimary follicles

secondary follicles  antrun/
developing
follicles  maturity follicles

ovulation
 corpus luteum
2)Ovarian steroid hormones
Estrogens
 rise
in plasma by 4th day of
cycle
 from granulosa cells and theca
cells
 negative feedback to FSH
 positve 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
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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
 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
3)vagina
 Thickening
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 center
 Progesterone
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-PO 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
Pituitary
 Producing
Gonadotropins
follicle-stimulating hormone(FSH)
luteinizing hormone(LH)
 be protein hormones secreted by the
anterior pituitary gland
 be pulsatile manner
 be 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

Viral Infection

Lack of exercise

Chemical Imbalance

Micro-trauma

Emotional State
– 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/Anemi
a/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 eliminatedinflammation
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



Ilio-tibial Band
friction syndrome

Patellar Tracking
disorders

Sport Specific
Injuries
Anterior Cruciate
ligament
Stress Fractures
Female Athlete Triad

Disordered eating: 15-62% female college
athletes have self-reported eating disorders.
– Anorexia/ Bulimia

Amenorrhea: 66%
– Primary, Secondary, Oligomenorrhea

Osteoporosis
Disordered Eating

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
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/Oligomenorrhe
a(<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 pregnant
New Patients for
management of pregnancy
New patients with
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/2wks
Less osseous adjusting
• 3rd trimester: 1x/wk
Decrease symptoms
Prepare for delivery
• Post-partum
ligamentus stability
alignment
Nutrition
behaviors
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:

R/O: ectopic pregnancy, miscarriage, GI problems, UTI

Varicose veins:
increases vascular congestion in pelvis, stretching
of round ligaments, pressure from presenting fetal part.
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:

Edema:

R/O: pregnancy induced hypertension

Joint aches/pains:
differentiate from
labor contractions-grow longer, stronger, closer together at regular
intervals
Sleeping on left side, Rest 2-3x/day, isometric
contractions, do not wear constrictive clothing, TAKE BP EVERY VISIT
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 warmup 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 warmup 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
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
Gonadarche
2.
•
•
•
Begins approx. 8 y/o
Hypothalamus-Pituitary-Ovarian Axis
Primary sexual characteristics: Increased
gonadal stimulation
3.
Menarche
The 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
Endometriosis
Estimate 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
HYSTERIA
Greek 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
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
factors
 Immune system stress
 Hormone levels
 The 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
Acupuncture
Herbs
Chinese
Medicine
Yoga
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
INDICATION
FOR TEST
TYPE
PROCEDURE
REVEALS
Laparoscopy
Pelvic tumors
Pelvic mass
Clinical symptoms of
endometriosis
Invasive surgery
Pelvic endometriosis
Pelvic adhesions
Tubal pregnancy
Uterine tumors
Pelvic cysts
Culdoscopy
Pelvic tumors
Pelvic mass
Clinical symptoms of
endometriosis
Invasive surgery
Pelvic endometriosis
Pelvic adhesions
Tubal patency
Uterine tumors
Pelvic cysts
Pelvic sonogram
Tumors
Cysts
Noninvasive procedure
Pelvic tumors
Pelvic cysts
Side Effects of Danocrine
Weight gain
Headaches
Fatigue
Acne
Depression
Oily skin
Breast
tenderness
Back pain
Hot flashes
Rash
Bleeding
Vaginitis
Breast lumps
Dizziness
Mild
Hirsutism
Inc. Allergies
Pelvic pain
Dec. Breast
size
Neck aches
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 process
Increase 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 obesity
chronic anemia
Low energy intake
low immunity
Inappropriate
Body Fat Ratio
 85%
< or equal to ideal weight
> to 120%
 athletes
 eating disorders
 amenorrhea
Diet & Supplements
Women 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 Disorders
as a psychiatric disorder.
Classification of Symptoms
Somatic:
water retention, pimples, intestinal
disturbance, low back pain, migraines,TMJ, cold
sores
Cognitive: lack of motor coordination, social
impairment, dysphoria
Emotional: 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 foods
 chronic stress
 Peri menopause
 Under active thyroid
UNDERACTIVE THYROID GLAND
‘HYPOTHYROIDISM’
 low
production of progesterone
 TRH (Thyrotrophin-releasing
hormone)
 TSH (thyroid-stimulating
hormone) produced by pituitary
gland
EXHAUSTED ADRENAL GLANDS
 Chronic
stress or
hypothyroidism
 Produce adrenaline & noradrenaline
 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 FIBERRICH 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 techniques
 get natural light
 antidepressants- st. john’s wort
 Exercise
 Vitamin 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,
mood swings, anxiety
66
PMT-H
Weight gain, swelling of
extremities, breast tenderness
abdominal bloating
65
PMT-C
Headache, sweets cravings,
increased appetite, heart
pounding, fainting, fatigue,
dizziness
24
PMT-D
Depression, forgetfulness,
confusion, crying, insomnia
23
PMT-A
Anxiety
 Irritability
 Insomnia
 Hormonal Imbalance

– Estrogen is CNS stimulant
– Progesterone is CNS depressant
PMT-A
Basic Dietary guidelines
B6(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-H
Dietary
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-C
 Magnesium:
430 mg
 B6: 100 mg
 lower salt and simple
carbohydrates
 Decrease salts and simple
carbohydrates
 Vitamin A 200,000 - 300,000 IU
PMT - D
Depression
 Forgetfulness
 Confusion
 Lethargy
 Possible excess progesterone

PMS-D
 Amino Acid
L - Typtophan: 6g
 Tyrosine 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

Vitamin B6
Lecithin

Magnesium
Zinc

Calcium
Flaxseed

Vitamin E
oil
C
or Fish
Exercise

Regular Aerobic: Endorphin release

Yoga: Especially inversions and sacral region

Specific strengthening: Keigel
Homeopathic





Evening Primrose oil: lessens uterine contractions & pain, 5001000mg/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 MEDICINE
BALANCE 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.
Acupuncture
Reflexology
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

Viral infection

Lack of Exercise

Chemical Imbalance
(GH, Serotonin)

Microtrauma

Autoimmune(RA)

Emotional State
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 brain
 composition and size of the
body
 infant’s metabolic competence
to handle nutrients
 mother’s future health
Recommended Weight Gain for
Pregnant Women
Prepregnancy Weight
classification (BMI)
Underweight (<19.8)
Normal (19.8 to 26)
Overweight (26.1 to 29)
Obese (>29)
Recommended
Total Gain
lb
kg
28-40
12.5 - 18
25-35 11.5 - 16
15-25 7.0 - 11.5
> 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.
Protein
Requirements= 60 g/day
20% increase over
nonpregnant level
Greatest concerns are
low levels of:
•iron
•calcium
•zinc
•folic acid
Iron
Iron 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
yogurt, plain, nonfat (1 cup)
yogurt, fruit flavored, low fat (1 cup)
chocolate milkshake (1 cup)
skim milk (1 cup)
whole milk (1 cup)
cheddar cheese (1 oz)
American cheese (1 oz)
ice cream, soft serve (1 cup)
ice cream, hard serve (1 cup)
cottage cheese (1 cup)
Calcium (mg)
452
345
256
302
285
204
174
206
170
154
Foods High in Calcium (Con’t)
(Recommended Intake 1,000 mg/day)
Protein
tofu w/calcium sulfate (1/2 cup)
sardines, canned, w/bones (1/2 cup)
tofu w/o calcium sulfate (1/2 cup)
almonds (1/2 cup)
Fruits & Vegetables
spinach, fresh, cooked (1/2 cup)
broccoli, cooked (1/2 cup)
okra, cooked (1/2 cup)
orange (1 medium)
calcium (mg)
434
428
130
165
122
85
88
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
germ
nuts
dried beans
Folic Acid
 most important vitamin
during pregnancy
all cell division
DNA synthesis
Recommended Daily
Allowances
adults 230 mg
childbearing years 400
mg
pregnancy 800 mg
Folic Acid
5-10 mg
fruits
vegetables
cheese
milk
eggs
100-150 mg
liver
orange juice
spinach
Deficiency
Neural
tube defects
in the fetus
megaloblastic
anemia in mother
Vitamin A
excess
is teratogenic
retinol
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,
Caffiene
does
cross the placenta
breast milk
half life higher in pregnancy 11 hours
infants (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) drugs
1. Anticonvulsants
2. Antiparkinsons
3. Hypnotics
4. 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
confirm viability
rule out ectopic pregnancy
confirm gestational age
birth control pill use
irregular menses
no dates
postpartum pregnancy
previous complicated pregnancy
caesarean delivery
RH incompatibility
diabetes mellitus
fetal growth retardation
establish/confirm dates
if no fetal heart tones
clarify dates/size discrepancy
large for dates--rule out
poor estimate of dates
molar pregnancy
multiple gestation
Leiomyomata
Polyhydramnios
congenital anomalies
small for dates--rule out
poor estimate of dates
fetal growth retardation
congenital anomalies
Oligohydramnios
if no fetal heart tones
clarify dates/size discrepancy
large for dates--rule out
Macrosomia (Diabetes)
multiple gestation
Polyhydramnios
congenital anomalies
poor estimate of dates
small for dates-- rule out
fetal growth retardation
Oligohydramnios
congenital anomalies
poor estimate of dates
Major Uses of Obstetric Sonography (Con’t
First Trimester
clarity dates/size discrepancy
large for dates--rule out
Leiomyomata
Bicornuate uterus
Adnexal mass
multiple gestation
poor dates
molar pregnancy
Small for dates--rule out
poor dates
missed abortion
blighted ovum
Second Trimester
If history of bleeding--rule out
total placenta previa
If RH incompatibilty--rule out
fetal hydrops
Third Trimester
determine fetal position--rule out
breech
transverse lie
If history of bleeding --rule out
placenta previa
abruptio placentae
Determine fetal lung maturity
Amniocentesis for
lecithin/sphingomyelin ratio
Placental maturity (grade 0-3)
If RH incompatibility--rule out
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
Reason for Performing Test
Breast Stimulation Test (BST)
Normal values: reactive; negative
Implies 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.
1
After 26 weeks’ gestation, the
nipples are stimulated to release
oxytocin that causes uterine
contractions similar to labor
contractions.
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; negative
Implies that placental support is
sufficient should labor begin
within one week.
2
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.
TESTS DONE TO PREDICT NORMAL FETAL
OUTCOME AND IDENTIFY FETUS AT RISK
FOR INTRAUTERINE ASPHYXIA
Name of Test & Normal Values
Acoustic Stimulation
Normal Values: Reactive
Nonstress test
Normal Values: Reactive; at least
two (2) episodes of fetal
movement associated with a rise
in FHR
Provides a baseline status & implies
an intact CNS and autonomic
N-S that are not being affected
by intrauterine hypoxia
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.
It determines fetus’ ability to
respond to environment by an
increase in FHR associated with
movement where not under the
stress of labor.
3
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 OFFERED
PRENATAL 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
physiological
stress 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
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
Improved sleep
Reduced anxiety an
dfrustration
Weight control
Improve chances for
easier labor
Body fat deposition to
a minimum
Improved self image
Treatment Protocol
Manipulation: decrease 2nd tri, inc. 3rd tri
 Massage(caution in severe edematoxemia)
 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
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 men
NIA, office of research on Women’s Health
1990’s
NCCAM: National Center for
Complementary and Alternative medicine
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
Resources
http://www.nlm.nih.gov/medlineplus/womenshealth.html
http://www.cdc.gov/women/index.htm
http://womenshealth.gov/topics.cfm
www.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.