September/October 2021

cndoctor.ca Serving Canada’s Chiropractic and Naturopathic Professions

Building
connections
Neurotrophic factors
in dementia
 September/October 2021 Cndoctor.ca

8
14

Contents 6 COVER STORY: Building connections Columnists

Neurotrophic factors in dementia
BY DR. ROMI FUNG, ND 12 Being bigger
than institutions
8 Helping the aging move better BY DR. ANTHONY LOMBARDI, DC
Life and longevity, part 8
BY DR. DON FITZ-RITSON, DC 22 Get ready for
the economic boom
14 Navigating scoliosis BY DR. ELIAS MARKOU, ND
Your 13-year-old son has a 53 degree thoracolumbar
scoliosis and is about to enter his growth spurt.
What would you do?
Cover photo: © vegefox.com / Adobe Stock, Icons: Freepik / Flaticon.com

BY DR. DEREK LEE, DC

16 Keep it simple, silly

Our CMCC externship experience
BY DR. ERIK KLEIN, DC, AND DR. M. JACOB HAYES, DC

18 Platelet rich plasma

What it is, and how it fits into multidisciplinary
treatment plans
BY DR. CHRIS SPOONER, ND

www.Cndoctor.ca September/October 2021 Chiropractic and Naturopathic Doctor 3

UPFRONT | From the editor

September/October 2021

Burning
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COVER STORY

BRAIN HEALTH

Building
connections
Neurotrophic factors
in dementia
by dr. romi fung, nd

D
ementia is an umbrella term that encompasses
multiple neurodegenerative diseases resulting
in cognitive symptoms. Characteristic to the
symptom picture of dementia is not only clas-
sic memory impairments, but also includes
language, problem-solving, executive func-
tions, arithmetic and other cognitive and
thinking capabilities. Therefore, dementia has a large impact
on the individuals activities of daily living.
Alzheimer’s Disease, or Alzheimer’s Dementia (AD), is the
most common cause of dementia, accounting for approxi-
mately 80% of dementia cases (Alzheimer’s Association,
2020).The other 20% of cases consists of Lewy Body Demen-
tia, Vascular Dementia, Parkinson’s Dementia, Crutzfeldt-
Jakob disease,Wernicke-Korsakoff syndrome, Frontotemporal
Dementia and Mixed Dementia. These dementias all have
differing etiologies that this article will not explore in depth.
The hallmark of the pathology of AD is the accumulation
of beta-amyloid protein fragments that have aggregated out-
side neurons in the brain. Also of importance are tau tangles
that are twisted in neurons and eventually lead to the death Longitudinal studies and meta-analysis have exhibited an association
of neurons thereby affecting brain tissue. This pathological of low vitamin D with cognitive impairment and Alzheimer’s disease.
development occurs progressively over many years before
symptoms emerge. form synapses throughout the life span.This process is initiated
One of the concerns regarding the development of demen- by neuronal depolarization, however the numbers of synapses
tia is the ability to create new neural connections. Synapto- formed is dependent on the level of three key nutrients—uri-
genesis is the creation of new synapses resulting in new con- dine, the omega-3 fatty acid DHA, and choline (Wurtman,
nections between preexisting brain neurons. Brain neurons 2014).

DR. ROMI FUNG is a Naturopathic Physician practicing in Richmond, Trophic factors for Alzheimer’s dementia
Photo: © javy / Adobe Stock

British Columbia, Canada. A recent graduate from the Canadian College of Trophic, as defined in the dictionary, is ‘of relating to nutrition;
Naturopathic Medicine, Romi helps patients living with dementia improve concerned in nutritive processes’ (Dictionary.com, 2021).
their quality of life by taking an integrative and functional approach. On top of Another definition by Merriam-Webster (2021) states that
his practice, Romi is currently pursuing doctoral studies in Aging and Health trophic factors “promot[e] cellular growth, differentiation, and
at Queen’s University and is an Adjunct Clinical Faculty at the Boucher Institute survival.” In other words, nerve growth factor is a trophic agent.
of Naturopathic Medicine. www.DrRomiFungND.com. This part will explore some nutraceuticals as trophic factors.
6 Chiropractic and Naturopathic Doctor September/October 2021 www.Cndoctor.ca
 et al., 2019). This indicates that the risk of AD was reduced
with increased vitamin D levels.
It is observed that low vitamin D levels is associated with
increased risk of AD. Vitamin D is suspected to be a potential
modulator of neurogenesis. Vitamin D has been shown to
regulate neurotrophic factors and influencing neuronal pro-
liferation, differentiation, survival and growth (Groves &
Burne, 2017). Low vitamin D levels, or hypovitaminosis D, in
AD rat models increased the number of amyloid plaques
(Morello et al., 2018).
Vitamin D is highly recommended to be tested before
considering supplementation. At this time, there is no concrete
evidence on an ideal level of serum vitamin D. However, a
study done by Oudshoorn et al. (2008) suggests that there is
a positive association between serum vitamin D levels and
MMSE scores, with participants with serum vitamin D higher
than 50nmol/L generally scoring the highest. In regards to
dosing, in a double-blind randomized controlled trial of post-
menopausal women with levels than 30ng/mL by Castle et al.
(2020), women who took 2000IU daily found to perform
better in learning and memory tests compared to the 600IU
and 4000IU groups.

Magnesium
Another intervention in supporting neurogenesis is magne-
sium. Magnesium affects many biochemical mechanisms vital
for neuronal properties and synaptic plasticity, including the
response of N-methyl D-aspartate (NMDA) receptors to
excitatory amino acids, stability and viscosity of the cell mem-
brane, and antagonism of calcium (Li et al., 2014).
Magnesium is arguably often overlooked however it is cor-
nerstone to our health. Magnesium levels were found to be
decreased in various tissues of AD patients and negatively
correlated with clinical deterioration (Li et al., 2014). More-
over, Magnesium was demonstrated to modulate the traffick-
ing and processing of amyloid-ß precursor protein in trans-
genic mice (Li et al., 2014).
Magnesium supplementation comes in many forms. One
form that is more appropriate in managing cognitive decline
is magnesium threonate. Magnesium threonate treatment
was shown to reduce Aß-plaque, prevented synapse loss and
memory decline in the transgenic mice (Li et al., 2014).
Strikingly, magnesium threonate treatment was effective even
when the treatment was given to the mice at the end-stage of
Vitamin D their Alzheimer’s disease-like pathological progression (Li et
One of the nutraceutical interventions to provide factors in al., 2014).
building neural connections is vitamin D. Cross-sectional Magnesium itself has a poor penetration across the blood
studies have consistently found that vitamin D levels are sig- brain barrier (Vink, 2016). However, magnesium threonate is
nificantly low in individuals with AD and cognitive impairment a more permeable magnesium salt and is a preferred option
compared to healthy adults. Longitudinal studies and me- in neurological conditions (Vink, 2016).
ta-analysis have also exhibited an association of low vitamin
D with cognitive impairment and Alzheimer’s disease (Sultan Phosphatidylcholine and Citocholine
et al., 2020; Chai et al., 2019; Llewellyn et al., 2011) Choline is a major constituent of all biological membranes
In another study done by Chai et al. (2019), there are sig- including neurons and glial cells (Blusztain et al., 1990). Brain
nificant positive associations between deficient vitamin D sample studies dating to the 1980s and 1990s showed reduced
(defined as <20 ng/mL) and risk of developing AD. By divid- levels of phosphatidylcholine and phosphatidylethanolamine
ing subgroups in the deficient vitamin D to moderate defi- and increased levels of their metabolites, glycerophosphocho-
ciency (10-20 ng/mL) and severe deficiency (<10 ng/mL), line and glycerophosphoethanolamine, respectively, in the
there was a greater association with AD in the severe deficiency cerebral cortex of AD patients as compared to age-matched
group in comparison to the moderate deficiency group (Chai CONTINUED ON PAGE 21
www.Cndoctor.ca September/October 2021 Chiropractic and Naturopathic Doctor 7
FEATURE

PAITENT CARE

Helping
the aging
move
better
Life and longevity, part 8 they change with aging, then we should be looking
at dual tasking, ie., combines walking with say
by dr. don fitz-ritson, dc mental tracking tasks to get a better appreciation
of their interactions. In a study comparing young

Y
vs old adults dual tasking, it showed that the older
group exhibited shorter times during single–leg
stance and single-leg stance + cognitive task com-
ou know that normal physiology pared to younger group(8). Another study looked
changes as you age. Gait and mo- at cognitive function and postural control showed
bility are altered with aging and that postural control during visuospatial tasks and
changes in gait speed is contributed dementia may share neural substrates, specifically
by impaired balance and stability, in memory-related regions(9). Also sex differences
lower limb strength, fear of falling such as the effect of aging on the recruitment of
and are related to functional de- muscles may explain overall increased instability
cline and impaired quality of life(1). Multisen- and fall risk in older adults(10).
sory aging is an important concept, as other Both gait impairment and cognitive decline
systems ie., vision, hearing, can contribute to have been shown to constitute major fall risk
cognitive load and decline(2,3). In a study of gait factors. Those are two big domains and it would
speeds with women >75 years old, decreased What would be be beneficial for doctors/therapists working with
cognitive function is associated with changes in the outcome if the aging population to have more specific areas
gait speed(4). we added to access. Some results are beginning to show that
The Canadian Longitudinal Study on Aging nutrition to in the cognitive domain, specifically the cortical
Photo: © Africa Studio / Adobe Stock, Icon: monkik / Flaticon.com

showed that all cognitive measures were related to aerobic exercise? executive system and its sub-domains – attention
indices of mobility and the relationship often in- control, is linked with gait performance in the
creased with age and brain health(5,6). Mobility aging with high risks of falls(11). Attention, sen-
limitations are heavily influenced by musculoskel- sory integration, and motor planning are the
etal mechanisms and higher brain centers espe- sub-domains of executive function associated with
cially the motor control circuit of the dorsal basal risk of falls through gait dysfunction(12). This
ganglia are all involved(7). Since the musculoskel- information will begin to guide us as we begin the
etal and brain systems are involved in mobility and task or improving gait/mobility.
The feet are significant for gait/mobility. Their
DR. DON FITZ-RITSON is a chiropractor and a rehab specialist. range of motion, flexibility, co-ordination and
He was an Assistant Professor at CMCC. He published 17 papers strength are all critical for the normal gait cycle.
and 3 chapters on chiropractic.He co-invented a laser and it By assessing all the evidence based studies, con-
received 7 Health Canada Approvals. He is focused on helping the clusions can be drawn regarding which maybe
aging population live better lives. the best approach to rehabilitate the gait/
8 Chiropractic and Naturopathic Doctor September/October 2021 www.Cndoctor.ca
 adults(65-80), found that a training program focus-
ing on exercising mechanisms of dynamic stability
in unstable conditions ie., dual task, enhanced
muscle strength as well as sensory information
processing within the motor system during balance
tasks, reducing the risk of falls in old adults(14).
Lack of stability with gait/mobility is caused also
by age-related neuromuscular changes in the hip
abductor-adductor muscles leading to reduced
performance, causing more medio-lateral sway
contributing to balance issues and falls. When
power training was introduced into the program,
ie. strengthening the hip muscles, it was found to
be more effective than strength training at eliciting
improvements in maximal neuromuscular perfor-
mance and enhanced medio-lateral balance recov-
ery(15).
Is there a reliable, easy and cost efficient way to
measure body strength in the aging person? By
reviewing the studies, stand-alone handgrip
strength can be considered an umbrella assessment
of the body systems that contribute to strength
capacity, and a panoptic measurement of muscle
strength that is representative of overall health
status(16). Results in older adults found that mus-
cle weakness of the leg extensors and forearm
flexors is related to slow gait speed and is suitable
for screening for muscle weakness in older
adults(17). Handgrip strength can also be used in
clinical settings for helping to determine the onset
and progression of cognitive impairment(18).
Looking specifically at the musculoskeletal sys-

Attention, sensory integration, tem and how it affects gait/mobility of older adults,
recent studies show that tibialis anterior and vastus

and motor planning are the lateralis muscles deserve attention in physical train-
ing for gait. Specifically, tibialis anterior strength

sub-domains of executive helps with obstacle crossing, and vastus lateralis

assists knee extensors when aiming at improving

function associated with risk of gait speed and step length(19). But we should also
condition the entire body, because the entire sys-

falls through gait dysfunction. tem functions as a unit, muscles affect the brain
and visa versa. After a 12 week program of regular
resistance exercises, the elderly group showed sig-
mobility cycle. Here are a few pertinent ones. nificant increases in the average upper body
This study evaluated the effects of resistive exer- strength (58%), lower body strength (68%), and
cise (RE) with head rotation exercise (RE+HRE) cognitive capacity (19%), these benefits bring en-
on postural balance, lower limb muscle strength, hanced life quality(20). For a complete neuro-mus-
and gait in older women. This is a dual task study. culoskeletal effect, adding plyometric training,
They are including head rotation exercises which which is safe training when done correctly, has
is a powerful means of stimulating the vestibular potential for improving various performance, func-
system and restoring proper proprioceptive sense tional, and health-related outcomes in older per-
to the cervical muscles, brain stem and brain(cog- sons(21).
nitive/motor).Their findings suggest that Balance training over a lifespan can improve
RE+HRE can improve dynamic postural balance, vestibular function and decrease postural deterio-
lower limb strength, gait speed, and cadence in ration. This training effect can contribute to the
older women(13). physical capabilities of the person functioning as
Another study looking at the effectiveness of been 10 years younger(22). The balance training is
exercise intervention to control dynamic postural inducing structural neuroplasticity in the human
stability under unstable conditions in old brain and to enhance cognitive functions. A
www.Cndoctor.ca September/October 2021 Chiropractic and Naturopathic Doctor 9
FEATURE
12-week study of balance training involving 19-65
year old subjects, found improved balance perfor-
mance which correlated with the increase of
precentral cortical thickness. This area is involved
with visual and vestibular self-motion perception,
spatial orienting and memory. Stimulating
visual-vestibular pathways during self-motion
might mediate beneficial effects of physical exer-
cise on cognition(23).
Dance is multi functional, a great way to have
fun and improve brain function. Dance practice
integrates brain areas to improve neuroplasticity.
In a systematic review, structural changes were
found indicating increased hippocampal volume,
gray matter volume in the left precentral, parahip-
pocampal gyrus and white matter integrity. Func-
tional changes included alterations in cognitive
function such as significant improvement in
memory, attention, body balance, psychosocial
parameters and altered peripheral neurotrophic
factor(24). Dance training promotes mental and
physical well-being of senior citizens(25).
Here is the real potential of the dual-task pro-
gram. A simple approach like walking and simul-
taneously performing a cognitive task, such as
counting backwards from 100 by 3, in older adults,
has been shown to effectively improve the normal
gait cycle and for complex real world tasks (26, Balance training multi-nutrient supplement and aerobic exercise
27). Aging cause declines in executive functions over a lifespan on mobility and cognition in older women 60-70
and basic motor skills such as posture control, can improve years, found significant improvements in self-re-
muscle strength, and balance performance. What vestibular ported emotional well-being with multi-nutrient
would happen if we trained executive functions function and and exercise groups v. placebo. The results suggest
and exercise - resistance training? In a 12 week decrease that the high-DHA multi-nutrient supplement
program of 68 year old males assessing balance postural produces similar improvements in cognitive func-
performance and working memory, the results deterioration. tion to aerobic exercise, offering the intriguing
found that dual-task interventions improved both prospect that supplementation may be able to
balance performance and working memory, but mitigate some of the effects of low physical activ-
more so if cognitive performance was specifically ity on cognitive function in the elderly.(30
trained along with resistance training(28). The aging population needs to be educated
The ability to walk and perform cognitive tasks that different types of exercise, along with dance,
simultaneously is a key aspect of daily life. When dual-task exercises, balance and cognitive train-
they are performance declines in these dual-tasks, ing are all necessary, in addition to taking good
it may be associated with early signs of neurode- supplements and eating properly to enjoy healthy
generative disease and increased risk of falls. living.
Dual-task aerobic exercise and cognitive training
intervention significantly improved cognitive per- REFERENCES
formance during a dual-task walking test in 1. Cruz-Jimenez M. Normal Changes in Gait and Mobility Problems in the Elderly.
Phys Med Rehabil Clin N Am. 2017 Nov; 28(4): 713-725.
healthy older adults.(29) Aerobic exercise is the
2. Li K, et al. Cognitive Involvement in Balance, Gait and Dual-Tasking in Aging:
next step up in physical demand, so of course we A Focused Review From a Neuroscience of Aging Perspective. Neurol , 9, 913
will see improvements. 2018.
What would be the outcome if we added nutri- 3. Morris R, et al. Gait and Cognition: Mapping the Global and Discrete
Photo: © michelangeloop / Adobe Stock

tion to aerobic exercise? There is a complex inter- Relationships in Ageing and Neurodegenerative Disease. Neurosci Biobehav
Rev. 2016 May; 64: 326-45.
play between mobility and cognition in older
4. Noh B, et al. Age-specific Differences in Gait Domains and Global Cognitive
adults. High-DHA multi-nutrient supplement Function in Older Women: Gait Characteristics Based on Gait Speed
improves habitual walking speed, verbal memory Modification. PeerJ. 2020 Mar 16; 8: e8820.
and psychomotor response latency in older 5. Demnitz N, et al. Cognition and Mobility Show a Global Association in Middle-
women. Exercise also improves mobility and cog- And Late-Adulthood: Analyses From the Canadian Longitudinal Study on
Aging. Gait Posture . 2018 Jul; 64: 238-243.
nition in older adults, and n-3 fatty acids and
6. Jee L, et al. Association of Neurocognitive and Physical Function With Gait
exercise share a range of overlapping biological Speed in Midlife. JAMA Netw Open. 2019 Oct 2; 2(10): e1913123.
e f f e c t s. T h e e f f e c t s o f t h e h i g h - D H A
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7. Clark B, et al. The Aging Brain & the Dorsal Basal Ganglia: Implications for Age-Related 19. Guadagnin E, et al. Correlation Between Lower Limb Isometric Strength and Muscle Structure
Limitations of Mobility. Adv Geriatr Med Res. 2019; 1: e190008. With Normal and Challenged Gait Performance in Older Adults. Gait Posture. 2019 Sep;
73:101-107.
8. Bonetti L, et al. The Effect of Mental Tracking Task on Spatiotemporal Gait Parameters in
Healthy Younger and Middle- And Older Aged Participants During Dual Tasking. Exp Brain 20. molarek A, et al. The Effects of Strength Training on Cognitive Performance in Elderly Women.
Res. 2019 Dec; 237(12): 3123-3132. Clin Interv Aging. 2016 Jun 1;11:749-54.
9. Sparto P, et al. Shared Neural Substrates of Cognitive Function and Postural Control in Older 21. Vetrovsky T, et al. The Efficacy and Safety of Lower-Limb Plyometric Training in Older Adults:
Adults. Alzheimers Dement . 2020 Apr; 16(4): 621-629. A Systematic Review. Sports Med. 2019 Jan; 49(1): 113-131.
10. Bailey C, et al. Sex-dependent and Sex-Independent Muscle Activation Patterns in Adult Gait 22. Wiesmeier I, et al. Balance Training Enhances Vestibular Function and Reduces Overactive
as a Function of Age. Exp Gerontol. 2018 Sep; 110: 18. Proprioceptive Feedback in Elderly. Front Aging Neurosci . 2017 Aug 11; 9: 273.
11. Fernandez N, et al. Age-related Changes in Attention Control and Their Relationship With 23. Rogge A, et al. Exercise-induced Neuroplasticity: Balance Training Increases Cortical
Gait Performance in Older Adults With High Risk of Falls. Neuroimage. 2019 Apr 1; 189: Thickness in Visual and Vestibular Cortical Regions. Neuroimage. 2018 Oct 1; 179: 471-
551-559. 479.
12. Zhang W, et al. Review of Gait, Cognition, and Fall Risks With Implications for Fall Prevention 24. Teixeira-Machado L, et al. Dance for Neuroplasticity: A Descriptive Systematic Review.
in Older Adults With Dementia. Dement Geriatr Cogn Disord. 2019; 48(1-2): 17-29. Neurosci Biobehav Rev. 2019 Jan; 96: 232-240.
13. Choi W, et al. The effects of head rotation exercise on postural balance, muscle strength, 25. Zilidou V, et al. Functional Re-organization of Cortical Networks of Senior Citizens After a
and gait in older women. Women Health. 2019 Oct 6:1-14. 24-Week Traditional Dance Program. Front Aging Neurosci. 2018 Dec 21; 10: 422.
14. Haned A, et al. Exercises of Dynamic Stability Under Unstable Conditions Increase Muscle 26. Salazar-González B, et al. A physical-cognitive intervention to enhance gait speed in older
Strength and Balance Ability in the Elderly. Scand J Med Sci Sports . 2018 Mar. 28 (3): Mexican adults. Am J Health Promot. 2015 Nov-Dec; 30(2) :77-84.
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27. Ehlers D, et al. Effects of Gait Self-Efficacy and Lower-Extremity Physical Function on Dual-
15. Inacio M, et al. Low-dose hip abductor-adductor power training improves neuromechanical Task Performance in Older Adults. Biomed Res Int. 2017; 2017: 8570960.
weight-transfer control during lateral balance recovery in older adults. Clin Biomech (Bristol,
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Balance and Working Memory in Older People. Phys Sportsmed. 2019 Nov; 47(4): 471-478.
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Speed in Older Adults. J Am Geriatr Soc . 2016 Jan; 64(1): 144-50.
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www.Cndoctor.ca September/October 2021 Chiropractic and Naturopathic Doctor 11

CND_ContemporaryAcupuncture_SeptOct21_CSA.indd 1 2021-09-10 12:32 PM
UPFRONT | Columnist

BUSINESS TALK

Being bigger than institutions

Practicing DCs need to become ambassadors of the profession

W
BY DR. ANTHONY J. LOMBARDI, DC

hat a tumultuous two

years this has been. In
between changes in world
leadership, pandemics,
travel restrictions, and
business closures our profession has quietly
been changing too.
Did you know? Of the 45 chiropractic
institutions worldwide that only 14 have
retained the word chiropractic in the school’s
name? Of those 14 schools with chiropractic
in their name only four are in the United
States (Texas, Sherman, Palmer, Life West)
and only CMCC sports the name of the
profession in Canada. Most recently New
York Chiropractic College shed chiropractic
from its name and became Northeast Col-
lege of Health Sciences. This trend worries
me. I fear that a serious identity crisis in the
profession is on the horizon. School are
trading the chiropractic name for a more
general, generic, better marketable moniker.
This might be understandable if the schools
were in financial peril, but most chiropractic
institutions are on solid financial footing.
Most recent annual financial reports show
that NYCC has over $50 million US in as-
sets – yet they still ditched chiropractic from
their name. schools that teach future ambassadors of our profession no
longer make chiropractic a visible priority in their own insti-
Questions tutions? Does the mass re-branding of chiropractic schools
What does this tell chiropractors in the profession? Does it across the world also re-brand the profession of practicing
suggest that schools are putting profits ahead of preservation chiropractors?
of the profession? Clearly these name changes have been
encouraged by the sharp decrease in enrollment and in order The answers
to maintain profits, the institutions feel that a more generic At first this bothered me. Then I thought that I needed to
name will attract a more diverse array of post-graduate stu- take a step back and take whatever positive aspects from this
dents to their school to enroll in allied health curriculums. academic trend. I pondered: Do chiropractic schools make
I wonder, how many medical schools or dental schools are the profession? Or, do practicing chiropractors set the tone
Photo: © Monkey Business / Adobe Stock

no longer called medical or dental schools? Chiropractic has for the future? There are tens upon tens of thousands of
a young but rich history. Will it hurt our profession if the practicing chiropractors worldwide: What are we doing to
demonstrate and foster pride in the profession?
The best we can do is to demonstrate clinical and civil
ANTHONY LOMBARDI, DC, is a private consultant to athletes in the NFL, CFL greatness through our actions. Practicing chiropractors can
and NHL, and founder of the Hamilton Back Clinic, a multidisciplinary clinic. make an impression on other chiropractors, chiropractic
He teaches his fundamental EXSTORE Assessment System and practice building students, allied health professionals and patients, simply by
workshops to various health professionals. For more information, visit www. being good role models and positive mentors in the profes-
exstore.ca. sion.
12 Chiropractic and Naturopathic Doctor September/October 2021 www.Cndoctor.ca
Be a mentor Mentoring is mutually beneficial
Mentoring is the key for developing and sustaining a satis- Mentoring can provide opportunities that can be mutually
fying career and enables us to grow, learn, transform and beneficial for both mentor and mentee. Mentors can be a
accomplish goals in education, in the clinic or business. coach or ally answering questions as they arise for the
Whether you are an educator, clinician or in the early stages mentee. They act as advocates to help mentees navigate
of your training, mentoring helps build a dynamic commu- the terrain of academia and move forward professionally.
nity for success. By providing guidance, support and other insights, men-
tors can learn and enhance their own leadership skills.
Mentors promote confidence Mentees often bring a fresh perspective to a difficult prob-
The importance of mentoring relationships becomes evident lem, and serving as mentor can provide a renewed sense
as we recognize the value of networking and maintaining re- of purpose in meeting the challenges of chiropractic.
lationships throughout our career.The value of a good mentor
is immeasurable when it comes to learning the tricks of the Be the change
trade as well as becoming connected to those in the know and Ultimately, the responsibility of mentorship rests with
who possess invaluable knowledge about business practice. DCs. Let us not worry about what the academic institu-
Most importantly, a successful mentor demonstrates and tions are doing. That is out of our control. If you do not
upholds the values and ethics of the profession they represent. agree with it then find an aspect of our profession that
A mentor can help alleviate much of the frustration students you can support. It is vitally important for us to help one
and new graduates often feel in their first few months of work- another grow and develop into competent professionals
ing in clinic. By sharing their insight and knowledge on clini- and entrepreneurs. There is no reason why we shouldn’t
cal and business skills, new DCs in the field can be spared a be sharing helpful information with our peers. After all,
great deal of stress. A good mentor can support students, new there is an abundance of potential chiropractic patients
graduates and practising DCs to help avoid unnecessary in Canada.
resignation due to feelings of incompetence and isolation. Lets be positive, Doc!

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www.Cndoctor.ca September/October 2021 Chiropractic and Naturopathic Doctor 13

CND_DesignHealth_SeptOct21.indd 1 2021-09-03 9:47 AM
FEATURE

COLLABORATION

NAVIGATING SCOLIOSIS
Your 13-year-old son has a 53 degree thoracolumbar scoliosis and is
about to enter his growth spurt. What would you do?
BY DR. DEREK LEE, DC

T
wo years ago, our family (AIS) is bracing followed by a wait and
doctor caught the initial see approach and if the curve pro-
24 degree curve after a gresses to 50+ degrees, then either live
routine chest X-ray for a with the curve or opt for posterior fu-
lingering cough. In retro- sion with rods and screws as the end
spect, I often look back game. Neither were great choices. In
on what I have learned my son’s case, it took three months to
since that heartbreaking diagnosis and get a referral to a local pediatric spine
kick myself for missing all the signs that surgeon and another month to get a
were staring me in the face for years. Boston-type symmetrical brace. I was
On the top of that list were his thoracic far from impressed by how the first
hypokyphosis and cervical kyphosis, spine surgeon managed my son’s care
the former the biomechanical hallmark with an outdated brace design and
of scoliosis progression, the latter, a dubious follow up plan. In the mean-
proximal junction compensation pat- time, his curve had more than doubled
tern to the former. to 53 degrees into surgical range. Those Many of the chiropractic treatments for
After moving on from the guilt of four critical months were completely scoliosis were developed about 30 years ago
missing it earlier, I started to research wasted. Unfortunately, this is an all too
all things scoliosis. Yes, I’m an experi- common scoliosis story. the top orthotists in North America,
enced chiropractor, but I rarely see I was completely frustrated, angry Luke Stikeleather based in Virginia,
scoliosis in my corporate practice with and looking for help. I reached out to USA.With a combination of daily phys-
Rogers Communications (21 years) or Toronto’s Sick Kids hospital for a con- iotherapy specific scoliosis exercises,
my private practice (28 years). I’m sultation. I consulted with chiroprac- traction and muscle work, my son saw
ashamed to say that I can’t recall being tors throughout North America. Many a 20% curve reduction from 53 to 42
taught anything about scoliosis in chi- of the chiropractic systems for scoliosis degrees in three months, which was
ropractic college and certainly nothing can be traced back to a posture system excellent considering braces are de-
about scoliosis treatment. It might developed by Dr. Burl Pettibon about signed to stop progression and not to
seem pathetic, but I turned to Google 30 years ago. I also reached out to correct the curve.
for answers. Of course what I found physiotherapists who were experienced I was happy for my son and proud of
scared me even more. I found a lot of with scoliosis-specific exercises includ- his dedication to a daily regimen of one
misinformation in general with miracle ing Schroth therapy. I also sought hour of exercise and treatment seven
cures, but also conflicting studies from better bracing treatment by speaking days a week for three months. This was
Photo: © Photographee.eu / Adobe Stock

apparent scoliosis experts and re- with several orthotists (brace makers) in addition to being braced 21 hours a
searchers on PubMed. The lack of from across the US and Canada. day which is horrific to witness, much
consensus was everywhere. Six months post-diagnosis my son less partake in. Unfortunately, I knew
The most common medical manage- was fitted with a Rigo Cheneau asym- these results wouldn’t last. He was
ment of adolescent idiopathic scoliosis metric brace from who I feel is one of entering his growth spurt and he had
atypical scoliosis. His spine was stiff
DR. DEREK LEE is a corporate health and wellness Doctor with Rogers Communications (20+ years), with a thoracic lordosis and I knew the
supporting three Rogers GTA on-site health centres in addition to a Markham private practice. He is a bracing, exercise and conservative
scoliosis education advocate: https://www.youtube.com/c/DerekLee. treatments would fail.
14 Chiropractic and Naturopathic Doctor September/October 2021 www.Cndoctor.ca
 Serial low dose EOS x-rays spanning 3.5 years of scoliosis correction from detection to bracing to non-fusion Vertebral Body Tethering surgery

I started doing more surgery focused the FDA VBT approval (summer Alanay in Turkey to see if he would be
research. I even lurked on Facebook 2019), he had also performed over interested in participating in an inter-
scoliosis forums to see how other sco- 250+ VBT surgeries. His clinical deci- view on VBT. Shockingly, he agreed
liosis patients with severe curves were sion making, experience and expertise and we recorded a 70-minute interview.
trying to manage their own care. Ridic- meant everything. On Labour Day Not only did I learn more about VBT,
ulous? Actually, these groups were the 2019, he accepted Jacob as a surgical but the interview gave insight to Dr.
most helpful. They shared information candidate for VBT and in December Alanay’s thought processes regarding
on non-fusion surgical scoliosis correc- 2019, my son had VBT surgery. surgical decision-making and surgical
tion techniques that use screws and One and a half years later, my son’s approach, but also his personality. This
cords to maintain spine flexibility. curve is down to 24 degrees from 53 long format interview reveals much
Vertebral body tethering (VBT) uses with a fully mobile spine. more than a typical 10 minute consul-
polyethylene terephthalate (PET) Everyone’s influences and approaches tation most patients get with a surgeon.
cords instead of metal rods to correct will differ, and chiropractors, naturo- Maybe I was on to something.
a scoliotic curve. The basic idea is quite paths, osteopaths and physiotherapists A year later, I’ve interviewed 30 of
elegant. Screws are inserted into the will lean on their experience and train- the top spine surgeons from Canada,
convex side of each vertebrae along the ing to try and find a solution. But what U.S., Germany, France and Australia.
span of the curve. Cords are tensioned about parents and patients? What That list includes Dr. Amer Samdani,
between each vertebrae to align the should they do, and who advocates for Dr. Peter Newton (San Diego), Dr. Per
vertebral discs which reduces the curve. them? Researching scoliosis treatment Trobisch (Germany), Dr. John Braun
This technique harnesses the Huet- options is a challenge considering all the (Boston), Dr. Noelle Larson (Mayo
er-Volkman principle of bone growth
modulation which proposes that bone
growth is retarded by increased me-
chanical compression, and accelerated My previous consultations
by reduced loading in comparison with
normal values. VBT is primarily for taught me so much – why not
adolescents that are still growing. As
they continue to grow post VBT, the share these insights...?
discs and vertebrae will maintain a more
symmetrical shape which will stabilize
the cure once bone maturity has been misinformation and lack of consensus Clinic) and many more. I’ve also inter-
reached. Fusion is avoided altogether. on the Internet. viewed scoliosis researchers, orthotists
This sounded like a solution! From my own experience, I have and other practitioners. These inter-
Via e-mail, Linkedin, Instagram and learned the best and most relevant data views have become popular in the
Zoom, I began reaching out directly to and information comes directly from scoliosis world and I’m happy parents
spine surgeons across Canada, the spine surgeons, especially the ones that can use this resource to make timely
USA and Europe. These specialists publish research papers consistently. and informed decisions. The interviews
were the most skilled in non-fusion This means they follow up with patients can be found at https://www.youtube.
scoliosis surgeries and I sought a con- long term and are experienced and re- com/c/DerekLee.
sensus of opinion. Six consultations spected by their peers. My previous The only way parents and patients
Photo: Author provided.

later, we drove down to Shriners Hos- consultations taught me so much – why can advocate for themselves is by edu-
pital for Children in Philadelphia to see not share these insights with other par- cating themselves as best they can. It
pediatric orthopedic and neurosur- ents or patients affected by scoliosis? doesn’t matter if you are a practitioner
geon, Dr. Amer Samdani. Dr. Samdani Last spring during the first COVID or a parent. Keep that in mind and it
not only led the research necessary for lockdown, I reached out to Dr. Ahmet will serve you well.
www.Cndoctor.ca September/October 2021 Chiropractic and Naturopathic Doctor 15
FEATURE
visits in their clinic year to graduate,
along with 30-40 new patient assess-
ments and all of the learning objectives
(LOs) that go along with it. During
COVID, interns struggled, and CMCC
moved away from a numbers-based in-
ternship, and guided 4th years through a
competency-based protocol for gradua-
tion. They really had no choice, because
holding back 150+ interns because of
their “numbers” was simply not practi-
cal, nor ethical. The downside of this, is
that CMCC was graduating academi-
cally capable DCs, but with a distinct
disadvantage with regards to patient
management, and technical skills. The
CCEB boards are set to create end of
education and licensing competency.
This is already in place. Missing your
EDUCATION “numbers” will come back to haunt

Keep it
grads who simply didn’t get the experi-
ence. Seeking out strong mentorship for
the first two years of practice will be es-
sential in launching their careers.

simple, silly
The college did indeed recognize this,
and supported enterprising interns who
sought out externships to complete their
clinical education in community clinics
around the country. Dr. M. Jacob Hayes
was one such intern who sought out the
support of Dr. Erik Klein, and Dr. Dan
Our CMCC COVID Comeau for his clinical education,
which took place in New Brunswick.
externship experience This is our story:
BY DR. ERIK KLEIN, DC,
AND DR. M. JACOB HAYES, DC JAKE ‘THE INTERN’
Not having family or strong social con-
nections in the GTA, I knew I was going
to have a great deal of difficulty complet-
This is our experience from both the intern, marked as if the status quo existed is ing my requirements, which led me to

C
and the supervising clinician, on CMCCs tough. Beyond that, imagine going back seek out Dr. Klein and Dr. Comeau.
first broad-based externship program. to chiro school and spending $25,000 to Even though clinic started in June, I
do virtual consults and desperately didn’t get into Sherbourne until August
OVID-19 turned educa- hoping some people come in during the to see my first in-person patient. I
tion on its head. Every- series of lockdowns experienced in the reached out to Dr. Klein to see if he
one struggled to some GTA. This has been a hard time for would be able to help and he was excited.
point, especially those chiropractic interns. I learned very quickly how differently
finishing high school and Any seasoned doc in the trenches will things happen in community clinics vs.
missing out on many tell a student that getting as much the teaching clinic. My clinicians really
rights of passage, and hands-on experience as possible is the endeavoured to provide a mentorship
Photo: © LIGHTFIELD STUDIOS / Adobe Stock

those entering higher education. The key to a solid start. You need to assess, that would help balance my educational
thought of paying $5,000 for university educate, adjust, and do your rehab. competencies while gaining knowledge
tuition and sitting in your dorm watching Over, and over, and over again. Tradi- of “the real world.”
glorified YouTube videos and being tionally, interns required 350 subsequent As with the beginning of every intern-
ship, your first patient intake appoint-
DR. ERIK KLEIN is a chiropractor and CEO of Town Health Solutions, a network focused on the growth and ment lasts about four hours. History –
development of clinical excellence and entrepreneurship for manual therapists. For more information, talk to your clinician. Ask more questions
please visit www.townhealthsolutions.com/franchising. that you missed – talk to your clinician.
DR. M. JACOB HAYES is a recent graduate of the Canadian Memorial Chiropractic College. He graduated Do a physical examination – talk to your
from the University of New Brunswick in 2017 with a Bachelors of Sciences. clinician. Go back in and complete
16 Chiropractic and Naturopathic Doctor September/October 2021 www.Cndoctor.ca
another SIJ test – talk to your clinician. inspire. I took this as an opportunity to Find the keys, and address them with
You then take about 25 minutes to write learn, and develop myself both profes- whatever tool you see fit. Using every test
out an ROF (for the first time anyway) sionally and personally. I fondly recall my and treatment modality available simply
– talk to your clinician.You finally get to internship at CMCC with Drs Decina is not practical. In the end of the day,
the treatment. But, this is necessary, as and deGraauw and I enjoyed having the CMCC gives you a lot of tools, but not
in the beginning we always miss little opportunity to “pay it forward.” all of them are practical in a real world
things in the history and physical exam- My teaching goal for Jake was to en- setting. For whatever reason, I know way
ination. Now, how applicable are these courage the transition from academic too much about Myasthenia Gravis, and
little details that we miss? That is up for assessment and treatment to real world not enough about how to manage a torn
debate, but overall this process is sup- assessment and treatment techniques hip labrum. Its all about taking these
posed to be lengthy and awkward, be- while allowing Jake to make decisions on tools, appraising them, and figuring out
cause it is something we have never truly what he feels will work with his own which are practical in a real clinical set-
done before. Going through comps in ethos. My experience and my academic ting. This will not only make you more
3rd year CE cannot replicate what you research has found that purely focusing efficient, but it will save the patient’s time
are about to experience in 4th year. In on orthopaedic testing as a stand-alone and money down the long run. Re-
addition to this, the school internship assessment tool is largely ineffective, and sults-driven solutions, in a patient cen-
does not necessarily prepare you for the frankly not evidence-based (Cox, de- tered, time orientated, and costly manner.
real world. Especially with the COVID-19 Graauw, Klein; JCCA 2016). Having I saw so many things, from the nor-
pandemic, this only complicated things said that, it does form the basis of an mal, to the abnormal, including ectopic
further. No class at CMCC can prepare assessment protocol that allows the prac- pregnancy, severe hypertensive head-
you to send a ROF PDF over Zoom and titioner to grow further, but they have to ache and neck pain, and rare neurolog-
then explain how the patient can down- choose to do so. I gave Jake all of my ical disorders. What was more impor-
load it, sign it, and send it back. Once I clinical pearls, my algorithms, and “tricks tant, was seeing all of the different
started my externship, I realized there of the trade” while keeping in mind he subtle presentations and trajectories
was another layer to learn. How to be still had board exams to complete and that low back, hip, neck pain and all
efficient in a 20-minute subsequent ap- encouraging him to keep his brain open MSK presentations can take so that I
pointment. How to get everything done to all angles. can make the best decision for the pa-
– history, physical, and treatment in a

You need to assess, educate,

one-hour initial appointment, and real-
izing that these patients are paying real

adjust, and do your rehab.

money for our services. I quickly learned
from Dr. Klein how to identify and exe-
cute a focused treatment plan.Test, treat,
re-test, give active care advice. How he
was able to do this over a 20 minute Jake excelled on all levels, showing tient AND be effective for them. People
period amazed me at first, but I quickly great competency, connecting with pa- aren’t cyborgs, they are people and we
realized that Dr. Klein, with his experi- tients, and really gaining traction on need to treat the whole person.
ence, prioritizes certain aspects of each what will be required of him once he
condition that he sees (These priorities completes his training. He finished with DR. KLEIN
can change depending on the patient, 467 subsequent visits under his belt, For me personally, I definitely grew as
even if it they have a similar problem). which to me seems like it must be some a doctor. It was a lovely opportunity to
Some patients in the short term truly kind of record! teach, AND be taught. We docs out in
only want pain relief, and some just want practice for 15-20 years still have a lot to
the ability to performed certain function. JAKE ‘THE INTERN’ learn, and this was the best opportunity
Dr. Klein does a good job at siphoning I learned to always keep red flags, yellow for me to do so. CMCC provided a
this out, and dictating the treatment to- flags etc., in mind. I also became more great deal of training and they were very
wards the patient’s needs in an evidence aware of applying the KISS principle: supportive and responsive. From a
based, and efficient manner. The test “keep it simple silly.” What stuck with me practical stand-point, having an extra
aspect is quick and to the point. I learned was the following concept: Abnormal set of hands and eyes in the office al-
I don’t need to do every single shoulder presentations of common conditions, are lowed me to spread the work a little bit,
impingement test to figure out if some- more common, than common presenta- freeing me up to take care of some
one has a shoulder impingement. Apply tions of abnormal conditions. This has business matters which made me a
pertinent tests depending on the sus- brought me a long way with my clinical more efficient business owner, and to
pected condition, and go from there. intuition, and not fearing the worst, but support my teams. So as a doc in the
yet being prepared for it. The treatments field, if you’re wondering if this is for
DR. ERIK I have learned to execute are an expres- you, and you enjoy the idea of paying it
It was an absolute pleasure having [the sion of what we find during the testing. forward. I also encourage CMCC to
now Dr.] Jake in the clinic. There is a Just because someone has PFPS, does make this a permanent option for their
saying that in order to learn, you should not mean to do soft tissue passes over clinical educational program. This is the
first listen, then do, then teach, then every muscle that influences the knee. most patient-centred path forward.
www.Cndoctor.ca September/October 2021 Chiropractic and Naturopathic Doctor 17
FEATURE

PAIN RELIEF

PLATELET
RICH
PLASMA
What is it, and how it fits
into multidisciplinary
treatment plans

N
BY DR. CHRIS SPOONER, ND

aturopathic doctors began using PRP for

tendonosis and tendonitis in the late 1990s.
In the early 2000s, PRP essentially became
viewed as the logical next phase in regen-
erative injection therapy and began to be
adopted by practitioners previously trained
in prolotherapy.
Platelet rich plasma is being utilized in musculoskeletal
medicine with increasing frequency and effectiveness by
providers in multiple specialties. PRP has been success- Platelets are the first to arrive at the site of tissue injury and have the
fully used in various specialties such as maxillofacial, potential to release growth factors that play a critical role in healing.
cosmetic, spine, orthopedic, podiatric and for general
wound healing.1,2 mediating healing. PRP essentially alters cell ratios, by re-
Soft tissue injuries treated with PRP include tendinopa- placing red blood cells which do not stimulate healing and
thy, tendonosis, acute and chronic muscle strain, muscle replacing them with platelets to release growth factors that
fibrosis, ligamentous sprains, and joint capsular laxity. PRP facilitate healing.
has also been utilized to treat intra-articular injuries. Ex-
amples include arthritis, arthrofibrosis, articular cartilage Stages of healing
defects, meniscal injury, and chronic synovitis or joint in- Wound healing is a well-orchestrated and complex series of
flammation. events involving cell-cell and cell-matrix interactions, with
The logic behind PRP is that platelets are the first to growth factors serving as messengers to regulate the various
arrive at the site of tissue injury, and thus have the potential processes involved.
to release growth factors that play a critical role in Normal platelet activation leads to four necessary stages
of healing: Hemostasis, Inflammation, Proliferation, and
DR. CHRIS SPOONER ND, B.SC. is a North Okanagan naturopathic doctor with Remodeling. If any of these stages are incomplete – or if
Photo: © PAstudio / Adobe Stock

20 years of clinical experience. In his private practice, Paradigm Integrative they proceed unabated – tissue homeostasis is disrupted,
Medicine, Dr. Spooner works with patients looking for a balanced approach and pain and loss of function may result.
to health care that combines conventional medicine with research informed With wounds, and also after surgical incisions, repair
integrative approaches. Dr. Spooner has advanced certifications through the begins with platelet clot formation, activation of the coagu-
College of Naturopathic Physicians of B.C., including prescriptive authority. lation cascade, and platelet degranulation with release of
He has been a board member and vice chair of the College of Naturopathic growth factors. The inflammatory process is initiated by
Physicians of British Columbia since 2008. migration of neutrophils and subsequently macrophages to
18 Chiropractic and Naturopathic Doctor September/October 2021 www.Cndoctor.ca
 POST PRP EXERCISE AND
PHYSIOTHERAPY PROTOCOL

The first 48 hours

0-24 HOURS
• Avoid NSAIDs and other • Rest, and avoid loading of the
anti-inflammatory drugs 3 joint and structures where PRP

post PRP involves an days prior to procedure

• Ice and/or cold Laser
was administered
• Light movement

inflammatory immediately following

procedure
• REST

response that should 24-48 HOURS

• Avoid NSAIDs and other (immobilization during sleep if

be monitored to anti-inflammatory drugs

• Avoid ice unless absolutely
needed
needed)
• LIGHT soft tissue to PRP-
treated area and surrounding

ensure that it is not • Avoid weight-bearing or loading

activities
tissue
• Gentle passive range of motion

overly vigorous. Keep active range of motion

gentle and limited
• REST

DAY 3 THROUGH DAY 7

the wound site. Activated macrophages release multiple (BEGINNING THE REGENERATIVE PHASE)
growth factors, including transforming growth factors- • Avoid NSAIDs and other reached by end of 1st week)
and - (TGF-, TGF-), PDGF, interleukin-1 (IL-1), and anti-inflammatory drugs (3X/wk)
fibroblast growth factor (FGF). Shortly thereafter collagen • Begin myofascial release to • Light mobilization to any joint
synthesis begins. This process leads to an early increase in hypertonic muscles and any restrictions (3X/wk)
wound breaking strength, which is the most important scar tissue surrounding injury • Light Proprioception/joint
wound healing parameter of surgical wounds, followed by (3X/wk) stability exercises to
epithelization and the ultimate remodeling process.2 • Ice and electrical muscle associated joints (3X/wk)
Multiple studies have demonstrated a role for plate- stimulation (3X/wk) • Light stretches to shortened
let-rich plasma (PRP) in accelerating and facilitating re- • Gentle passive/active range of muscles (3X/wk)
sponse to injury through enhanced cellular or molecular motion (full ROM should be
activity.1,4–19 Blood plasma and platelets are responsible for
hemostasis, while leukocytes and activated platelets me- WEEK 2 THROUGH 4 (REGENERATIVE PHASE)
diate inflammation, and growth factors derived from • Avoid NSAIDs and other associated joint (2-3 X/wk)
platelet α-granules influence tissue regeneration. Specifi- anti-inflammatory drugs • Continue proprioceptive
cally, the leukocyte content of PRP is thought influence • Continue myofascial release to exercises
the inflammatory phase, while angiogenic and mitogenic hypertonic muscles and any • Stretch and foam roll shortened
growth factor concentrations are believed to aid tissue scar tissue surrounding injury and hypertonic muscles
regeneration.20 (3/wk) • Patient returns for follow-up
The goal of any tissue regeneration therapy is to facil- • Grade 4-5 mobilization to any visit with doctor who
itate the development of a well-organized extracellular joint restrictions (3X/wk) administered PRP injection at
matrix capable of attaining the mechanical performance • Ice and electrical muscle the end of 4th week
and functionality of non-injured tissue. Therefore, it is stimulation (3/wk)
imperative to characterize the molecular constituents of • Functional exercises to stabilize
these therapies when evaluating their efficacies. The cel-
lular response to PRP is influenced by the composition WEEK 5 TO 8 AND FOLLOWING WEEKS AS NEEDED
of the PRP, including the relative concentrations of plate- (FUNCTIONAL PHASE)
lets, white blood cells (WBCs), fibrinogen and fibrin, and • Begin to use natural anti- exercises (3X/wk)
growth factors. inflammatory/NSAID’s (as • Continue progressing through
It must be mentioned that one of the major limitations directed by doctor) proprioceptive exercises
in the field of PRP is that most studies include PRP for- • Myofascial release to hyper- • Begin gait, biomechanical,
mulations obtained by different methods, with different tonic muscles and scar tissue sport-specific training
compositions and characteristics, and therefore the out- surrounding injury (2X/wk) • Stretching and foam rolling as
comes could be different depending on the product used, • Grade 4-5 mobilization to any directed by doctor
even though they are all called PRP. This makes the joint restrictions (2X/wk) • Follow-up visit with injection
comparison among results of different studies often con- • Ice and electrical muscle doc at the end of 8th week
fusing and contradictory.12 stimulation (as needed) • Return to activities when fully
PRP preparation demonstrate great inter-product var- • Continue progressing through functional or as directed by
iability based on the device and preparation methods.21 full weight-bearing functional doctor
Preparations of PRP can vary in many areas, including
www.Cndoctor.ca September/October 2021 Chiropractic and Naturopathic Doctor 19
FEATURE
platelet concentration, number of white blood cells, pres- PRP graft. The following is the protocol that I recommend
ence or absence of red blood cells, and activation status of to my patients for post PRP care.
the preparation. It is beyond the scope of this article to go
into a detailed discussion, but at the very least, the physician Summary
who performed the PRP injection should be able to the the Platelet-rich plasma has been safely and effectively em-
other members of the care team 1) The percent red blood ployed in many areas, including orthopedics, sports medi-
cell concentration; 2) The percent increase in platelet con- cine, dentistry, neurosurgery, ophthalmology, urology,
centration; 3) White blood cell percentage; 4) If the PRP wound healing, cosmetics, cardiothoracic, otorhinolaryn-
was activated and with what; 5) Volume of injection, and 6) gology and maxillofacial surgery. Research has expanded
Whether or no ultrasound guidance was used our knowledge of the role of PRP in the wound healing
process. Initially, it was thought that platelets were used
Integrating PRP into Multidisciplinary Care: solely to assist in clotting. However, it has become clear that
Post PRP Rehabilitation platelets are also responsible for releasing many bioactive
In my experience, multidisciplinary post PRP care can proteins and growth factors responsible for recruitment of
greatly enhance the outcome and I recommend all a patients macrophages, mesenchymal stem cells, and osteoblasts,
consider it. I recommend that PRP be considered after which not only promotes necrotic tissue removal, but also
appropriate first line therapies have been exhausted prior to improves the quality of tissue regeneration and the healing
the utilization of these PRP matrix grafting protocols. These process. Based on this principle, platelets are now used in
include relative rest, appropriate bracing and kinesiotaping, clinical practice to stimulate cells responsible for healing
evaluation of kinetic chain mechanics, and physical therapy and increase healing potential and has demonstrated sig-
– with or without eccentric loading protocols. nificant promise in pain medicine and in treatment of
The first 48 hours post PRP involves an inflammatory chronic injury.
response that should be monitored to ensure that it is not
overly vigorous. In my experience this intensity of the in- For the list of references, please visit cndoctor.ca/
flammatory response is determined by the extent of inflam- PRPinjectiontherapy
mation before the procedure and by the composition of the

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20 Chiropractic and Naturopathic Doctor September/October 2021 www.Cndoctor.ca

CND_BOOKSTOER_SEPT_OCT_HALF_BAS.indd 1 2021-09-01 9:55 AM
 COVER STORY
CONTINUED FROM PAGE 7
controls and to patients with Down
syndrome, Parkinson’s disease and
Huntington’s disease (Blusztain et al.,
1990).
Citocholine is another treatment
option. Citicoline exhibits neurore-
generative effects and activates neuro-
genesis, synaptogenesis, and angio-
genesis and enhances neurotransmitter
metabolism (Martynov & Gusev,
2015). In the IDEALE study testing
for effectiveness and safety of citocho-
line by Cotroneo et al. (2013), 1000mg
of citocholine was administered to 349
patients with mild cognitive impair-
ment. Results found that there were
positive results in the treated group in
comparison to the control group
based on MMSE scores 9 months into
the study (Cotroneo et al., 2013).

DHA
DHA is a component of omega-3 fatty acid which is found in affected our ability to encode memory for regurgitating in
fish oils and plays a role in neuron development. DHA sup- exams, especially with long term memory. In a study done by
plementation significantly promotes neurite growth, synapto- Fan et al. (2019), participants with short sleep duration (de-
genesis, and increases the levels of pre- and post-synaptic fined as less than six hours) had decreased BDNF levels
proteins involved in synaptic transmission and LTP thereby compared with the healthy controls who slept greater than six
improving synaptic function (Cao et al., 2009). A double-blind, hours. There is definitely a need to work with the foundations
randomized controlled trial by Yurko-Mauro et al. (2010) of health including optimizing sleep to improve cognition and
showed that in 485 subjects, those supplemented with 900mg BDNF levels.
daily of DHA had improved learning and memory function. Although these are interventions that show evidence that
there are benefits to addressing cognitive decline, the primary
Considerations care practitioner must first conduct a thorough assessment of
Besides relying on nutraceutical interventions, there are life- the patient. Understanding which cognitive domain is affected
style habits that are foundational to our cognitive health. can provide better insight on which parts of the brain are af-
Ideally, these are considerations that need to be made along- fected and if it truly is cognitive impairment (eg. Focus,
side or prior to nutraceutical interventions. These lifestyle concentration and working memory and the frontal lobe can
changes influence a major neurotrophin. also be misinterpreted as dementia).
One of the most extensively studied neurotrophins is In addition to neurotrophic factors, there is a need to un-
Brain-derived neurotrophic factor (BDNF). In general, the derstand that for any chronic condition there are two sides of
functions of BDNF are related to control of development of the condition. In this case, fortifying synaptogenesis through
neuronal and glial cells, as well as activity-dependent regula- trophic factors and supplementation is one approach, but only
tion of the synaptic structure and its maintenance, which are if underlying processes that impede the neuronal health have
critical for memory and cognition (Kowianski et al., 2018). In been addressed. A holistic, functional approach in addressing
other words, BDNF has a central role in brain plasticity (Ha- cognitive decline is warranted; factors that contribute to the
kansson et al., 2017). expression of B-secretase in creating insoluble amyloid plaque
There are many ways to upregulate BDNF. Basic activities needs to be addressed such as chronic inflammation, dysgly-
include physical activity and sleep. cemia and hyperinsulinemia, toxins and heavy metals, cardi-
Physical activity has been shown to affect BDNF levels. A ovascular health and anemia can impede on the proper
study done by Hakansson et al. (2017) found that even a functioning of the brain. By only primarily supplementing
single 35-minute session of physical exercise had a larger im- patients with trophic agents only depicts one part of the pic-
Photo: © Daisy Daisy / Adobe Stock

pact on serum BDNF than cognitive training or mindfulness ture; without addressing the factors that impede on brain
practice. Physical activity is probably the biggest proponent to health, we are not taking a holistic, functional approach in
cognitive health and cannot be stressed enough! optimizing cognitive health.
Sleep also has a significant contribution to BDNF. Chronic
sleep deprivation has been found to be associated with down-
regulation of hippocampal BDNF (Rahmani et al., 2019). In For the list of references in this story, please visit cndoctor.ca/
reading this, there may be some memories of those days back neurotrophic-dementia
in studying in medical school; these nights of deprived sleep
www.Cndoctor.ca September/October 2021 Chiropractic and Naturopathic Doctor 21
THE BACK PAGE

BUSINESS MINDSET

Trending topics
Get ready for the economic boom BY DR. ELIAS MARKOU, ND

T
he other day I had a favorite Conventional medicine an influx of patients looking for care in
client of ours reach out and stepped back the coming months and years. Patients
asked if we were still open It is no secret that during the pandemic will be looking for regular massages,
during the pandemic. I’d the medical profession stepped back monthly osteopathic visits, alternative
stressed to them that we’ve from treating their patients. They only blood work recommended by naturo-
been open since June 12, 2020 and we took medical emergency appointments. pathic doctors, chiropractic doctors
had continued seeing patients through Many of our clients told us that it was helping people get back on track as they
the pandemic lockdown. They were tough to get an appointment with their resume regular activity dealing with their
excited to hear that we were open and medical doctor, often they had limited aches and pains. What’s interesting is
stressed to me that they had not re- zoom calls for their clients. Many med- that many clinics have pivoted and gone
ceived any treatments over the last year ical doctors would not have in-person online. The future of online practice will
and we’re excited to come and join us visits happening at their clinics,and it be short-lived. Patients will be looking
for their first treatment in a long time was recommended that patients go to for hands-on care and not ZOOM
at the clinic. This got me thinking, if ER when issues arose. We know that the health care. For those clinics that have
this client was one who hadn’t received hospital system was dealing with many survived the pandemic lockdown, pa-
a treatment in the last year and was COVID patients who were reporting tients will be seeking clinics that treat in
very excited to come to resume treat- there with breathing complications. person – they want acupuncture, hands
ment, then how many more patients Doctors at hospitals were overwhelmed on massage care, a chiropractor that will
were out there waiting to come back? with patients with emergency issues adjust. I predict that clinics will be seeing
So this posed a very interesting like cardiovascular episodes, cancer new patient loads, old patients that re-
question for me, when the pandemic and with COVID. The biggest issues quire care, and many new patients that
is over and we’ve reached vaccination we heard were patients were asked by are looking towards natural alternative
herd immunity and all of the busi- government to stay home. Many of medicine to help them with their medi-
nesses are finally open, what will this those patients interpreted that request cal needs. All in all there will be a dra-
mean for clinics across Canada who as meaning stay home, unless they has matic uptick in patient numbers in many
offer alternative medicine like natur- something very serious. Routine blood clinics across Canada.
opathic care, chiropractic, massage, lab visits became confusing and com-
osteopathy and any other alternative plicated for patients – they had to book Get ready for the boom
care? An interesting idea jumped into visits online weeks before I encourage you all in the next
my mind: There is a large cohort of their blood draws. Nowhere few months leading up to the
patients out there who are desperately in the medical conventional We should be end of 2021 to sit down and
craving practitioner care and attention system could you just show seeing an evaluate your marketing plan,
which they have not received for a up anymore for a visit. This influx of the systems you have in place,
year. This got me to conclude that created a lot of anxiety in patients and the staff and professionals
health clinics across Canada should patients when they could not looking for that are ready to deliver care.
get ready for an economic boom in address their health con- care in the As soon as we return back to
2022 that we have not seen for many cerns. We observed during coming normalcy post pandemic, we
years. We will see patients flocking to this time that patient visits months and should be ready for the eco-
clinics in droves looking for care, and patient numbers did years. nomic boom. I see these as
hands-on care, from health profes- increase significantly. exciting times, our professions
sionals in the alternative health care If my observation and hy- will be under the microscope,
space. pothesis is correct, we should be seeing our alternative professionals will be
asked to do a lot from the public as we
DR. ELIAS MARKOU, RHN, R.ACU, ND is one very busy naturopathic doctor. He is in private practice move forward. So it is imperative we
in Mississauga, Ontario and is the clinic director of pureBalance Wellness. Dr. Markou (ND) has been have all of our systems in place. We
a naturopathic doctor for 18 years and has conducted over 100,000 patient visits during this period. should be prepared to tackle every
Dr. Markou is a writer and blogger who is regularly featured in the media. Contact him at drmarkou@ patient and their needs post pandemic.
mypurebalance.ca Get ready for the boom!
22 Chiropractic and Naturopathic Doctor September/October 2021 www.Cndoctor.ca
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