Five Bullet Friday: Women’s Health January 17, 2019

Happy Friday!

Today’s Five Bullet Friday:

1. A Clarification of Use of Mesh in Gynecological Surgeries from the President of the AAGL

2. NEW Guidelines for Recurrent UTIs, 2019

3. Heavy Menstrual Bleeding Common in Teens and Requires Multidisciplinary Care

4. Weight & Major Psychiatric Disorders Genetically Linked

5. Improve Sleep by Losing Fat from Your Tongue?

Five Bullet Friday: Women’s Health is meant to be a quick, easy to skim resource for you and other health and medical professionals to keep you up to date with all things related to women’s health. My goal for these emails will be to bring to you pertinent and helpful resources for patients (such as short videos or handouts), new research and guidelines, clinical pearls, or anything else interesting related to women’s health! If you’d like to be added to my email list to receive my Five Bullet Friday: Women’s Health, or if you would like suggest particular topics you are eager to hear about, please send an email to cassie@tayloredtraining.ca.

Thank-you, and happy reading!

  1. A Clarification of Use of Mesh in Gynecological Surgeries from the President of the AAGL

President of the American Association of Gynecologic Laparoscopists (AAGL) recently commented on the announcement from the US FDA which recalled transvaginal mesh used for the treatment of pelvic organ prolapsed (POP).

Dr. Fidela Paraiso explained that there is an important distinction that many people aren’t realizing: the FDA recalled surgical mesh for some – but not all – procedures related to pelvic floor disorders, which some media sources are not disclosing that subtlety.

Dr Fidela Paraiso furthers that the mesh itself is not defective and that the recall only applies to repairing of POP. It has not, however, been recalled when the mesh is inserted through an abdominal incision for POP repair, nor mesh used in midurethral sling procedures for the treatment of stress urinary incontinence.

For more details on the difference between the use of mesh for POP repairs and for the treatment of stress urinary incontinence, please see Dr. Fidela Paraiso’s full explanation in the reference below.

Ref: Click here for Link

2. New Guidelines for Recurrent UTIs – 2019

Uncomplicated urinary tract infection is one of the most common indications for antimicrobial exposure in otherwise healthy women. We are obviously concerned with overuse of antibiotics as it has led to drug-resistant organisms in the past 20 years. Because of this, new guidelines were created and published in the Journal of Urology in 2019 to help guide treatment of recurrent UTIs.

Note: recurrent UTIs are defined as two culture-proven UTIs in a 6-month period, or three culture proven events in 1 year. The following guideline is heavily focused on treating not only symptoms, not only cultures, but rather the important combination of symptoms combined with positive cultures. This new guideline is an important step in helping physicians reduce the “collateral damage” or over-prescription of antibiotics to slow the rate of development of antimicrobial resistance.

2019_UTI_Guidelines

Ref: Anger, Jennifer & Lee, Una & Ackerman, Roger & Chou, & Chughtai, Bilal & Clemens, J. & Hickling, Duane & Kapoor, Anil & Kenton, Kimberly & Kaufman, Melissa & Rondanina, Mary & Stapleton, Ann & Stothers, Lynn & Chai, Toby. (2019). Recurrent Uncomplicated Urinary Tract Infections In Women: Aua/Cua/Sufu Guideline. Journal of Urology. 202. 10.1097/JU.0000000000000296.

3. Heavy Menstrual Bleeding Common in Teens and Requires Multidisciplinary Care

The reported prevalence of heavy menstrual bleeding in adolescents ranges from 34% to 37%, authors Dr. Borzutzky and Dr. Jaffray note in their recent paper.

This can lead to anemia, fatigue, and hemodynamic instability which may result in ED visits, hospital stays, the need for transfusion and oral or intravenous therapies to stop blood loss.

Authors say it is important to distinguish the etiology of this in adolescent girls to guide treatment, which can include hemostatic medications, hormonal agents, or a combination of both. They also note that historically the evaluation of heavy menstrual bleeding has been predominately the role of a primary care clinician or gynecologist, but given that a high prevalence of female individuals (specifically adolescents) with heavy menstrual bleeding have underlying bleeding disorders, hematologists should also have a prominent role.

Ref: Borzutzky C, Jaffray J. Diagnosis and Management of Heavy Menstrual Bleeding and Bleeding Disorders in Adolescents. JAMA Pediatr. Published online December 30, 2019. doi:10.1001/jamapediatrics.2019.5040

4. Weight & Major Psychiatric Disorders Genetically Linked

New research shows that there appears to be a robust genetic link between body weight and major psychiatric disorders, an international research team has concluded.

Using data from more than a 500,000 individuals with major depression, bipolar disorder, and schizophrenia, the investigators showed extensive genetic overlap between body mass index (BMI) and psychiatric disorders. Interesting, they found that although the genetic risk variants for major depression and bipolar disorder were primary associated with increased weight, the majority of genetic variants for schizophrenia were related to reduced weight.

Authors found this quite interesting, because essentially this meant that if people had a susceptibility for increased BMI they were also likely to suffer from depression or bipolar disorder, but for schizophrenia it was the opposite: if they were at risk of schizophrenia, they were less likely to be obese. They conclude that increased body weight in schizophrenia seems to be directed mainly by diet, lifestyle, and side effects of mediation, but that it is a completely different picture with bipolar disorder and depression.

Authors further conclude that, “aligned with epidemiological findings, [their] results underscore the importance of considering both metabolic and psychiatric factors when trying to understand and treat mental illness effectively.” They are hopeful that this could lead to more prediction tools and better treatment choices for individuals with severe mental disorders.

Ref: Bahrami S, Steen NE, Shadrin A, et al. Shared Genetic Loci Between Body Mass Index and Major Psychiatric Disorders: A Genome-wide Association Study. JAMA Psychiatry. Published online January 08, 2020. doi:10.1001/jamapsychiatry.2019.4188

5. Improve Sleep by Losing Fat from Your Tongue?

A new study published in the American Journal of Respiratory and Critical Care Medicine just this month discovered that reducing the amount of fat in your tongue improves sleep apnea.

Previous research has shown that obesity is a key risk factor for sleep apnea, and that those who are obese who suffer from the condition tend to have considerably larger tongues with a higher percentage of tongue fat than obese people who do not suffer from sleep apnea.

So, how do you trim down your tongue fat? It comes down to overall body fat loss, the study found. “This study shows reducing excess fat in general can reduce tongue size. [And] the more tongue fat you lost, the more your apnea improved”.

This leads authors to believe that tongue fat is a potential new therapeutic target for improving sleep apnea, and they suggest future studies explore whether certain diets are better than others in reducing tongue fat, and whether cold therapies might be applied to reducing tongue fat.

Ref: Stephen H. Wang, Brendan T Keenan, Andrew Wiemken, Yinyin Zang, Bethany Staley, David B. Sarwer, Drew A. Torigian, Noel Williams, Allan I Pack, Richard J Schwab. Effect of Weight Loss on Upper Airway Anatomy and the Apnea Hypopnea Index: The Importance of Tongue FatAmerican Journal of Respiratory and Critical Care Medicine, 2020; DOI: 10.1164/rccm.201903-0692OC

Splints and Orthotics of No Benefit for Achilles Tendinopathy

A recent systematic review with meta-analysis (for those non-science folks reading one of the highest quality studies you can have!) looked at a common treatment options for Achilles tendinopathy: exercise, orthotics and splinting.

What they Measured:

Researchers measured function, pain and quality of life for managing Achilles tendinopathy, and analysis 22 studies with over 1100 participants.

What they Found:

Exercise improved pain and function while splinting at night and wearing orthotics provided no benefit to pain, function, or quality of life.

What this Means:

If you’re dealing with Achilles tendinopathy then seek the guidance and assistance of a physiotherapist who can coach you with the best exercises that are appropriate for you and your injury to get you feeling and moving better!

Don’t waste your money or effort on things like orthotics or splints that make no difference in your pain, function, or quality of life !

📖Study Link HERE

Whole Body Cryotherapy and Ice: Worth the Hype?

Whole Body Cryotherapy seems to be the latest rage, touting amazing benefits for all. But, is it really worth all the hype?

Key Points (for those of you who want the Coles Notes)WBC

  • Whole body cryotherapy is an inferior method to cooling subcutaneous and core body temperatures
  • Placebo is likely largely responsible for the positive effects of cryotherapy
  • Definitive evidence shows that cryotherapy (cold water immersion) does NOT enhance adaptations to exercise training
  • Not only this, but cryotherapy (cold water immersion) has been shown to negatively impact cell proliferation and muscle hypertrophy

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Whole Body Cryotherapy is a recent fad that purports to enhance your recovery after exercise, improve mobility, relieve arthritic pain and facilitate rehabilitation post injury.

What exactly is Whole Body Cryotherapy (WBC)? It is a large metal chamber that is filled with nitrogen gas at an ultra-low temperature of less than -100 degrees Celsius (often reaching as low as -150 degrees Celsius). Users walk in to this cold metal chamber and stay there for about 2.5 minutes.

Advocates of Whole Body Cryotherapy preach that this method of cooling is superior due to its extreme temperatures, and sell [decently expensive] sessions to paying clients to help them reap all of these aforementioned benefits.

So, is this really the miracle cure for delayed onset muscle soreness (DOMS – the soreness associated with working out), poor mobility, pain, and/or injury?

It’s time we take a closer look at the evidence, and to do so we are going to focus on TWO specific areas of research:

  1. The effectiveness of Whole Body Cryotherapy versus other simple forms of cryotherapy (such as Cold Water Immersion (a cold bath) and a simple Ice Pack)
  2. The Benefits of Cryotherapy (cold therapy), Period.

Lets jump in.

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The Effectiveness of Whole Body Cryotherapy versus other simple forms of cryotherapy (ie cold water immersion and ice pack application).

There is currently no strong evidence that Whole Body Cryotherapy offers any distinct advantage over traditional (read: easy, self-administered and cheap) methods of cryotherapy – such as cold water immersion or ice pack application.

Proponents of Whole Body Cryotherapy claim that because of the extremely low temperatures in the chamber it is a superior method of cooling the body.  However in truth, compared to water and ice, air has significantly lower thermal conductivity at 0.024 K vs 0.58 K (water) and 2.18 K (ice). (1,2)  (Note, K is a measure of thermal conductivity or a materials ability to transfer temperature.)

What this means is that air, as a material to transfer temperature, actually prevents significant subcutaneous and core body cooling compared to the other two methods. (2)

Delving further in to this, studies have found lower surface skin temperatures following a session of Whole Body Cryotherapy vs cold water immersion or a simple application of an ice pack.

One particular randomized controlled study looked at skin temperatures of the knee – a bony area highly susceptible to temperature change.

(Note the relevance of using the knee – Subcutaneous adipose tissue has a very low thermal conductivity, meaning it has an insulating effect on the body. What this means is that certain areas of the body will be more susceptible to a reduction in temperature with application of cryotherapy, with bony regions such as the patella (knee) generally experiencing the largest reduction in tissue temperatures (1,2,3).)

This study found that that 10-60 minutes post treatment surface knee temperatures were lower in the cold water immersion group versus the Whole Body Cryotherapy group.

What that means is that even in areas of the body that have very little adipose tissue and are mostly bony, Whole Body Cryotherapy was an inferior modality 10-60 minutes post treatment.

And these findings weren’t the only ones determining that these chambers were inferior to other methods of cryotherapy.

In a study looking at exercise induced muscle damage, soreness and function after strenuous exercise (4) results showed that greater reductions in blood flow and tissue temperature were observed after cold water immersion in comparison to Whole Body Cryotherapy.

Another study again compared cold water immersion and Whole Body Cryotherapy on recovery kinetics after exercise-induced muscle damage. This study found that again cold water immersion was more effective effective in accelerating recovery kinetics for performance at 72 hours post exercise and demonstrated lower soreness and higher perceived ratings of recovery (5).

 I don’t mean to get to science-y on you, but everything I just said above is a lot of research that shows that the expensive, gimmicky cold chamber is no better (and actually in some cases it is inferior) to other methods of cryotherapy which are mostly easy to self-administer and … well, free.

Key takeaways from this research?

  • Whole Body Cryotherapy is actually inferior to cold water immersion and simple ice pack application when it comes to thermal conductivity, preventing significant subcutaneous and core body cooling.
  • Cold water immersion was found to be superior to Whole Body Cryotherapy in accelerating recovery kinetics as well as levels of soreness and perceived ratings of recovery.

Okay, so cold water and ice packs work the same or better than those huge cold chambers. But, should we even be icing in the first place? This brings us to the second part of this article, or second focus of research:

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The Effect of Cryotherapy, Period

Okay, so we now have some evidence demonstrating that Whole Body Cryotherapy isn’t actually superior to other methods of cryotherapy including cold water immersion and ice pack application but that it is actually inferior.

But what about cryotherapy in general. What is the evidence backing its use?

A recent study just published this month looked at the effects of cryotherapy (like the above studies, cold water immersion and Whole Body Cryotherapy was used) vs placebo on markers of recovery following a marathon (6).

Results indicated that either form of cryotherapy was NO MORE EFFECTIVE than placebo at improving function, recovery or perceptions of training stress following a marathon. Not only this, results demonstrated that Whole Body Cryotherapy actually had harmful effects on muscle function compared to cold water immersion post marathon, including a negative impact on muscle function, perceptions of soreness and a number of blood parameters. (6).

Another randomized control study looked at the difference between a placebo and cryotherapy by looking at the recovery of the muscle strength 48 hours after an acute high intensity interval exercise session. Results showed that the recovery placebo was superior in the recovery as compared to cryotherapy (7).

These results lend strong evidence that shows that placebo may be largely responsible for the beneficial effects of cryotherapy.

Another recent paper (8) looked specifically at cold water immersion and the tenet that it enhances post-exercise recovery and resilience, thereby leading to greater adaptations to training. The author of this paper explained how evidence supporting this idea was very much lacking, and outlined two of his studies designed to find out more.

The first study measured muscle mass (using an MRI) and strength in two groups before and after a twice weekly exercise program for three months. One group performed active recovery for ten minutes after each exercise session (low intensity cycling) and the other performed cold water immersion for ten minutes. Results demonstrated that both groups gained muscle mass and strength, but that these gains were significantly smaller in the cold water immersion group compared to the active recovery group. Even more, the cross sectional area of type II (fast twitch) muscle fibres also only increased in the active recovery group.

This is definitive evidence against the idea that regular cold water immersion enhances adaptations to exercise training.

The second study performed looked at men who completed two separate session of resistance exercise on separate days and with separate legs. Researchers analysed blood samples and biopsies before exercise and 2, 24, and 48 hours after.

They found that exercise activated processes in the signalling pathway and stimulated cell proliferation and proteins that regulate muscle hypertrophy. In contrast, these processes were significantly attenuated following cold water immersion.

Inflammatory markers in the blood were also looked at and it was found that there were no significant different between the cold water immersion and active recovery treatments.

This is the first evidence in humans (there has been other evidence in animal studies) that is against the idea that cold water immersion provides anti-inflammatory benefits in muscle after exercise (8).

This shows that not only does cold water immersion not improve inflammation, but it seems to actually negatively effect our bodies ability to adapt to exercise training.

Key Takeaways from this research?

  • Cryotherapy is no better than placebo at improving function, recovery or perceptions of training stress
  • Cryotherapy reduced the amount of cell proliferation and proteins stimulating muscle hypertrophy leading to smaller muscle and strength gains
  • Cryotherapy did not show anti-inflammatory benefits in muscle after exercise

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In Conclusion:

When I started writing this article I truthfully did not intend for it to be so long. But when I got in to my research I saw SO many studies – many of them GOOD quality, randomized controlled studies – that simply needed to be discussed!

We have always believed that ice is the way to go for any sort of muscle damage, be it from an injury or from high intensity exercise. The fact that current research shows that it simply is not the best option anymore is one that is hard to swallow for many people, as they have spent their lives recommending or using ice. It is also these beliefs that we’ve held on for so long, that makes the idea of Whole Body Cryotherapy and all it touts to offer seem so appealing.

But, if you sit down and go through the evidence… I think you will see that there are many cheaper, easier, and most important better options out there.

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References:

  1. Costello J, McInerney CD, Bleakley CM, Selfe J, Donnelly A. (2012) The use of thermal imaging in assessing skin temperature following cryotherapy: a review. Journal of Thermal Biology, 37:103–110.
  2. Bleakley, C., Bieuzen, F., Davison, G., Costello, J. (2014). Whole-body cryotherapy: empirical evidence and theoretical perspectives. Open Access Journal of Sports Medicine, 5:25-36.
  3. Costello, J., Donnelly, A., Karki, A., Selfie, J. (2014). Effects of whole body cryotherapy and cold water immersion on knee skin temperature. International Journal of Sports Medicine, 35(1): 35-40.
  4. Mawhinney, C., Low, D., Jones, H., Green, D., Costello, J., Gregson, W. (2017). Cold water mediates greater reductions in limb blood flow than Whole Body Cryotherapy. Medicine and Science in Sports and Exercise, 49(6): 1252-1260.
  5. Abaidia, A et al. 2017. Recovery from exercise induced muscle damage: cold-water immersion versus Whole Body Cryotherapy. International Journal of Sports Physiology and Performance, 12(3): 402-409.
  6. Wilson, L et al. 2018. Recovery following a marathon: a comparison of cold water immersion, whole body cryotherapy and a placebo control. European Journal of Applied Physiology, 118(1): 153-163.
  7. Broatch, J., Petersen, A., Bishop, D. 2014. Postexercise cold water immersion benefits are not greater than placebo effect. Medicine and Science in Sports and Exercise, 46(11): 2139-2147.
  8. Peake, J. Cryotherapy: Are we freezing the benefits of exercise? Temperature, 4: 211-213.

 

First Sleep, then Coffee.

The Newest Research Links Pain and Sleepiness.

coffee-mug

A new research study from Harvard Medical School brought together researchers from a pain and sleep background to look at an area not yet well studied: does sleep, or lack thereof, influence pain?

Researchers from Boston Children’s Hospital and Beth Israel Deaconess Medical Centre determined that decreased sleep increases pain sensitivity, though this isn’t all too surprising. What was surprising, however, was the role of alertness in pain sensitivity.  You see, researchers found that even with sleep loss, the more alert subjects were (for example had they been given caffeine), the less sensitive to pain they were.

In other words, the more sleep subjects had the less sensitive to pain they were; however, if they were deprived of sleep they experienced less sensitivity to pain than their other sleep deprived counterparts if they were given medications that promoted wakefulness, such as caffeine. Not only that, but these medications promoting wakefulness actually worked better than standard pain medications such as ibuprofen and morphine!

Let’s go through in more details:

The Study

Researchers looked at normal sleep cycles using EEG and EMG readings in mice. They then proceeded to deprive the mice of sleep. In a unique methodology, however, they tried to mimic the way most humans would lose sleep: they entertained them!

Essentially what this means is that they kept the mice subjects awake in a non-stressful manner (as opposed to making them run on the treadmill or fall off platforms as other studies frequently have done). Subject mice got to play with toys and do fun activities (similar to how us human counterparts may scroll through facebook, or watch late night TV). During there sleep deprived entertainment, researchers monitored the mice’s sleepiness, their levels of stress hormones (to make sure the mice weren’t stressed out) and tested their response to both painful and non-painful stimuli.

Pain sensitivity was measured by how long it took the subject to move away from a painful stimulus (heat, cold, pressure, or capsaicin – the agent in hot chili peppers), while non painful stimuli included looking at the subjects startle response to loud noises.

The Results

Findings of the study demonstrated that in otherwise healthy mice even just five consecutive days of moderate sleep deprivation significantly exacerbated pain sensitivity. This was specific to pain and common painkillers including ibuprofen and even morphine, a strong painkiller, did not block the pain hypersensitivity that was induced by the sleep loss.

However, researchers did find an interesting result that caffeine and modafinil, drugs that promote wakefulness, successfully blocked the pain hypersensitivity caused by both acute and chronic sleep loss.

What it All Means

This study is a great example of learning more about the sometimes complicated ties of lifestyle to both chronic and acute pain and tells us a lot about some new future areas of study.

Sleep is critical in all areas of our life, including managing our pain. Even acute sleep deprivation can worsen pain and can lead to a vicious cycle of pain and poor sleep quality. Therefore working on your sleep hygiene and ensuring you get sleep and avoid the distractions before bedtime can play an important role in feeling better.

Does this study mean you should go out and pump yourself up with wakefulness promoting drugs, like caffeine? No – remember, so far this study has only been done on mice – but it is an interesting note to think about. Because perhaps it is something we will need to consider in the future, as according to the authors, “This represents a new kind of analgesic that hadn’t been considered before, one that depends on the biological state of the animal…. Such drugs could help disrupt the chronic pain cycle, in which pain disrupts sleep, which then promotes pain, which further disrupts sleep.”

Key Takeaways

  • Acute and chronic sleep deprivation increases pain sensitivity
  • Painkillers such as ibuprofen and morphine may not block this hypersensitivity from sleep loss
  • Caffeine, and other wakefulness promoting agents, did seem to improve pain sensitivity when sleep deprivation had occurred.

Read the full study here, or read a bit more about the importance of sleep on injury and performance with a previous article of mine, here.

Questions, let me know!