Many people experience popping in their hips. Most patients come to the clinic complaining of back or knee pain, and a popping hip may be a secondary complaint. Although typically not a significant pain generator, popping in the hip is a sign of an underlying dysfunction in the hip needing to be addressed. If the popping in the hip is not attended to, more serious orthopedic issues may arise down the road.  

Causes

There are three main causes of a popping hip – external, internal, and intra-articular. External is most frequent and refers to the iliotibial (IT) band snapping over the greater trochanter of the femur. Internal is also common and refers to the iliopsoas (hip flexor) tendon snapping over a bony prominence on the pelvis or at the lesser trochanter of the femur. Intra-articular is least common and refers to a floating loose body within the joint such as a torn labrum. External and internal variations are often due to gradual onset, whereas an intra-articular loose body is often due to trauma. There is a higher incidence of hip popping in females, especially those who perform sports requiring repetitive flexion and extension of the hip such as gymnastics, dance, soccer, and running.  

How to fix it 

Popping in the hip is often related to a stability issue in the hip or the core. To address this, work to improve your hip stability in all three planes of motion. Train slowly, controlling the motion to avoid the pop. Train only through ranges of motion where you can avoid the pop, and gradually increase the range of motion as your stability improves. The external hip pop (ITB over greater trochanter) is often related to poor hip stability in the frontal plane (abduction/adduction), and increasing strength of muscles such as the gluteus medius will be helpful in decreasing the external hip pop. The internal hip pop relates to the iliopsoas muscle. The iliopsoas muscle has shared attachments with the diaphragm. If the diaphragm is not providing a solid anchor point for the iliopsoas muscle, function of the hip flexor will be impaired increasing the likelihood of an internal hip pop. For this, focus working on diaphragmatic breathing to create better stability patterns in your core. Intra-articular hip popping requires an in-depth examination to determine which structures may be injured and to determine the best course of care.

To know exactly which exercises and treatments are best for you, it is important to seek out a therapist who understands hip biomechanics and can help you address the specific stability limitations causing the pop. Whatever the cause, popping in the hip should not be ignored. Even if caused by mild muscle imbalance, a popping hip can worsen over time if not addressed early.  

Post written by Dr. Riley Kulm.  Check out his bio here.

Goal setting has been touted as the most effective way to achieve success in life.  We’ve been told to write them down, stick them to our refrigerator door and even to write them on our bathroom mirror.  You’ve heard that goals should be SMART – specific, measurable, attainable, realistic, and time oriented.  I even wrote a blog post on effective goal setting.  Recently, I’ve moved away from goal setting with both myself and my patients, focusing instead on daily habit formation and the implementation of routines that set you up for success now and in the future.  The inspiration for this change came after listening to the Atomic Habits audiobook by James Clear.  Clear argues that goals are easily procrastinated upon, and can often be too daunting to even get started in the right direction.  By focusing on daily habits and routines, you will improve yourself each day, setting yourself up to achieve success and ultimately to conquer even the loftiest of goals. 

The problem with goal setting

One of the main problems I see with goal setting is that time oriented goals are susceptible to procrastination.  If my goal is to lose 20 lbs. by the end of the year, it’s very easy to let myself wait until 6 or even 3 months are left in the year to start working towards the goal.  Why start now when I have an entire year to accomplish my goal?  A goal that is set out over a year may lose steam after a couple of months, which is what I commonly see with patients looking to make health changes at the beginning of the New Year.  Everyone knows that you will see more people out walking in your neighborhood or exercising at the gym in January, February and March only for it to taper off as the year progresses.  Rather than setting a time oriented goal, instead pick daily habits that will incrementally help you achieve whatever you envision for yourself.

Define your ideal self

Before completely throwing away your list of goals, make sure you have a clear idea in your mind of what you want for yourself.  Envision your ideal job, body composition, and skill set.  Where do you see yourself in 5 or 10 years?  Where do you want to be financially?  How do you define your ideal self?  Once you’ve established these parameters, you are better suited to implementing daily habits that align with this vision.  If you envision yourself as having a fit and healthy body, implementing a daily habit that helps you save money or be more organized doesn’t necessarily bring you closer to your vision.  Instead, for weight loss, pick habits such as a consistent gym routine, a healthy breakfast at the same time each morning, or reading a book before bed to help promote optimal sleep and recovery.  

Do this instead

As stated previously, the alternative to goal setting is the implementation of daily habits and routines.  Habit formation is beneficial because it focuses on daily growth.  If we aim to grow and improve ourselves little by little each day, the culmination of consistent work will be incredible in the long term.  We may not notice the improvements on a day to day, micro level, however, if we step back after a year and look at the macro improvement the results are substantial.  True growth and change does not come with drastic lifestyle changes such as an extreme 10 day fast or juice cleanse but rather with small steps each day in the right direction.  

 

Next, I show you how to reframe your goals into daily habit formation.

Goal #1: ‘I want to lose 20 lbs. before summer’

Habit: I will work to implement a habit where I do 3 sets x 15 push-ups in the morning followed by drinking a 16 ounce glass of water.  

Habit: Weather permitting, I will go outside in the morning for a 10 minute walk in the sunshine before work.

(First morning exercise and sunshine stimulates cortisol release and helps to regulate our circadian rhythm.  Sufficient cortisol release in the AM will decrease cravings for fried and sugary foods in the evening which occurs if cortisol levels remain high.)

Habit: I will place a pan, plate, and eating utensils out in my kitchen before I go to bed each night.  Already having the pan on the stove increases the likelihood that I will cook a homemade breakfast and adopt a more consistent eating schedule that includes breakfast each day.

 

Goal #2: ‘I want to increase my sales at work by 15% this year’

Habit: I will wake up at the same time every day to ensure a consistent sleep schedule and to increase my productivity at work. 

Habit: I will call 2 potential new clients each day prior to leaving for lunch.

Habit: I will send a thank you card to 2 existing clients each week thanking them for their business.  

For work related goals, consider setting up a daily, weekly, and monthly checklist in a binder or whiteboard to track progress of tasks to be completed.  Make these tasks part of your habits at work and you will see your productivity increase.

 

Goal #3: ‘I want to improve my relationship with my parents’ 

Habit: Each morning I will practice gratitude by writing down 3 things in my life that I am grateful as part of a journaling routine. 

Habit: I will call one of my parents every Friday after work to check in.

 

Goal #4: ‘I want to be more organized’

Habit: Each morning I will make my bed as the first task to be completed in my day.  Making your bed each morning sets yourself up for success throughout the rest of your day and helps you to establish a task completion mindset.

Habit: Each morning when my coffee is brewing I will take 5 minutes to tidy up my living room so I leave for work with an organized living space. 

 

Goal #5: ‘I want to get better sleep this year’

Habit: I will develop a habit where I turn off all electronics at least 1 hour before bed time.  Blue light exposure stimulates cortisol release at the wrong time of day and will make falling and staying asleep more difficult. 

Habit: Prior to going to bed I will write out tomorrow’s ‘To Do’ list in a journal that I keep by my night stand.  Getting tomorrow’s tasks written down will give you peace of mind and allow your brain to turn off before going to sleep.

Habit: I will read for 20 minutes before bed.  Reading, especially fiction, gives your brain a singular point of focus, and helps you get your mind off of the day’s stresses.  

 

I hope this article gives you valuable insight into daily habit formation and the power it can have.  I finish with a quote from W.H. Auden – ‘Routine, in an intelligent man (or woman), is a sign of ambition.’

Post written by Dr. Riley Kulm, DC.  Check out his bio here

My Least Favorite Exercise Part 2 – The Quadricep Knee Extension

Continuing with the theme of our last blog post My Least Favorite Exercise – The Clamshell, I’d like to highlight another popular exercise that should be avoided at all costs.  This week, my least favorite exercise is the quadricep knee extension exercise.  I regularly see people at the gym using the quadricep knee extension machine, and I truly worry about their orthopedic health when I’m watching them.  To perform the machine based knee extension exercise, people sit in a chair with a pad on their shins.  Next, they kick their legs straight against the resistance of the machine, contracting the quadriceps muscle.  People perform this exercise because they want to improve the strength and size of their quadriceps muscle – some may even think it’s healthy for their knees; however, the biomechanical consequences of this exercise can be highly detrimental to the health of your knees.  

Open vs. closed chain exercises

The machine based knee extension is a single joint, open chain exercise.  Open chain exercises refer to movements where the distal extremity (hand or foot) is not fixed and is freely moving in space with or without external resistance.  Examples of open chain exercises include a bicep curl, hamstring leg curl, and shoulder fly.  Open chain exercises cause an isolated muscle contraction over a single joint of movement, which some believe to be beneficial in the early stages of an injury rehabilitation program.  Open chain exercises are in contrast to ‘closed chain exercises’ where the hand or foot is fixed to the floor.  Examples of closed chain exercises include the squat, deadlift, or push up.  Closed chain exercises involve multiple muscle groups and require coordinated muscle contractions to complete the compound (multi-joint) movement.  

The forces imparted on the joints differ between open and closed chain exercises.  For open chain exercises (quadricep knee extension) the force imparted by the weighted resistance is transmitted back up the leg and into the knee joint.  This force can cause compression in the knee joint, putting increased pressure on the meniscus, ACL, PCL, and patella-femoral joint.  In contrast, with closed chain exercises (deadlift) the force imparted by the external resistance is transmitted into the ground.  For instance, in a deadlift, the force from the load is pressed through the feet into the ground rather than up the body into the knees and hips.  

The second problem with the exercise is that it is a repetitive concentric exercise.  Remember from my last post, concentric muscle contractions occur when the muscle is shortening and repetitive contractions over time can cause a shortening and tightening of the muscle fibers even while at rest.  Ignoring the eccentric (muscle lengthening) component of a muscle’s function can be detrimental to movement patterns and ultimately put you at an increased risk of injury.  Additionally, a short and tight quadriceps muscle can pull upwards on the patella, altering the mechanics of the patella-femoral joint and cause conditions such as patellar tendinitis which is also known as Jumper’s knee.  

What to do instead – deadlifts, squats, single leg squats, reverse lunges

If you want to strengthen your quads and the rest of the muscles in your leg, the best exercises are closed chain, compound movements that integrate the feet, hips, and core to create a functional and stable lower body.  My favorites are deadlifts and lunges because you can add a lot of weight without placing much force on the knee joint (when performed properly). 

As I said previously, closed chain exercises like the squat and lunge transmit force down into the ground, which is why they are popular for building speed and explosiveness in strength and conditioning programs. 

Post written by Dr. Riley Kulm, DC.  

Check out his bio here.

The most common hip exercise I see prescribed to patients for hip pain is the ‘clamshell’.  The clamshell exercise, shown in the picture below, is commonly used to increase the strength of the gluteus medius muscle with the goal of improving hip stability. The clamshell is prescribed for conditions such as hip impingement, low back pain, or knee pain, and is commonly used to strengthen the glutes during post surgical knee rehabilitation programs. While the clamshell targets the gluteus medius muscle, one of our main stabilizers of the hip, there are functional limitations to the exercise which can cause adverse effects on a patient’s movement patterns and overall function of the lower extremity. 

The issue with the clamshell exercise is it is a repetitive concentric exercise. A band is used around the knees to create resistance of the top leg moving into abduction (leg moves away from body). The gluteus medius is a primary hip abductor, and is thus contracted when the patient separates the top knee away from the bottom against the band’s resistance.  A ‘concentric’ muscle contraction refers to a contraction where the muscle shortens as it contracts. This is in contrast to an ‘isometric’ contraction where muscle length does not change during contraction, and also an ‘eccentric’ contraction where the muscle contracts while lengthening. The problem with only training the concentric phase of muscle contraction is over time the muscle fibers will become short and tight. Remember, muscle fibers are shortening during a concentric contraction, and doing so repeatedly will cause a gradual tightening of the muscle.  A short and tight muscle often equals a weak muscle and weakness in the gluteus medius muscle puts your low back, hips, and knees at risk for injury.  Muscle function should be a coordinated blend of isometric, concentric, and eccentric contraction to maintain proper muscle function and physiology.  

To determine if you have a short and tight gluteus medius not functioning properly, look for a ‘gluteal hollow’ – a concavity easily visualized on the outside portion of the glute complex.  While some believe hollow hips to be aesthetic, they indicate poor function and stability of the hip. Ideally, the glute complex should be full and round with no hollowing.  Notice the hollowing in the hips of the bodybuilder below.  The athlete is overdeveloped in the gluteus maximus muscle and underdeveloped in the gluteus medius and gluteus minimus muscle.  Despite having an impressive muscular build, the function and stability of this athlete’s hips are suspect.  Contrast the bodybuilder’s hips with the athlete on the right.  The football player on the right has a round and full shape throughout the entirety of the glute with little to no hollowing in the outer aspect of the hip.  The football player has strong and stable hips in all planes of motion allowing him to jump, change direction, and accelerate effectively.  

What to do instead –  the DNS 7 month hip lift exercise

If your goal is to strengthen the gluteus medius muscle and improve hip stability in all planes of motion, the Dynamic Neuromuscular Stabilization (DNS) 7 month hip exercise is your go to movement.  The DNS 7 month hip exercise linked here, is a movement pattern based on the 7 month developmental pattern as outlined by the Prague School of Rehabilitation. The 7 month hip lift is a transitional movement from a side sitting position into a quadruped position, and it incorporates all 3 phases of muscle contraction for the gluteus medius muscle.  

To perform, lay on one side with your hip flexed to just below 90 degrees. Initiate the movement by rotating your pelvis forward on top of the bottom leg. Doing so will lengthen the gluteus medius on the bottom side and you may even feel a stretch in the hip. Once the pelvis is fully closed down on top of the bottom leg, load weight into the bottom knee and use your strength to lift your hip off of the ground. You should feel the muscle contract on the outer portion of the bottom hip (gluteus medius).  Hold at the top for 2-3 seconds and then slowly lower down to the ground. Focus on slow and controlled raising and lowering of the hip, which forces your body to coordinate isometric, concentric and eccentric contractions – closely replicating the demands placed on the gluteus medius muscle during sport and everyday life. Start with 3 sets of 6 reps for this exercise. Expect to be sore in the outer hip as this exercise is challenging and forces the gluteus medius to function in ways it may not have for a while.  

Post written by Dr. Riley Kulm, DC.  

Check out his bio here.

 

 

After a car accident your ‘to do list’ may be long – get your car fixed, find an attorney, file a claim with your insurance agent, find a rental car to get to and from work, etc. For most, the damages to your body are less of a concern in the initial stages following an accident. Unfortunately, many do not know where and how to find treatment for their injuries. Without the guidance of someone who understands the system, it’s possible to get taken advantage of as there are extensive legal businesses built around profiting from MVAs. In this post I’ll describe some of the most common injuries sustained during MVAs, as well as give you insight into the medico-legal process and how to make sure you get the care you deserve. 

Opt into MedPay

In Colorado it is state law every insurance company provides their drivers with a minimum $5,000 Medical Payments Coverage (MedPay) policy in addition to their automobile liability policy¹. MedPay should be included on any insurance policy by default and is against state law for an insurance company to deny a customer MedPay.  The $5,000 policy provides coverage for the driver, as well as the passengers in the insured driver’s car, regardless of which party is at fault. MedPay even covers you when you’re in a car that isn’t your own. Unlike other medical insurance, MedPay never carries a deductible or co-pay in the policy and is available immediately following the accident².  Colorado MedPay covers payments related to bodily injury, sickness, or disease resulting from the ownership, maintenance, or use of the motor vehicle.  Colorado MedPay can be used to cover accident related expenses such as emergency or trauma care, ambulance rides, emergency room care, imaging services (X-rays, CT scans, or MRI’s), and conservative care treatments from chiropractors, massage therapists, and physical therapists. 

Despite being mandated by Colorado state law, some insurance companies find ways to avoid providing their customers with the required $5,000 MedPay coverage. I’ve had numerous patients tell me they unknowingly opted out of their MedPay coverage before being told what the payment meant or included. Insurance companies in Colorado are required to include MedPay by default into any new policy, however, if you’ve opted out in the past, the insurance company is not required to remind you of MedPay or to ask if you want to opt in. If you use MedPay for an accident where you were not at fault your insurance company cannot raise your premium following the accident. I highly recommend calling your insurance agent today and making sure you have not opted out of MedPay. MedPay should be of little or no extra cost to your policy, and will provide you with much needed, immediately available funds following an accident.  

Common injury patterns with MVAs

The injuries sustained in even minor MVAs can be severe. Many patients I’ve treated for a MVA report little to no pain the day of the accident, with symptoms hitting them hard the following morning. The shock involved with being in an accident is one explanation for the latency of symptoms, and oftentimes the brain is focused less on pain in the body and more on the financial and legal implications of the accident. Pain typically starts in the spine, with symptoms radiating down the extremities as the full effects of the injury are realized. I recommend waiting 2-3 days following a MVA to receive treatment. Waiting will ensure the treating physician gets the full picture of your injuries and can determine the appropriate treatment approach.  

The most common type of injury sustained during a MVA is a whiplash type injury.  Whiplash involves a sudden acceleration – deceleration force on the spine and muscles.  Cervical acceleration – deceleration injuries are very common in MVAs and the whiplash injury causes tearing of muscle and ligament fibers. The muscles damaged in a cervical acceleration – deceleration injury are typically the cervical deep neck flexors which include the longus colli, longus capitis, and also the sternocleidomastoid. These muscles are extremely important for normal biomechanical function of the cervical spine. Weakness and inhibition of these muscles due to injury can lead to instability in the cervical spine and poor healing outcomes. Exercises targeting the function of these muscles are critical following a MVA and the guidance of a trained therapist is recommended to determine which exercises will be most beneficial.  

Concussion

Concussions are another possibility after a MVA and are most often associated with a blunt force trauma to the head against the steering wheel, dash, side window, or even an airbag.  If the patient lost consciousness due to head trauma and post concussive symptoms are severe, a CT is recommended to rule out a more serious pathology such as an internal hemorrhage inside the brain. Any concussion, no matter how severe, deserves attention. Less severe cases warrant a neurologic examination by a trained therapist to assess for damage to the brain, spinal cord, or peripheral nerves. Some of the assessments used include a cranial nerve examination, ocular examination, and a high index neurologic exam that includes skin sensation, muscle testing, and deep tendon reflexes. The patient should also be taken through a verbal Sport Concussion Assessment Tool (SCAT 5) which helps determine severity of concussion and also to track treatment progress. Treatment of concussions often requires a nutritional component and an anti-inflammatory diet free of refined sugar and highly processed vegetable oils. High dose EPA/DHA from fish oil and vitamin D is also recommended to help heal brain tissue. Finally, our clinic uses a class 2 therapeutic infrared laser that can safely penetrate the skull and help to heal brain tissue via mitochondrial upregulation.  

How long will it take to get better?

Tissue healing times are different for every patient and depend on age, injury history, genetics, nutrition, and lifestyle status. The severity of the accident and associated discrepancies in physical forces placed on the body are also a factor. As a general rule, the below gives the healing times for different tissue in the body which may be injured in a MVA³: 

Muscle Strain (Grade 1): 0-2 wk

Muscle Strain (Grade 2): 4d-3mo

Muscle Strain (Grade 3): 3wk-6mo

Ligament Sprain (Grade 1): 0-3d

Ligament Sprain (Grade 2): 3wk-6mo

Ligament Sprain (Grade 3): 5wk-1yr

Bone: 5wk-3mo

Many insurance companies try to fit every client into the same recovery timeline which is not realistic. If you are still in pain and someone handling your case says you need to be finished with care, advocate for yourself and demand the care you need. 

At our clinic we use passive therapies such as acupuncture/dry needling, active release technique, therapeutic laser, cupping, and instrument assisted soft tissue manipulation among others to help you heal faster. We also use a wide variety of physical rehabilitation exercises to treat the specific deficits caused by the MVA. The focus of care after a MVA is to build strength, stability, and resilience in the cervical and lumbar spine and other body regions affected by the accident. Our goal is to make the patient stronger and more functional than they were before the accident.  

Post written by Dr. Riley Kulm, DC.  Check out his bio here

Sources and References

  1. Colorado Revised Statutes Title 10. Insurance § 10-4-636. Disclosure requirements for automobile insurance products offered–rules.
  2. Med Pay Insurance in Colorado.
  3. Potential Applications of Hyaluronans in Orthopaedics.

With the recent passing of Colorado Proposition EE, Tobacco and E-Cigarette Tax Increase for Health and Education Programs Measure (2020), the cost of using tobacco products in the state of Colorado is higher than ever. For smokers in Colorado, the estimated increase in taxes will be $222 in the state budget year 2021-22, increasing to $291 by state budget year 2027-28¹. The minimum price for a pack of cigarettes will be $7 in 2021, and will increase to $7.50 by 2024². Tobacco products will see the current 40% tax rate increase to 62% by 2027, and the new nicotine tax aimed at e-cigarettes will be applied at 30% starting in 2021 and go up to 56% starting in July 2024. These taxes are mainly incurred on Coloradans in lower income brackets. Of the 14 percent of Coloradans who use tobacco products, 80% of those individuals make less than $40,000 per year.  Financial incentives aside, smoking is the leading cause of preventable death in the US, accounting for 1 out of every 5 deaths in the US each year or 480,000 deaths³.  For context, the covid-19 pandemic has taken the lives of 269,763 Americans in approximately the last year⁴, many of whom were significantly immunocompromised and suffering from two or more comorbidities. These statistics beg an important question – why is smoking cessation not a greater public health concern?

Why you should quit smoking

Smoking is strongly linked to chronic diseases such as cancer, heart disease, and stroke. Smoking damages your hair, skin, and nails leading to premature aging on the inside and out. Smoking eats away at the cartilaginous cushioning between our joints and promotes arthritis and joint pain.  Smoking promotes a chronic chest and neck dominant breathing pattern leading to headaches and muscle tightness in the upper shoulders and neck. Second hand smoke exposure can create these problems for family members and friends.  

The detrimental effects of smoking are related to oxidative stress, which occurs when the delicate balance between pro-oxidant and antioxidant systems in our bodies can no longer be maintained. Regular smoking increases the amount of reactive oxygen species (free radicals) in the body, overwhelming the antioxidant defense systems in the body.  Free radicals are circulating molecules that have an unpaired electron. In an attempt to bind the unpaired electron, free radicals steal electrons from normal, healthy cells in the body and alter their structure and function. Damaged cells do not function properly and are flagged by the immune system for destruction resulting in widespread inflammation. Damaged cells can also become cancerous as normal cell replication processes are disrupted. The cell walls of our arteries and veins are damaged by smoking, increasing the likelihood of artheroscletoric plaque formation and subsequent heart disease and stroke. The good news? Your body starts healing within one day of quitting smoking. 

How does acupuncture help you stop smoking?

Acupuncture helps you quit smoking by decreasing the mental and physical stress involved with quitting, as well as helping to diminish cravings. The most powerful detox points for alcohol abuse, drug addiction, and nicotine are located on the ear. The treatment of these areas is referred to as auricular acupuncture, and the protocol I use is based on the National Acupuncture Detoxification Association (NADA) nicotine cessation protocol. I also incorporate specific body points which help improve blood flow, decrease stress, and increase the likelihood of successfully quitting. Additionally, we use semi permanent acupuncture needles (seeds) which are implanted into the ear like a small piercing and stay there for 3-5 days providing constant stimulation of the acupuncture point. I use seeds at the designated nicotine point which is located on the lower tragus and can be manually stimulated by the patient when a craving is felt.  

Combining acupuncture with patient education seems to be more effective than acupuncture or education alone⁵. I encourage my patients to adopt some of the strategies found on state sponsored quitting websites, like Colorado QuitLine. Beneficial strategies I’ve used with patients include telling loved ones when and why you are going to quit, making a list of all of the items or experiences you can buy with the money normally spent on tobacco, disposing of all tobacco or tobacco related products at the house or in the car, setting a strict quit date instead of trying to slowly wean yourself off, and to write out a daily health journal to track improvements in energy, mood, and pain levels.

Case Study 

I recently treated a patient at the clinic for smoking cessation. For this case study, we will refer to the patient as Laura. Laura is a middle aged female who has been a pack a day smoker for 20 years. She was spending upwards of $1,000 per month on tobacco products. Laura came to me wanting more than anything to quit smoking. She had tried everything from nicorette to patches, and had even tried hypnosis. However, nothing seemed to work and the nicorette made her nauseous. She was open to the idea of acupuncture because it had been a helpful treatment for a low back injury I was seeing her for.  We settled on a treatment plan of 8, 30 minute visits over a 4 week period. Laura set her quit date in conjunction with her first day of acupuncture. 

Within a week, the immediate improvements in her health were palpable. Her skin was clearer and was less red and inflamed. Her stiff and leathery muscles felt relaxed and pliable. Her breathing was slower, deeper, and less labored. She seemed less stressed, and had a calm nature about her. The acupuncture helped her deal with the day to day stress of quitting, and also mitigated cravings and withdrawal symptoms. On top of this, the chronic low back pain she was experiencing dramatically improved as her body’s internal healing mechanisms were better allowed to do their job. Overall, her transformation was inspirational. It motivated me to want to help more people struggling with nicotine addiction create lasting change in their lives. I’m happy to report it is now 3 months since her quit date and she has not had a cigarette since.

If you or someone you know smokes and wants to quit but doesn’t know where to start, please direct them to this article or me personally. It would be a privilege to assist you or a loved one quit for good and to help you realize the immense financial and health benefits of quitting today.  

Post Written by Dr. Riley Kulm, DC.  Check out his bio here

Sources and References 

  1. Colorado Proposition EE, Tobacco and E-Cigarette Tax Increase for Health and Education Programs Measure (2020)
  2. Proposition EE: Taxes On Nicotine Products, Explained
  3. Centers for Disease Control and Prevention, Current Cigarette Smoking Among Adults in the United States.
  4. CDC COVID Data Tracker
  5. Auricular Acupuncture, Education, and Smoking Cessation: A Randomized, Sham-Controlled Trial

Despite the chaos of 2020, the coming holiday season brings with it a time for self reflection, family bonding, and solidarity within the community. For many, personal health initiatives such as dietary, lifestyle, or exercise improvements go on pause during the holiday season, only to be resurrected come the new year.  To avoid taking steps backwards during the holidays, I’d like to offer some suggestions to make the end of 2020 your healthiest yet.

Gym Alternatives

Many people still feel uncomfortable going to the gym. However, not having access to a gym is not an excuse to let your fitness goals go unaccomplished. There are numerous ways to get an excellent workout from the safety and comfort of your own home with no equipment at all. One option is to perform a 15 to 30 minute guided yoga, tai chi, or qi gong class.  Each practice combines controlled movements with deep breathing and can help with stress and anxiety, as well as improve blood flow throughout the body. There are hundreds of free classes you can take on YouTube, turning your home into your own yoga studio. I personally enjoy the  Yoga With Adrienne YouTube Channel which has classes for all different skill levels and even has sports specific classes that cater to what you love most.

Another excellent alternative to going to the gym is to perform an at home bodyweight exercise circuit. You can create a challenging workout with no equipment necessary. Make sure to include movements such as the body weight squat, body weight forward and reverse lunge, wall sits, planks, side planks, and push-ups. Here is a sample home exercise routine that is a great alternative to going to the gym: 

Perform 3 rounds of: 

10 body weight squats

20 reverse lunges (10 each leg) 

15 push-ups

30 second wall sit 

30 second front plank 

30 second side plank (each side) 

(Rest for 2 minutes between each round)

Once this circuit becomes easy, you can add additional rounds, increase repetitions, extend the time for the planks and wall-sits, and decrease rest time between each round. You can also add more explosive movements such as jump squats, speed skaters, jumping lunges, clap push-ups, and burpees. If you have someone to join you for a home workout, have them provide manual resistance to make exercises such as the push-up and planks more difficult. 

You’ll be amazed at the quality of workout you can get once you start being creative and learn how to use your own body weight to your advantage!

Holiday Sweets Alternatives

Make this holiday season your healthiest yet by choosing these delicious alternatives to the sugar laden treats of Halloween, Thanksgiving, and Christmas. Each of these options is low in refined sugar and absent of harmful vegetable oils. These ‘desserts’ will leave you feeling energized instead of fatigued and mentally sluggish.

  • Dark chocolate and nut butter 
    • Opt for a dark chocolate that is 85% cocoa content or higher to limit the amount of sugar. 
      • Cocoa is an excellent source of nutritional antioxidants, bioflavonoids, and arginine which helps improve blood flow. It is also a great source of healthy saturated fat.
    • For the nut butter, do your best to choose a freshly ground, organic option.  Make sure the sugar content is 3 grams or less per serving or more ideally, none.  
      • Nut butters are an exceptional source of healthy fats and also are protective against heart disease and type 2 diabetes due to their high fiber and magnesium contents.  
  • Sliced apples fried in coconut oil with cinnamon
    • Over medium heat, sauté your thinly sliced apples in coconut oil until golden brown on each side. Sprinkle with cinnamon and enjoy by themselves or with unsweetened greek yogurt or whipped heavy cream from an unpasteurized milk source.
      • Apples are a great source of vitamin C, fiber, and potassium.  Regular apple consumption is consistently associated with lower rates of heart disease, cancer, asthma, and type 2 diabetes.
      • Cinnamon’s health benefits, which come from the oils in its barks, include reduced risk of heart disease, improved insulin sensitivity and decreased risk of type 2 diabetes. It also acts as a nutritional antioxidant and anti-inflammatory.  
      • Coconut oil is a top choice for healthy saturated fats and also has a high smoke point which makes it ideal for cooking.  
  • Paleo nut energy bars 

Connect with your family and community 

Staying connected socially is very important not only to the health of the body, but also the mind. Human beings crave connection, social interaction, and a sense of community. Consequently, the health of our bodies will suffer if we cannot maintain these connections. Having a positive interaction with your community is vitally important for your health. Steps you can take to improve your personal relationships, as well as with your community include sending a handwritten letter to a relative you haven’t spoken to for awhile, volunteering at a local food or clothing drive, helping an elderly neighbor with landscaping or other small maintenance job at their house, or preparing one of the desserts above to surprise your neighbors with a healthy treat! 

This holiday season could not come at a more vital time in our society. I encourage you to use these next couple months to treat your body and mind with care and to create a greater sense of unity in your family and communities.

Post written by Dr. Riley Kulm, DC.  Check out his bio here.

The recent snowstorms in Denver are a reminder ski season is right around the corner. Skiing is an incredibly demanding sport requiring high levels of fitness and athleticism. As with any athletic endeavor, it is important to prepare your body for the forces and demands of the sport. A skier must have strong legs and hips so they can turn sharply on their edges, brace for impacts, and hike at high altitudes to reach the best terrain. Off season preparation drastically decreases your risk of injury and subsequent time away from the mountain, and is an integral part of every successful athlete’s program. I will provide 5 simple exercises you can do from home which will prepare your body to hit the slopes come winter.

The SAID Principle 

Well accepted in the strength and conditioning world, the SAID Principle (Specific Adaptation to Imposed Demands) states training should be specific to the type of sport the athlete is preparing for. The intensity, volume, and duration of training should be tailored to the specific sport. Skiing requires a diverse mix of strength, balance, and endurance that is unparalleled in other sports. The athlete must be strong enough to dig their edges into the snow at high speeds, have the endurance to hike at altitudes above 10,000 feet, and have the balance and stability to correct body position when uneven surfaces are encountered or landing from a jump. The skier must build strong quads, hamstrings, and glutes to effectively and safely navigate the mountain. The program I outline below addresses each of these muscle groups with functional exercises specific to skiing.

Off-Season Ski Workout – perform the following sequence of exercises for 3 rounds.

Body Weight Reverse Lunge – 3 sets x 20 reps (10 each leg)  

Body Weight Squat – 3 sets x 10 reps

For the body weight squat start in the standing position. Sit back as if you are sitting into a chair. Keep knees pressing slightly outwards as you descend to activate the lateral glutes. Reach arms out in front for a counter balance. Go down as far as you can while maintaining a straight spine. Do your best to keep your eyes looking forward. Muscles activated should include the glutes and quads.

Rear Foot Elevated Split Squat – 3 sets x 10 reps

Wall-Sit – 3 sets x 45 second hold

For the wall sit, make sure to keep your low back pressed against the wall. Doing so will force you to use primarily your quads to hold you up. The wall-sit exercise recreates the prolonged periods of partial squatting used in skiing and helps improve the athlete’s isometric muscle strength and endurance.

DNS 7 Month Side Lying Hip Get Up – 3 sets x 10 reps 

I recommend performing this exercise routine 3-4 times per week. You can increase the number of rounds as you gain strength and endurance and as ski season gets closer.

Post written by Dr. Riley Kulm, DC. Check out his bio here.

You’ve heard the stories, watched the YouTube videos, and maybe even experienced it yourself.  The ‘pop’ or ‘crack’ made during a chiropractic adjustment is a mystery to most people. Are the bones cracking? The joints popping? The ligaments snapping? Where is the noise actually coming from? When a chiropractor delivers a high velocity, low amplitude thrust (HVLA) to a specific joint, there is often an audible sound associated with the adjustment.  What is really causing this noise? Read on to find out more! 

Cavitation 

To understand where the noise in a chiropractic adjustment comes from, it’s important to first define the engineering phenomenon called ‘cavitation.’ Cavitation refers to air pockets or bubbles formed in response to a rapid change in the pressure of a liquid. Cavitation is often seen with underwater propellers, where bubbles are formed in response to the rapid change in water pressure caused by the spinning propeller. As pressure increases, these bubbles can burst, releasing a shockwave of energy. The field of engineering views the cavitation as a negative phenomenon to be avoided, because the energy released by the bursting bubbles can damage the propeller by subjecting it to uneven stress. 

Synovial Joints 

A joint is formed when two bones come together or ‘articulate.’ The surface of a bone comprising one half of a joint is called an articulating surface and is aligned with the articulating surface of another bone. Joints in the spine and extremities are referred to as synovial joints. There are several types of synovial joints in the body such as the ball-and-socket joint (hip joint, shoulder joint), hinge joint (elbow), and the pivot joint (between C1 and C2 vertebrae), among others. Despite having different shapes and planes of movement, all synovial joints share some common characteristics. Synovial joints are encased in a fibrous joint capsule called the articular capsule. Within the articular capsule is viscous liquid called synovial fluid. Synovial fluid is the consistency of egg-whites and its main purpose is to lubricate the joint, reducing friction and stress between the two surfaces of the joint. Healthy levels of synovial fluid help keep our joints moving freely and prevent the formation of arthritis.  

Putting it all together 

The phenomenon of cavitation is observed in the human body. When a chiropractor delivers an adjustment, the therapeutic goal is to gap or widen the two joint surfaces, resulting in a decrease in pressure within the joint capsule.  The pressure decrease occurs within the synovial fluid, and bubbles are formed in response to this change in pressure. The bubbles rapidly collapse on themselves, releasing a shockwave of energy. The collapse of the bubbles and subsequent release of energy is believed to cause the audible pop or crack caused by the chiropractic adjustment. The noise made during a chiropractic adjustment is caused by the bursting of small bubbles within the synovial fluid of a joint in response to a rapid change in fluid pressure. Damage to the joint does not occur like it does to the propeller. The cavitation associated with the propeller takes place thousands of times per minute, whereas most patients get adjusted twice per week at the most. As such, regularly self adjusting your spine can lead to an array of negative outcomes. For more information, please reference my blog post, The Dangers of Self Adjusting.  Lastly, to determine how frequently you should get adjusted, review my blog post, How Often Should I Get Adjusted?


Post written by Dr. Riley Kulm, DC.  Check out his bio here.

Patients often ask what the ideal treatment frequency is for getting adjusted. However, if you asked ten different chiropractors this question, you might get ten different answers. Within chiropractic, many different technique systems and schools of thought exist. Chiropractic treatments and treatment plans are not standardized within the profession and there is a high level of variability from doctor to doctor. With this in mind, the answer to how often you should get adjusted is it depends on your situation. Factors such as your age, health status, activity level, and diagnosis all factor into how often you need to be adjusted. For this post, I will address the question for someone who has mild or no symptoms and is looking to chiropractic for maintenance care and promoting overall health.  To begin, I’ll describe the typical treatment plan for a new patient at our clinic. 

Typical Treatment Plan

When a new patient comes to our clinic with a common complaint such as low back, neck, knee, shoulder, or elbow pain, we typically see them twice a week for 1-2 weeks, once a week for 3-4 weeks, and then reassess after 6-8 visits over 4-5 weeks. Adjustments will be performed at each visit. If the patient is markedly improved, we will push visits out 2-3 weeks and start seeing them on a less regular basis. Most patients feel substantial relief in just 2-3 visits, however, the underlying functional issues (posture, movement, breathing) causing the injury in the first place, take longer to reverse.  Once the pain is gone and the patient is passing all of the functional tests relating to the original injury, we place the patient on a maintenance care plan where they come in once a month. The purpose of the maintenance care visit is to make sure the patient has not re-injured themselves or sustained any new injuries. We will also review exercises they have been prescribed in the past and check their spines to see if an adjustment is needed. At our clinic we use a mixture of chiropractic adjustments, physical therapy exercises, nutrition and supplements, and soft tissue therapies such as instrument assisted technique, active release technique, dry needling, laser, and acupuncture. By combining multiple therapies, we decrease healing times, allowing for a shorter and less costly treatment plan.  

Maintenance Care 

How often should a patient get adjusted for maintenance care and promotion of overall health? As stated previously, one chiropractor’s answer may differ from another’s, and our answer is based on the combined clinical experience of nearly a decade from the two doctors at Mile High Spine and Sport, Dr. Ryan Dunn and Dr. Riley Kulm. For maintenance care and promotion of overall health, we suggest patients come in for a full spine assessment and adjustment once per month. Maintenance care visits also include a functional movement exam to see if any limitations in muscle strength, stability, and range of motion exist predisposing the patient to future injuries. The purpose of the full spine assessment and functional movement exam is to identify issues before they surface to help prevent pain or injury. Similar to how it is necessary to go to the dentist every 6 months for a cleaning and exam, you should go to the chiropractor once per month to have your spine assessed for restricted joints and muscle imbalances to help prevent issues down the road. For quality preventative maintenance care, chiropractic is one of your best, and most cost effective treatment plan options.

Can I get adjusted more than once a month? 

As a result of the numerous health benefits of getting adjusted, many of our patients decide to come in for adjustments more than once per month. Patients report improvements in breathing, energy, digestion, and sleep following their treatments. If you’d like to learn more about how the chiropractic adjustment can positively affect multiple areas of your health, please check out my post, Beyond Biomechanics: Exploring the Hormonal Benefits of the Chiropractic Adjustment.  

From a safety perspective, it is entirely fine to get adjusted on a regular basis. However, I would not suggest getting adjusted more than three times per week as you run the risk of causing hypermobility in the joints. Hypermobility means the joints are moving too much and lack the muscular stability for normal motion and can lead to a variety of orthopedic issues. In general, we rarely see maintenance care patients more than once per week. We encourage patients to come in more than once per month if they find the benefits of regularly getting adjusted enhances their lifestyle and well-being. 

Post written by Dr. Riley Kulm, DC.  Check out his bio here