The Intersection of Orthopedics and Lifestyle Medicine

Inflammation and Your Joints
Stephan Esser MD, USPTA

Esser’s Health
Ranch
Dr William Esser ND, DC 1911-2003

What I Do at SOS?
• All Ages 7 - Banana Peel
• Top of Head to Bottom of Feet
• All Problems
• Non Surgical Options/ Maximize Natural
options
• Eg: Evaluations, PT, Injections, Medx,
Supplements, Acupuncture, Nerve Blocks, PRP,
Stem Cell, Hydrodistentions, Exercise
Programs, Weight Loss Programs etc

Food, Movement and Orthopedics:
Why What you do Matters!
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Tenets of a Healthy Life
• Clean Food
• Clean Water
• Exercise
• Sleep
• Emotional Poise
• Sunlight
• ( Avoidance of Toxins)

Orthopedic Complaints
• Pain
• Loss of Function
• Alteration in Performance
• “Prevention”

Orthopedic Complaints
• Pain
– Anatomic
• eg: Fracture, Ligament tears, Tumors, Large Disc bulges
– Biomechanical
• eg: Body Weight, Weak hips/Glutes, Tight Hip flexors,
Weak Shoulder muscles, Sarcopenia
– Physiologic
• Biochemical/Cellular or Neurophysiologic

Management
Anatomic
Biochemical + Biomechanical

Biomechanical
• Weight
• Muscle Balance
• Ligament/Tendon Flexibility
• Lean Muscle Mass
• Limb Lengths/Postural Issues etc

Biomechanical
• Weight:
– Lower Extremity Joints
• 1lb above the waist = 3-10 below
– Upper Extremity Joints
• Inc. Weight = Inc. work for RTC, neck muscles
– Alters Spinal Mechanics
• Inc. Lumbar Lordosis and “facet based pain”
• Inc. Risk of Spinal Stenosis

Weight and Plants
• Vegetarian diets are associated with reduced body weight, lower
incidence of certain chronic disease, and lower medical costs compared with
non-vegetarian diets Vegetarian Diets and Weight Status Nutrition Reviews
2006.
• Self-identified semivegetarian, lactovegetarian, and vegan women have a
lower risk of overweight and obesity than do omnivorous women.
The advice to consume more plant foods and less animal products may help
individuals control their weight. Risk of overweight and obesity among
semivegetarian, lactovegetarian, and vegan women American Journal of
Clinical Nutrition 2005
• The 5-unit BMI difference between vegans and nonvegetarians indicates a
substantial potential of vegetarianism to protect against obesity. Increased
conformity to vegetarian diets protected against risk of type 2 diabetes after
lifestyle characteristics and BMI were taken into account. Pesco- and semi-
vegetarian diets afforded intermediate protection. Type of Vegetarian Diet,
Body Weight, and Prevalence of Type 2 Diabetes Diabetes Care 2009

Weight and Joint OA
• Obesity is a primary risk factor for disease onset, and mechanical factors increased
the risk for disease progression. Moreover, inflammatory mediators, in particular, adipose tissue‐derived
cytokines (better known as adipokines) play a critical role linking obesity and osteoarthritis Biomechanics, obesity, and
osteoarthritis. The role of adipokines: When the levee breaks Journal of Orthopedic Research, 2017
• Obesity enhances the cross-talk between chondrocytes and synovial
fibroblasts via raised levels of the pro-inflammatory adipokine leptin, leading to greater production of IL-6 in OA
patients. IL-6 secretion in osteoarthritis patients is mediated by chondrocyte-synovial fibroblast cross-talk and is enhanced
by obesity Scientific Reports 2017
• Higher body mass index was associated with an increased risk of hip
replacement due to osteoarthritis (P for trend = 0.0001). Compared with women in the lowest category of body
mass index (<22 kg/m2), those in the highest category of body mass index (≥35 kg/m2) had a twofold increased risk
(95% confidence interval [CI]: 1.4 to 2.8), whereas those in the highest category of body mass
index at age 18 years had more than a fivefold increased risk (95% CI: 2.5 to
10.7). Total hip replacement due to osteoarthritis: the importance of age, obesity, and other modifiable risk factors The
American Journal of Medicine 2003
• Increased weight = increased risk of OA and resultant need for THA and TKA. Role of Obesity on
the Risk for Total Hip or Knee Arthroplasty Clinical orthopedics and Research, 2007
• This underscores the immediate need for greater use of clinical and public health interventions, especially those that
address weight loss and self‐management, to reduce the impact of having knee OA. Lifetime risk of symptomatic knee
osteoarthritis Arthritis Care and Research 2008

Weight and Joints
• Don’t leave the “snow on the roof too long”

Muscle Balance
• Stronger Quad Muscles = Less Osteoarthritis
Goldman et al Osteoarthritis Cartilage 2016
• Improving Quad Strength = decreased knee
pain, reduced knee osteoarthritis and
decreased risk of knee replacement Wang, Y et al Arthritis Rheum 2012
• Improving Lateral Hip Strength reduces knee
pain in patient’s with knee OA Sled et al, Physical Therapy 2010

Muscle Balance
• Neck: Deep Flexors, Upper Back
• Shoulder: Upper Back, Back of Shoulders
• Low Back: Hip flexors, gluteal muscles, lateral
hips
• Hips: Flexors and lateral hip muscles
• Knees: Quads, lateral hip

Flexibility
• Improved Hip, hip flexor, hamstring flexibility
improves back pain, quality of life > NSAIDs
• Quad, Hip Flexor, Lateral Hip Flexibility for
knee, hip pain
• Pec stretching for shoulder and neck issues

Sarcopenia
• “Age-Related” Muscle Loss

“There may be no single feature of age-related
decline that could more dramatically affect
ambulation, mobility, calorie intake, and
overall nutrient intake and status,
independence, breathing, etc. than the
decline in lean body mass.”
Aging, Atrophy and Apoptosis:Failing “A’s” for Frailty
National Conference on Aging

Sarcopenia
• The only proven approach to slow or prevent
or reverse sarcopenia is…………..
Exercise

“Physical fitness can neither be
achieved by wishful thinking nor
outright
purchase.” Jos
eph Pilates

• “You have to work at living, period. You’ve got
to train like you are training for an athletic
event. Most older people just give up. They
think, “I’m too old for that,” because they
have an ache here or a pain there. Life is a
pain in the butt; you’ve got to work at it.”
Jack LaLanne

Exercise and Physical Health
• Reduces risk of
– Heart Disease ≈ 40%
– Obesity: ≈ 30-100%
– Stroke ≈ 50%
– Type 2 Diabetes ≈ 50%
– Hypertension ≈ 50%
– Disability delayed ≈15 years
– Colon Cancer ≈ 25-40%
– Breast Cancer ≈ 20%-44%
– Osteoporosis ≈ 20+%
• As many as 250,000 deaths per year in the United
States areattributable to a lack of regular physical
activity

Physical Health Cont’d
• Improve Balance
• Reduce Fall risk
• Improve Systemic Circulation
• Accelerate Skin Healing
• Bowel Regularity/  risk diverticulosis
• Improved Energy/Resilience

Exercise and Mental Health
• Regular Exercise:
– Reduces risk/severity of:
• Depression
• Anxiety
• ADD/ADHD
• Alzheimers Dementia
– Improves:
• Mental Clarity, test scores, focus

Fact
Exercise is “Medicine”

Goals
• CV Exercise : 150 minutes/week
• Resistance Training: 2-3 days per week
• Flexibility/Balance Training: 2-3 days per week

Physiologic
• Cellular Inflammation
– Arachidonic Acid and Prostaglandins
– Generalized Cytokine Release
– Absence of “Anti-oxidant rich” foods
– Inflammatory Joint Problems: Gout,
Rheumatologic disease
– Impaired Perfusion
– Visceral Fat: Adipokines

Arachidonic Acid
https://epi.grants.cancer.gov/diet/foodsources/fatty_acids/table4.html

Cytokine Release
• Diet influences Cytokine Release
– Fruit and Vegetable Intake reduce levels of Pro-Inflammatory Cytokines Root, M et al. Combined
Fruit and Vegetable Intake Is Correlated with Improved Inflammatory and Oxidant Status from a
Cross-Sectional Study in a Community Setting Nutrients 2012, 4(1), 29-41

Spices
• Turmeric: 1500mg/day
– Knee Osteoarthritis: Clinical Intervention in Aging 2014
– 1500mg/day vs 1200mg/day Ibuprofen
• Boswellia: Indian Journal of Pharmacology 2007
– 1000mg/day vs Valdecoxib 10mg/day
• Ginger: Archives of Iranian Medicine 2005
– 30mg/day Ginger Extract vs 400mg Ibuprofen/day
– Osteoarthritis and Cartilage 2015

• Cellular Inflammation
– Arachidonic Acid and Prostaglandins
– Generalized Cytokine Release
– Absence of “Anti-oxidant rich” foods
– Inflammatory Joint Problems: Gout,
Rheumatologic disease
– Impaired Perfusion
– Visceral Fat: Adipokines

Deep Greens, Purples, Blues, Reds……….the Rainbow

Rheumatology
• Inflammatory/Autoimmune Conditions
– “Leaky Gut” Hypothesis
– Tissue Mimicry
– Excess Purines leads to excess Uric Acid
• 27 patients were allocated to a four-week stay at a health farm. After an initial 7-10 day subtotal fast, they were put on an individually
adjusted gluten-free vegan diet for 3·5 months. improvement in number of tender joints, Ritchie's articular index, number of swollen
joints, pain score, duration of morning stiffness, grip strength, erythrocyte sedimentation rate, C-reactive protein, white blood cell
count, and a health assessment questionnaire score Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis
Lancet 1991
• A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis correlate with a reduction
in antibodies to food antigens Rheumatology 2001
• 4-week, very low-fat (~10%), vegan diet on 24 free-living subjects with RA, average age, 56 ± 11 years old. All measures of RA
symptomatology decreased significantly (p < 0.05), except for duration of morning stiffness (p > 0.05). Weight also decreased
significantly (p < 0.001). At 4 weeks, C-reactive protein decreased 16% (ns, p > 0.05), RA factor decreased 10% (ns, p > 0.05), while
erythrocyte sedimentation rate was unchanged (p > 0.05). Effects of a Very Low-Fat, Vegan Diet in Subjects with Rheumatoid Arthritis
The Journal of Alternative and Complementary Medicine 2004

Perfusion
• Blood Flow is essential for
– performance, healing, function, prevention
• High Fat/High Cholesterol meals
– Impair vascular dilation
– Produce Fatty streaks, CVD precursors
– Impair blood flow to MSK tissues
– Reduce O2 and micronutrient delivery
– Alter regional pH

Perfusion
• High Total Fat, High Saturated Fat, High
Refined sugar meals inhibit blood flow and
arterial dilatation
– Effect of a Single High-Fat Meal on Endothelial Function in Healthy Subjects single high-fat
meal transiently impairs endothelial function by up to 50% at 4 hrs after the meal AJC 1997
• Minimally Processed, Plant-Based Foods have
vasodilatory effect
– Flavonoid-rich apples and nitrate-rich spinach augment nitric oxide status and improve endothelial function in healthy men and women: a
randomized controlled trial Free Radical Biology and Medicine 2012
– An increase in F&Vs, regardless of flavonoid content in the groups as a whole, mitigated increases in vascular stiffness measured by PWA (P =
0.0065) and reductions in NO (P = 0.0299) in the control group Flavonoid-rich fruit and vegetables improve microvascular reactivity and
inflammatory status in men at risk of cardiovascular disease—FLAVURS: a randomized controlled trial AJCR 2014
– In healthy overweight and slightly obese men a single dose of beetroot juice attenuates the postprandial impairment of FMD following a
mixed meal, possibly through increases in plasma NO concentrations. Beetroot juice improves in overweight and slightly obese men
postprandial endothelial function after consumption of a mixed meal Athersclerosis 2013

Perfusion
• Spinal Degeneration and Impaired Perfusion
• Aortic Calcifications as a risk for back pain
– Advanced aortic atherosclerosis, presenting as calcific deposits in the posterior wall of the aorta, increases a person's risk for
development of disc degeneration and is associated with the occurrence of back pain. Disc Degeneration/Back Pain and
Calcification of the Abdominal Aorta: A 25-Year Follow-Up Study in Framingham Spine 1997
– A significant association is indicated between atheromatous lesions in the abdominal aorta and low back pain. Association of
Atherosclerosis with Low Back Pain and the Degree of Disc Degeneration Spine 1999
– Aortic atherosclerosis and stenosis of the feeding arteries of the lumbar spine were associated with DD and LBP. Atherosclerosis
and Disc Degeneration/Low-Back Pain – A Systematic Review EJVES 2009
– High serum lipids predicted incident radiating LBP, consistent with the atherosclerosis-LBP hypothesis. Serum Lipids and Low
Back Pain: An Association?: A Follow-up Study of a Working Population Sample Spine 2006

Perfusion/Cholesterol
• Serum Lipids and risk of Rotator Cuff Tear
– Impaired micro-perfusion
– Increased risk of injury
– Increased risk of re-tear and slowed healing
• Patients with rotator cuff tears were more likely to have hypercholesterolemia when compared with the control
group.
• The Effect of Hypercholesterolemia on Rotator Cuff Disease Clinical Orthopedics and Related Research 2010
• Dyslipidemia may decrease the improvement of patient-reported outcomes in
• patients undergoing treatment for RCTs; high triglycerides and low HDL may have
• the most impact.The effect of lipid levels on patient-reported outcomes in patients
• with rotator cuff tears JSES Open Access 2017 The present study found a significant
• association between moderate and high perioperative total cholesterol and LDL
• levels and the rate of revision surgery after primary arthros copic rotator cuff
• repair. Perioperative Serum Lipid Status and Statin Use Affect the Revision Surgery
• Rate After Arthroscopic Rotator Cuff Repair AJSM 2017

Perfusion/Increased Cholesterol
• Achilles Tendon Rupture
– Impaired healing
– Increased risk of tear/re-tear
• Total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) concentrations of the patients with ATR were higher
(p<0.001), and their high-density lipoprotein cholesterol (HDL-C) was lower than the control group (p<0.05). Moreover,
the concentrations of triglyceride (TG) and very low-density lipoprotein cholesterol (VLDL-C) were significantly higher
than controls (p<0.05). Is high concentration of serum lipids a risk factor for Achilles tendon rupture?
• People with altered tendon structure or tendon pain had significantly higher total cholesterol, low-density lipoprotein
cholesterol and triglycerides, as well as lower high-density lipoprotein cholesterol. Is higher serum cholesterol associated
with altered tendon structure or tendon pain? A systematic review BJSM 2015
• One intrinsic factor that appears to have an association with tendinopathy is body composition; more specifically central
adiposity Adiposity and tendinopathy Disability and Rehabilitation 2008

Perfusion
• Plants with MORE color!

Perfusion
• Healing
– Impaired perfusion
• Increased risk of infection
• Impaired healing
– Pre and Post Surgery

Perfusion
• Beet Juice
– reduced time to exhaustion and improved
performance ( V02Max) Cermak et al Sports Nutrition and Exercise Metabolism 2012
– improves submaximal aerobic endurance and
blood pressure Eggebeen et al JACC 2016
– Improved time trial performance in cyclists and
kayak racers Peeling et al SNEM 2015
• Pomegranate Juice
– Improves running time to exhaustion Trexler et al 2015

Biomechanical and Biochemical
are Closely Linked

Orthopedic Application
• Reduce Pain
– Reduce inflammatory foods
– Increase anti-inflammatory foods
– Reduce weight and reduce adipokine production
– Improve Fitness and Flexibility
• Improve Perfusion
– Enhance oxygen, nutrition delivery
– Facilitate prevention and Accelerate healing
– Exercise and “Angiogenesis”

5 Principles
• 1: Evaluate Need and Readiness for change

Need
• Pain
• Loss of Function
• Age > 50
• Hx of Injury
• Increased Weight
• Dx of Blood pressure, blood sugar issues
• Depression, Anxiety

Stages of Change (Prochaska and DiClemente)
1: Pre-contemplation
2: Contemplation
3: Preparation/planning
4: Action
5: Maintenance
6: Permanent Maintenance
(Termination)

Identify
• Openings
– Tired of Medications
– Frustrated by weight
– Chronic Pain
– Chronic inflammation
– Aesthetics etc

• 2: Determine clinically the extent of change
needed to result in the effect desired

• 3: Develop a “plan of care”

Goals
• Prevent
• Reverse
• Reduce
• Eliminate

Case
• A 72 y/o male presents with low back pain.
– PMH: HTN, HLD, Psoriasis, Obesity, Hand OA
– Xrays: Aortic Calcifications noted
• Patient comments he is tired of his 5 medx.
• Plan: Offered PT and a 4 week plant based
“detox”
• At 6 weeks, 30lbs lighter, off all BP medx,
Psoriasis resolved, back pain 60% improved,
resizing wedding ring to fit fingers

Case
• A 54 y/o female with advanced knee OA
presents to discuss stem cell treatment
– PMH: HTN, HLD, Obese
– Plan: 6 week plant based “detox,” Pool swimming,
HEP
– Results: 28lbs weight loss, Knee pain 75%
improved
– Plan: PRP injections and continued knee PT

Tracking
• What will you track?
– Pain, Performance, Labs, Weight ?
• Are the goals SMART?
– Specific, Measurable, Achievable, Realistic, Timely

Case
• 65 y/o male with bilateral leg numbness and
burning and knee pain and foot drop
– PMH: S/p spinal surgery, Borderline T2D, HTN, HLD
– Plan:
• Reduce inflammation thru 4 week Plant-based detox
• Add in high dose B vitamins, Omega 3, Inositol, Mag. G.
• Continue PT, Follow up on all recent films, labs, EMG
• Provide AFO for foot drop
– Follow Up
• Foot Drop Unchanged
• 24lbs weight loss, Stopped 1 BP, 60% reduction in leg pain

Case
• A 56 y/o male presents to clinic walking with
crutches due to severe knee pain. Knees are
swollen, painful to move at all. Labs show
highly elevated serum uric acid levels.
– Plan: Standard discussed, patient requests
alternative (agrees to 1 week juicing, 3 week
plant-based detox)
– Follow up: 3 weeks with update
Need was real, Readiness was present
Uric Acid 9---0.9
ESR 30----2
Lawn

Outcomes
• Complete Improvement
• Partial Improvement
• No Gains

Conclusion
• There are multiple levels of intersection where
plant based nutrition, exercise and MSK care
overlap
• Excellent Nutrition and Exercise can
– Reduce Pain
– Reduce Inflammation/Swelling/Edema
– Reduce Weight/Alter Biomechanics
– Improve Perfusion and Nutrition delivery
– Reduce and slow “disease” risk
– Improve performance and function

Take Home
• Do YOU have: Pain, Loss of Function
• Do YOU want to Reduce, Eliminate or Prevent
Pain and improve function and performance
THEN
• What is your daily exercise plan?
• What is your daily nutrition plan?

Plan
• Add more color and micronutrient rich plants
to your daily diet
• Add Spices like turmeric, ginger, boswellia to
your food and your supplements
• Be sure you get some form of exercise every
day…..flexibility, balance, CV, strength
• Achieve a BMI in the 18-24 range, and a
normal waist-hip cicumference

YOUmay be the most powerful influence of
health in your life today, tomorrow and for
years to come!

Thank You!
Follow me at Esserhealth on
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Thank You!
Follow me at Esserhealth on Facebook and Instagram

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