Wednesday, July 11, 2018

Do you have GUTS? 3 Tips for Improving Gut Health

Did you know that 70% of our immune system lies in our gut?

Our gastrointestinal tract (gut) is an organ system, within humans and other animals, that takes in food, digests it to extract and absorb nutrients as well as energy, and expels the remaining waste as feces and urine.  Our gut lining acts as a barrier for healthy living, essential in keeping a strong immune system and therefore minimizing inflammation. 

In fact, this barrier decreases the chances of developing autoimmune disorders, degenerative diseases, and dementia. According to the American Autoimmune Related Diseases Association, inc (AARDA), 50 million Americans are living with autoimmune disease, and women make up 75% of those living with autoimmune diseases.
Here are 3 helpful tips to help you and your patients start restoring your gut health, and staying on the road to living an anti-inflammatory lifestyle:
Eat your vegetables – Increase your fiber intake through vegetables. Fiber promotes growth of good bacteria in our gut. The American Dietary Guidelines indicate 25-35 grams of fiber daily should be consumed. This equates to 2-3 servings of vegetables per day. So in other words, vegetables should take up about half of your plate at meals.  To get a variety of vegetables in your diet, a common phrase among nutritionists and practitioners is “Eat the rainbow”. In essence, eat different colored vegetables throughout each day as they provide different nutrients. Dr. Justin Sonnenburg, associate professor in the department of microbiology and immunology at Stanford University School of Medicine, cautions “If you’re not eating dietary fiber, your immune system may be existing in kind of a simmering pro-inflammatory state.”
Reduce your Stress- Add one hour of a pleasurable activity each week to reduce stress. This can include meditation, exercise, reading, etc. Being in a constant state of stress can lead to change in our gut over time. This can erode the good bacteria in our gut and damage our gut barrier. A weakened and damaged gut barrier can allow pathogens to enter our blood stream leading to long-term illness or inflammatory diseases.
Drink plenty of Water- Increased water intake helps to transport nutrients and assists in digestion as well as absorption of key nutrients.  Water can also support the body in helping waste to pass more smoothly through the intestines, thus preventing constipation. The Institute of Medicine recommends women drink 9 cups (2.2 liters) of water daily. For men, 13 cups (3 liters) daily is recommended. Please note, these are general guidelines and depending on your body mass or lifestyle, your amount may vary.
So the answer is YES! You do have the GUTS!  Your GUT is your secret weapon to living a healthy, happy, anti-inflammatory lifestyle.  

Blog post by: 
Nicole Lovett, DPT, OCS

Nicole Lovett is physical therapist working at Kaiser Permanente. She is a movement science fellowship graduate, Movement Links certified clinician and instructor, and has taught movement concepts in the Loma Linda Residency.


1. Konturek, P. C., Brzozowski, T., & Konturek, S. J. (2011). Stress and the gut: pathophysiology, clinical consequences, diagnostic approach and treatment options. Journal of physiology and pharmacology: an official journal of the Polish Physiological Society, 6, 591–599.

2. Shui-Ming, Kuo.The Interplay Between Fiber and the Intestinal Microbiome in the Inflammatory Response.  Advancement in Nutrition. 2013 January 4th.  

3. Clarke, S. F., Murphy, E. F., O’sullivan, O., Lucey, A. J.,     Humphreys, M., Hogan, A., . . . Cotter, P. D. (2014). Exercise and associated dietary extremes impact on gut microbial diversity. Gut63(12), 1913–1920.

4. Popkin B, D’Anci K, Rosenberg I. Water, hydration, and health. Nutr Rev. 2010;68(8):439-458

5. Drewnowski A, Rehm CD, Constant F. Water and beverage consumption among children age 4-13y in the United States: analyses of 2005–2010 NHANES data. Nutr J. 2013;12(1):85.

6. Drewnowski A, Rehm CD, Constant F. Water and beverage consumption among adults in the United States: cross-sectional study using data from NHANES 2005–2010. BMC Public Health. 2013;13(1):1068.

7. Ann E. SlingerlandZaker SchwabkeyDiana H. Wiesnoski, and Robert R. Jenq..    Clinical Evidence for the Microbiome in Inflammatory Diseases.  Frontiers in Immunology.  April 12th 2017.

8 .                       

Tuesday, June 12, 2018

Current Evidence on Low Back Pain: The Lancet 2018

Low back pain is a “catch-all” diagnosis without a clear pathoanatomical source generator and treated in a plethora of ways ranging from medications, rest, manual care, traction, acupuncture, & exercise. But what does the current evidence tell us, both about diagnostics and treatment? More so, how is a clinician supposed to interpret the literature to produce meaningful outcomes with the patients they treat? Recently, The Lancet Low Back Pain Series Working Group published a series of articles focused on examining the current evidence surrounding low back pain to provide an understanding of low back pain and current evidence on its diagnosis and treatment. What was unique was that the articles looked at current practice in various countries around the world. To this point, I’d strongly encourage reading the articles to get a flavor for how differently low back pain is viewed and treated around the world. Below is my brief summary of the key points of these articles. 


1.    Low back pain is now the number one cause of disability worldwide. It affected 60.1 million lives (yes, I said million) in 2015 alone. Disability was found to be highest in working age groups of low-mid socioeconomic status. Most episodes were found to be short lasting and self-limiting. The authors concluded that these numbers are expected to increase in low to middle income countries over the next few decades.

2.   The authors noted that the following:

a.   identifying source tissue was quite difficult with the use of MRI and other types of imaging. This was due to a large percentage of population who do not have any specific pain, despite having positive MRI findings, (e.g. disc bulges or facet arthritis). It was noted however, that Modic Type I (vertebral end plate changes associated with degenerative findings)  changes may be indicative of some type of back pain, as well as fractures, malignancies, or infections (although the prevalence of these were low).

b.   low back pain was multi-factorial with physical factors being influenced by co-morbdities (e.g. asthma, diabetes, obesity etc.), psychological factors, social factors, & genetics.

c. there is moderate evidence that a centralized pain process could occur in patients with chronic back pain.

With the above current findings, it is obvious to see why assessment of low back pain can be quite a challenge for even the most seasoned clinician. But what about treatment?


The authors of the Low Back Pain Series Working Group looked at all the various types of care for low back pain with their recommnedations.

1.    First and foremost, they recommended that patients be initially treated non-pharmacologically and educated on their back pain.  The thought here was to overcome fear avoidance and dispel the idea of bedrest as a treatment.

2.    Patients should be encouraged to move and function within their day-to-day activities. For those who required more care, the recommendations again fell upon movement and graded exercise to nurse a patient back to health.
3.   Spinal manipulation, acupuncture, & massage may be beneficial in the short-term management of LBP, but there was not solid evidence to support long-term care. 

4.   For the patients who failed these forms of care, pharmacological care such as with NSAIDs were considered another treatment option or as an adjunct to current care. However, opioids were not recommended.  Patients who were prescribed opioids were encouraged to be monitored given the medication risks, which include addiction.

5.   Lastly, there were recommendations on spinal epidurals which were shown to be effective in only severe forms of radicular pain. Surgery was considered as a last resort in the face of neurological deficits or when all other conservative forms of care had failed.

What’s a clinician to do?

Being a Movement Links Clinician and instructor, I’m a big believer in the APTA’s 2020 vision of physical therapists as movement practitioners.   I was delighted to read that exercise and education are the forms of care currently endorsed as best practice. Although the articles do not specifically highlight which type of exercise or what specific muscle groups to target, it is important to note clinically that getting your patient to move, (and do so correctly) is paramount in managing their overall condition. Additionally, manual therapy can be included in the initial stage to assist a patient in getting back on track. 

Passive forms of care such as electrical stimulation, ultrasound, diathermy, or traction were not recommended or found to be effective in the management of low back pain.

That all being said, what direction should a clinician take in management of back pain? First and of utmost importance, a clinician should rely on sound clinical reasoning. Spending time clinically to actively listen to your patient and get a good understanding of what is going on with your patient can pay huge dividends.  Understanding the patient’s story can easily point the provider in the direction of where they need to go objectively and ultimately assist in the treatment of choice. Second, it is important to always take the WHOLE patient presentation into consideration. One point made from Foster et al’s article was the role that other co-morbidities play in patients with back pain. Here, the authors noted that patients with asthma, diabetes, headaches, & depression had a higher likelihood of having LBP.  Lastly, regardless of your clinical bias with regards to treatment approach, remember to educate your patient on the importance of movement and exercise, as well as a solid understanding of pain. Doing so will no doubt ensure that your patients are well on their path to recovery.

Jiten ( Jay ) Bhatt is a physical therapist at Kaiser Permanente Panorama City. He is a Movement Links Certified Clinician and instructor. Jay has been published in JOSPT and has presented at APTA CSM conferences. He is also a graduate of the Kaiser Permanente fellowship program.  


1.    Foster, NE, Anema, JR., Cherkin, D,  Chou, R, Cohen, SP, Gross, DP, Ferreira PH, Fritz JM, Koes BW, Turner, JA, Maher CG.  & Lancet Low Back Pain Series Working Group. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet.

2.  Hartvigsen, J., Hancock, MJ., Kongsted, A, Louw, Q, Ferreira, ML, Genevay, ., Hoy D,     Karppinen J, Pransky G, Sieper J, Smeets, RJ, Underwood M, Lancet Low Back Pain            Series Working Group.  (2018). What low back pain is and why we need to pay attention.     The Lancet.