CBD is an opportunity for us to try something new without risks, such as CBD and a healing laser for knee injury
Chiropractors are dedicated to patient care, scientific innovation, research, advancing the understanding of the therapeutic benefits of chiropractic, and now medical cannabis and CBD. We are practitioners seeking premium products, safe, consistent and effective treatments, and utilizing new products and technologies such as a healing laser, hemp oil and CBD.
For some this may be a little outside the box or perhaps outside the comfort zone. We are well positioned to educate and service patients who may benefit from the use of CBD products.
A 59-year-old male patient with left knee pain noted intermittent pain for the past three years at 3-4/10 on a VAS. If he attempts to run (i.e. run across a walkway at a light) the pain increases for several days to weeks afterwards.
He is able to maintain going to the gym, using free weights and body weight exercise, and he rides a bike on the weekends without aggravation. Sitting more than two hours aggravates the medial knee pain. He presents to the office with current pain as constant and a 6-7/10 VAS. He indicates to the left medial knee and notes that it “aches and it hurts to move.”
There is a slight reduction of full flexion and extension motion. Pivot motions are painful. His gait is protective of the knee and interferes with normal fast walking. The medial knee joint feels slightly “inflamed” and tender to touch.
As DCs we know about the synovial pouch and that it is cushioned by articular cartilage. We know that chronic inflammation in the synovium deteriorates cartilage, eventually exposing the underlying subchondral bone to greater and more asynchronous forces. These cause both softening of the bone as well as stimulation of bony growths, i.e. osteophytes, spurs, and sometimes cysts. A previous MRI confirms a “medial meniscus tear” and early left-knee degenerative osteoarthritis.
The treatment plan
Inflammation impairs neural input to the muscles around the joint(s). The consequence of this is the change in the muscles co-contraction of agonists and antagonists. The changes in strength and stability along with the poor support and increased impact forces to the articulating surfaces leads to further deterioration of the joint.
After the exam, I lay out a treatment plan. He is going to need therapies for pain relief and an exercise program. I explain that lasers and shockwaves are being called regenerative therapies and can be effective treatments for a range of arthritic conditions. The addition of “rubbing on” a cannabinoid cream has helped other patients and may be an effective adjunct treatment option for these types of conditions. Topical and oral cannabinoids can be especially helpful for people who are resistant, intolerant, or allergic to common medications.
Healing laser treatment
In managing the patient with knee osteoarthritic pain, the functional examination guides me to treat with ankle and hip mobilization, lumbopelvic spine manipulation, exercise therapy, the class 3B laser, tape and cannabis topicals. For arthritic knees I prefer the class 3B healing laser for its sophisticated dosing capability, ease of operation in that the patient can hold the probe over the painful area, and the potential for photobiomodulation.
A healing laser helps re-balance the sodium-potassium pump located in a nerve cell to eliminate pain; reduces inflammation by increasing iNOS (Inducible Nitric Oxide Synthase); induces the lymphatic system to become more porous; hence, removing interstitial fluid from the swollen region faster; stimulate cell growth and repair by accelerating the production of Adenosine TriPhosphate (“ATP”) through oxidation/reduction status in the mitochondria of a cell, allowing faster tissue healing.
The plan for this patient was to try and come in every day for five days in a row. He achieved making it into the office for four treatments.
The treatment sequence each visit included joint/muscle therapy (mobilization/manipulation), a Class 3B healing laser, kinesio tape applied to the knee, CBD cream rubbed over the tape, and he was given exercises to perform at home.
The specific exercises were based on the functional examination and included training in foam roll for the gluteals, deep-six rotators, TFL/ITB, and adductors; seated quadriceps stretch and activation with CLX band resistance; seated and standing ankle plantar/dorsiflexion (see-saws), eversion/inversion (side-side) and internal/external ankle rotation; hamstring stretch with CLX behind the knee + hip flexion + leg extension; one-leg stand with flex hip + extend knee “march;” and side-lying hip abduction leg raises.
CBD for positive biological changes
The same way I use the medical application of the healing laser, shockwave, etc., I use cannabinoids from the cannabis plant to effect positive biologic changes. We all have an endocannabinoid system. Cannabinoids may have another therapeutic benefit in managing acute and chronic pain — they may help sleep.
The patient tells me sleep is interfered with because turning over in bed increases the left medial knee pain and often wakes him up. Applying topical creams to the knee at night helps normalize sleep, improve pain relief, and his mood is improved. We are all born with brain cannabinoid receptors (receptors in the brain that respond pharmacologically to various compounds in cannabis as well as other endogenous compounds) and the naturally-occurring messenger molecules that activate and bind to them (endocannabinoids). This patient was instructed to apply a topical cannabis cream four times a day. He could apply it right through the tape and we did not find skin irritation or adverse wear on the tape.
The use of hemp oil and other related products offers a unique pathway (cannabinoid system) along with healing laser to decrease pain that many patient’s bodies have not yet tried. My experience suggests that using CBD is an opportunity for us to try something new without risks. Many are familiar with botanical extracts (menthol, camphor, arnica, etc.) and what they are capable of doing.
The endocannabinoid system is known for important developmental functions, neural development, neuroprotection, immune protection and pain relief. Osteoarthritis, joint inflammation, a dysfunctional endocannabinoid system, and things we are still discovering. This combination may be responsible for certain syndromes we commonly see, and it certainly helped this patient get back to fast walking without knee pain, and getting back on his bike pretty quickly.
JEFFREY TUCKER, DC, is the current president of the ACA Rehab Council. He practices in Los Angeles, Calif., and can be reached at DrJeffreyTucker.com.
Kogan N, et al “Cannabidiol, a major non-psychotropic Cannabis constituent enhances fracture healing and stimulates lysyl hydroxylase activity in osteoblasts” JBMR 2015; DOI: 10.1002/jbmr.2513.
Nugent SM, Morasco BJ, O’Neil ME, et al. The effects of cannabis among adults with chronic pain and an overview of general harms: a systematic review. Ann Intern Med. 2017;167(5):319-331.