72. Examining Upper Extremity Pain with Pradeep Chopra, MD

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00:00
Dr. Pradeep Chopra
When patients with Eds go to a doctor who has probably never seen Eds, gets all excited about it and says. 

00:07
Dr. Pradeep Chopra
Hey, show me what you can do. 

00:09
Dr. Pradeep Chopra
That's when you say, no, I'm not going to show it to you because it's not going to help me in any way. It's just going to entertain you. I'm not doing it because remember, stretching your joint will stretch the ligament, and that's going to damage it forever. 

00:33
Dr. Linda Bluestein
Welcome back every Bendy body. To the Bendy bodies. Podcast. I'm your host and founder, Dr. Linda Bluestein, the Hypermobility MD, here to provide you with accessible information and inspiration about hypermobility disorders like Eds, HSD, Marfan syndrome, and so much more. Combining my medical expertise and personal experiences and my passion for the science and clinical treatment of symptomatic joint hypermobility, I also treat patients and coach clients to optimize their quality of life. 

01:04
Dr. Pradeep Chopra
So let's get after it. 

01:06
Dr. Linda Bluestein
As always, this information is for educational purposes only and is not a substitute for medical advice. Today, we are so excited to have my friend and mentor, Dr. Pradeep Chopra, back with us for yet another great conversation. Before I welcome Dr. Chopra, let me introduce my friend and yours, Jennifer Milner, former professional ballet and Broadway dancer who trains hypermobile artists to work to their fullest potential. She knows a thing or two about being a Bendy Body. We are so fortunate to have Jen here today co hosting this episode. Hey, Jen, it's so good to have you here. 

01:38
Jennifer Milner
Hey, always good to be here. 

01:40
Dr. Linda Bluestein
All right. And Dr. Pradeep Chopra is a Harvard trained anesthesiologist, double board certified in pain management, and anesthesiology director of the center for Complex Conditions and Assistant Professor Brown Medical School, with a special interest in chronic complex pain conditions and their associated coexisting conditions. Dr. Chopra, hello and welcome back to Bendy Bodies. 

02:04
Dr. Pradeep Chopra
Hello. 

02:05
Dr. Pradeep Chopra
Hi, this is Pradeep Chopra, and it's. 

02:07
Dr. Pradeep Chopra
A pleasure and an honor again to. 

02:10
Dr. Pradeep Chopra
Be back with you guys. Thoroughly enjoyed doing the last two, three podcasts. I'm not even sure how many at last come. This is our third one. But happy to talk about Eds and my 30 years of experience in treating this condition fabulous well. 

02:30
Dr. Linda Bluestein
We love getting to learn from you, and always our listeners are very grateful for the information. And we did previously speak about pain in the abdomen, the chest, the head, the neck, and the spine. And so I highly encourage listeners to check out those episodes as well. And today we are going to speak about pain in the extremities. So, Dr. Chopra, maybe you can start off by telling us why this is such an important topic to cover when we're talking about Ehlers Danlos Syndromes. 

03:02
Dr. Pradeep Chopra
So I'm going to talk about the reason I want to talk about upper extremities, because we are covering the whole body part by part, and obviously, upper extremities are extremely important for a number of reasons. It's also, among all the body parts. It's the most used body part, the upper extremities. That's the one we use for our activities of daily living, writing, eating, everything. 

03:30
Dr. Pradeep Chopra
Else. 

03:34
Dr. Pradeep Chopra
Before we go on to going on the upper extremity part. After the last podcast on abdominal pain, there was something I remembered we forgot to talk about and that was on upper back pain. 

03:50
Dr. Pradeep Chopra
One of the reasons, actually one of. 

03:52
Dr. Pradeep Chopra
The more common reasons for upper back pain, which is the area between the shoulder blades is actually gastroparesis. And it has been seen again and again patients with gastroparesis that is slowing down of their stomach movements causes upper back pain. 

04:10
Dr. Pradeep Chopra
So for all the reasons we talked. 

04:12
Dr. Pradeep Chopra
About, just wanted to recap upper back pain, gastroparesis, which is slowing down, or the movement of the stomach contents. The second was the posture in which you hold your head and neck and the slouching posture. And then we talked about loose ribs and loose vertebra in the upper thoracic and cervical region. So these are the common reasons. There's another reason which is not particular in Eds, but it is common amongst everybody. And of course the EDSS have to get the non Eds conditions as well as Eds conditions and that is called repetitive strain injury and that's from excessive use of your upper extremities. So we'll talk about that when we talk about upper extremities. So starting from the top, let's talk about shoulder pain. So the shoulder joint itself is so when I talk about the shoulder joint, I mean the rounded portion that you see, the rounded portion of the shoulder is called the shoulder joint for our discussion purposes. 

05:18
Dr. Pradeep Chopra
And this is generally made up of two joints. One's called the glenohumural joint, which is a bigger joint, which is a rounded portion. And then you have a tiny little joint next to it which you can barely see. And it's called the AC joint or the Acroclavicular joint. 

05:35
Dr. Pradeep Chopra
And they both hurt. 

05:36
Dr. Pradeep Chopra
So that's the problem. But in any case, the shoulder joint is one of the most unstable joints in a human body. It's not a very stable joint. Actually, the two most unstable joints in my thinking are the TMJ and the shoulder joint. Now, the shoulder joint is not a stable joint is because it needs an excessive range of motion. So you can literally turn your shoulder 360 degrees and that allows not exactly 360, but mostly 360. And the reason we have that movement is because evolutionary from an evolutionary point of view you need that movement to say if you're being chased by a saber toothed tiger you can climb up a tree or something. Or if you want to hunt a mammoth for a woolly mammoth for dinner. 

06:25
Dr. Pradeep Chopra
You can throw a spear at it. 

06:28
Dr. Pradeep Chopra
So you need that range of movement. And that range of movement is what the price we pay for getting that excessive range of movement is loss of muscle around it. And to give you an example. The hip joint is an extremely stable joint and it is packed with muscles all around it. It's a deep joint, but its range of motion is just very lousy. All it does is it moves backwards and forwards. So in contrast, the shoulder joint is a very flexible joint. It's not a super stable joint. And obviously in EdsRS, it becomes a problem. At this point, I'd like to talk about why do EDSS have a loose shoulder joint? What happens? It starts you have to go back to your childhood. Most people with Eds have they're very flexible and because of their flexibility, they're always chosen to be in all sorts of dances, which, as you guys know, they are always chosen for ice skating and cheerleading and all of those exercises, sports and athletics. 

07:37
Dr. Pradeep Chopra
And this is the point at which their shoulders get damaged. So for all of the parents who are listening to this is a very cautionary move. I would suggest is to avoid any of these at a young age, or if you are going to do it, be very careful that they do not have an excessive range of motion to their shoulders, because once a joint is overstretched, there is very little chance of it ever going back again. In my experience. The reason I say this is because I've seen in adults who don't have very unstable joints, shoulder joints, and when you ask them about their childhood and they'll say, yeah, I was one of those nerds who never really took part in athletics. And then you have this other group of people who are all gung ho about cheerleading and dance and athletics, and their shoulders are now gone. 

08:30
Dr. Pradeep Chopra
So that's the problem. 

08:32
Jennifer Milner
Well, and it's interesting that you say that, because those sports or arts are inherently attractive to people with a large range of motion in their shoulders, because they can reach those full, completely crazy, incredible lines, and they can do those crazy, amazing things. And when your child is ten and they're like, yeah, it clicks all the time, but it doesn't hurt, right? It's hard to say, well, stop doing that, because it'll hurt when you're 20. 

08:59
Dr. Linda Bluestein
Well, especially if they don't even say. 

09:01
Jennifer Milner
That it clicks, they may think everybody. 

09:04
Dr. Linda Bluestein
Clicks, or if they have no problems whatsoever. I mean, this is a really important thing, because I know I get asked this all the time should my child dance, do gymnastics? How do I know? And if they have no problems whatsoever, but they do have either localized or peripheral or generalized joint hypermobility. It is a tricky conversation, especially if they're passionate about what they're doing and it's helping their mental health and helping them stay strong. I think it can be hard to make those choices. Don't you think sometimes that knowing what the future might hold for one person as compared to another person? 

09:48
Dr. Pradeep Chopra
Obviously, I've had very dirty looks from kids when I tell them that, listen, you can't do cheerleading or you can't do dance anymore because it's not dance as much as things like cheerleading or roller blading or whatever, roller skating and things like that. And I do get dirty looks on that. So I figured it out, figured out a way. 

10:11
Dr. Pradeep Chopra
So I tell them that swimming, so. 

10:15
Dr. Pradeep Chopra
You give them an alternative exercise or alternative athletic activity, and I'll say, look, swimming is a good choice for you, and you can look at swimming and other things, other activities where you're not old, you can do your athletic. I mean, you can do your dance moves, you can do all of these, but not on a competitive level. And the parents need to talk to their teachers about keeping it low key and not pushing them and preferably the best option is, of course, not to. 

10:47
Dr. Pradeep Chopra
Do it at all. 

10:48
Dr. Pradeep Chopra
And if they have to do it, then they need to keep that low key or else redirect them to some other athletic activities which are not going to be as harmful, like swimming and even running. And running is a good one. Track is another good one. They can do, but track only when. 

11:08
Dr. Pradeep Chopra
They'Re children, not when they grow up. Once they grow up, track is a very bad idea. So you can redirect their attention to something else. 

11:17
Jennifer Milner
Well, but even swimming, all of my clients who swim or swim at some time, they specialize in the butterfly stroke because they have the shoulders that they can just pop out of the socket and give them this fantastic range of motion. So I think wherever they end up and however healthy they're trying to be, I think a huge part of that is the intentionality of finding someone that can train them in that end range of motion. If they're a baseball pitcher or if they're a gymnast, or if they're a swimmer, whatever it is, saying, okay, this is the range of motion you're working in. We have to make sure you're as stable as possible. And not just don't just cross your fingers when you're ten and hope it's all going to be great, but find people who understand hypermobility, even if you're not in one of those higher risk, more extreme sports that can really understand and train you to work safely with your wonky body. 

12:09
Dr. Pradeep Chopra
Did he say monkey body or wonky body? 

12:16
Dr. Linda Bluestein
Monkey sometimes would be somewhat appropriate. Also, I think it's also to me, it's kind of like thinking about football players and head injury, and I try to give them the information and say, think about your family history. What do your parents look like in terms of are they having problems with chronic pain or not? Do you have difficulty building muscle mass to protect your joints or know kind of where are you on that spectrum? Because yesterday I gave a talk at the Colorado Ballet Academy and all the kids wanted to have their knee hyperextension measured. And a lot of them, of course, have hyperextended knees, but not all of them by any means have. 

12:57
Dr. Pradeep Chopra
We would. 

12:58
Dr. Linda Bluestein
And we don't know. We don't know at these ages. We won't know until a lot later whether or not they start to develop more symptoms and problems. And so I think those conversations I would rather that they make that decision for themselves, I guess, is what I'm thinking. 

13:14
Dr. Pradeep Chopra
Right. And the thing is, a lot of times parents don't realize that their children have hypermobility or they don't take it. 

13:24
Dr. Pradeep Chopra
Seriously because they have never heard of. 

13:27
Dr. Pradeep Chopra
Eds or aren't aware of that. And I've always said that in schools you always have this mandatory Scoliosis test. 

13:37
Dr. Pradeep Chopra
Right, which is not really a very. 

13:39
Dr. Pradeep Chopra
Helpful thing to do anyway. Why can't we do the Byteon score, which takes 9 seconds to do, and look at it? And if the Byteon score is super high, like nine or nine. All right, go down to see the guy who does ads and tell us whether what's the next step to bring to your point about hypermobility. So you've got a crowd, you spoke at the Colorado Ballet Association and now you have a crowd of 200 people. 

14:07
Dr. Pradeep Chopra
And who's got Eds and who's not got Eds. 

14:11
Dr. Pradeep Chopra
They all look like they have Eds, but you don't want to brand them as Eds just because they're hypermobile. 

14:18
Dr. Pradeep Chopra
So in my mind, I have a little hack. 

14:23
Dr. Pradeep Chopra
A hack number one for our podcast this time is I ask them if they have other symptoms, unrelated, like do you get lightheaded when you get up. 

14:34
Dr. Pradeep Chopra
From bed or do you get palpitations? And if they say yes, then it. 

14:39
Dr. Pradeep Chopra
Sort of triggers me to go more. 

14:41
Dr. Pradeep Chopra
Into the ads part of it. 

14:43
Dr. Pradeep Chopra
If they say no, I don't have any of that and their bite and score doesn't seem to be terrible, then I'll just say keep an eye, things may get better, things may get worse, but if they get worse, you really. 

14:55
Dr. Pradeep Chopra
Need to follow up on that. So I just taken that little Pots. 

14:59
Dr. Pradeep Chopra
Thing into that picture because if they have Pots, that means they probably do have Eds and are probably getting to I mean, it's not very scientific, this connection, but it gives the parents some sort of a parameter as to know where to stop and look for a specialist. 

15:19
Dr. Linda Bluestein
Yeah, no, I think that makes a lot of sense. And I do want to point out, just so we don't get people panicking, if you have had a really hard day of class and rehearsals and haven't drank enough, you're going to get dizzy when you stand up. We're talking about if this happens on a more frequent basis, has it happened once in a while or maybe you had the flu or a cold or something and that happens. So yeah, no, I think that's an excellent way to look at it. And I do a similar thing and do they have gastrointestinal problems, for example? And it's not uncommon that they'll say, yes, I have certain ones. We'll say, yes, I have pain after eating, or whatever. So, yeah, I think that's a good approach. 

15:59
Dr. Pradeep Chopra
Right. 

16:01
Dr. Pradeep Chopra
So getting back to the shoulder joint, as I said, is. 

16:06
Dr. Pradeep Chopra
Inherently a very unstable joint, whether you. 

16:09
Dr. Pradeep Chopra
Have Eds or you don't have Eds. But obviously, when you have Eds, the first thing you've got to remember, especially for parents, is to make sure your children do not hyperextend their shoulder joints. Think of the ligaments around any joint in your body as an elastic band. 

16:28
Dr. Pradeep Chopra
An elastic band. 

16:29
Dr. Pradeep Chopra
If you stretch it a little bit, it's fine, it'll go back. But if you stretch it too much. 

16:33
Dr. Pradeep Chopra
It'S not going to go back. 

16:35
Dr. Pradeep Chopra
And then the shoulder becomes unstable. And here's the problem. When the shoulder joint becomes unstable, because the ligaments around the shoulder joint don't just support the shoulder itself, they support the whole arm. So the arm starts to hang off. And because the weight of the arm then drags on the shoulder joint, and when that happens, then they have a constant pain down their arm, it's always hurting. And of course, the shoulder is super loose. And for any of our listeners who are thinking like, oh, I can just go to the orthopedic surgeon, and they can tighten it up bad, very bad idea. 

17:15
Dr. Pradeep Chopra
It has been shown again and again. 

17:18
Dr. Pradeep Chopra
In studies that any surgery on a joint makes the joint inherently weaker again, worse and worse. I've had patients who've had six joint surgeries. I had a patient last week who had 17 right knee surgeries. I mean, at some point, the surgeon should have said, wait a minute, we're not getting anywhere. I paid my mortgage 20 times over on surgery, think we should stop. But this is what I'm trying to say, is what happens is when they do surgery, they cut tissue. And when they cut the tissue and then they sew it up again with the idea that this tissue is then going to heal by itself and it'll keep the joint tight, which does happen under non Eds conditions. But in Eds, once you cut that tissue, no matter what, it's going to restretch again. And this time it's become weaker than before. And so the stretching is going to be even greater, which makes the joints, not just shoulder joints, but the joints unstable. 

18:31
Dr. Pradeep Chopra
And there's really no good surgery to fix that. There's no good mechanism. 

18:35
Dr. Pradeep Chopra
Also, there are no good braces to fix that. 

18:41
Dr. Pradeep Chopra
Well, there is one brace, which I like, and we'll talk about that. We did talk about it the last time the body braid, but we'll get into that later on. But what I'm trying to caution people is with your shoulder joint, stay under your range of motion so you don't have to go all the way. So I can bring my arm all the way up next to my ears, straight up. 

19:05
Dr. Pradeep Chopra
I don't need to do that. 

19:07
Dr. Pradeep Chopra
There's no reason unless you're trying to reach something on the top shelf, there's no reason to do that. So most of the time, stay at 90 degrees. 

19:14
Dr. Pradeep Chopra
So your arm, let's say the right. 

19:17
Dr. Pradeep Chopra
Arm should be at 90 degrees to your body, or your armpit should be at 90 degrees so that your hand can reach your face. 

19:25
Dr. Pradeep Chopra
That's all you need. 

19:26
Dr. Pradeep Chopra
We don't need our hands going higher. 

19:28
Dr. Pradeep Chopra
Than our head because it's not really. 

19:30
Dr. Pradeep Chopra
Helpful, not very valuable, only under special circumstances. If you're being chased by a saber tooth tiger, yes, then you can go up the tree, that's fine. But otherwise there's no need to do that. So your arm should be at I don't know if I'm explaining this correctly. 

19:47
Dr. Pradeep Chopra
Or not, but the arm should not. 

19:49
Dr. Pradeep Chopra
Exceed 90 degrees at your armpit. 

19:53
Dr. Linda Bluestein
Do you mean 90 degrees of flexion or do you mean 90 degrees of abduction? 

19:59
Dr. Pradeep Chopra
Or it's abduction. 

20:02
Dr. Pradeep Chopra
Yes, that's a good point. I forgot to bring abduction. That means moving your arm to the side. So you bring your arm, raise your. 

20:09
Dr. Pradeep Chopra
Arm to the side up to 90. 

20:11
Dr. Pradeep Chopra
Degrees, so that's enough to bring. 

20:14
Dr. Pradeep Chopra
Your hand to cover your face. 

20:15
Dr. Pradeep Chopra
So that's protect your face, take care of your face, eat, be able to, let's say, bring it up to your face. That's all we need to do, the range of motion we need on our shoulder. And that is way under the full range of motion. So it doesn't damage the shoulder capsule or the ligaments. 

20:36
Dr. Pradeep Chopra
That's the idea. 

20:38
Dr. Pradeep Chopra
So that's how you can protect it. And now, most adults, people with adult EDSS do have loose shoulder joints, and some more than others, but this rule applies to everyone, is to keep, not. 

20:53
Dr. Pradeep Chopra
To bring the shoulder joint, and not. 

20:55
Dr. Pradeep Chopra
To bring the shoulder joint, keep it under its range of motion. So keep it at 90 degrees, away from what's called abduction or away from your body is 90 degrees. And it should be enough to cover your hand, should be able to cover. 

21:08
Dr. Pradeep Chopra
Your face, so you can brush your. 

21:10
Dr. Pradeep Chopra
Teeth, feed yourself, take care of your, protect your face. And this rule of staying under your range of motion applies to every single joint in the body. So you don't want to overstretch your elbow joint, you don't want to stretch your knee joint. This is important because the analogy is if you overstretch an elastic band, it'll never go back. 

21:31
Dr. Pradeep Chopra
It'll just stay as a loose thread. And that's the whole idea. 

21:35
Jennifer Milner
One of the things I talk about with my clients, and this may not be 100% accurate, but I talk about how if other people's joints are rubber bands, ours are closer to thinking putty or Silly putty that stretches, but doesn't necessarily come back to its original form the way that rubber bands do. So I encourage them to think about, are we going to sit in a hypersplit or throw your shoulders into some comfortable but crazy position and just allow the joints and the connective tissue to stretch and then end up where they are? Or do we want to keep it smaller so that we'll have that resilience still in there? Does that make sense? 

22:15
Dr. Pradeep Chopra
Yes, absolutely. On that point, it's not related to the excessive range of motion, but oftentimes. 

22:22
Dr. Pradeep Chopra
People with Eds will crack their joints. 

22:26
Dr. Pradeep Chopra
Okay, now cracking, let's differentiate between cracking and popping joints. Cracking is how you crack your knuckles, sort of release the pressure on your joints. That's called cracking. And popping is subluxing or dislocating your joint. Now, cracking joints is common in Eds. 

22:45
Dr. Pradeep Chopra
And it's okay to do that. I have had parents who freak out. 

22:49
Dr. Pradeep Chopra
Because their kids are constantly cracking their knuckles or their spine. And it's okay to do that as long as they are doing it. And theory behind that is that between every joint there is a gap. And in that gap is a fluid. 

23:03
Dr. Pradeep Chopra
That lives in a pocket. 

23:05
Dr. Pradeep Chopra
That's the joint fluid. 

23:06
Dr. Pradeep Chopra
And there are different theories, but generally. 

23:10
Dr. Pradeep Chopra
The volume of the fluid increases in these joints. Now, if your joint is loose, that means you can hold much more fluid. And so once it holds a lot more fluid, their pressure on that joint, the inside pressure on the joint, is excessive. So what they do is they crack their joints more often to release the pressure, and that's fine. And most times they'll tell you that they feel better, they have less pain. 

23:34
Dr. Pradeep Chopra
When they crack their joints. 

23:37
Dr. Pradeep Chopra
We do that too. We, meaning non EDSS, do that too. We crack our necks a few times or we crack our shoulders, stretch our shoulders and we crack it. And it's fine as long as you're doing it and not anybody else. 

23:52
Dr. Linda Bluestein
I'm curious because a lot of those things become habitual, right? The cracking of the joints. And I definitely have joints that crack and ones that pop and had shoulders that popped and subluxed a lot before I knew what that was and let it happen or did it a lot more than I wish that I hadn't done all that. But do you think, though, if you're doing that cracking, that over time causes those ligaments to stretch out or you don't think that happens? 

24:17
Dr. Pradeep Chopra
No, they don't, because they're not really stretching their ligaments. What they're doing is they are just trying to move the joint in a certain way that the pressure inside the joint is released. There are several theories as to why the pressure inside the joint increases. There's one theory that there's collection of carbon dioxide. There's another theory that says fluid simply collects in there. No one knows why, but we know that the volume increases. And when you're cracking a joint, you're not overstretching the joint. 

24:46
Dr. Linda Bluestein
And that's also called cavitation, right? 

24:49
Dr. Pradeep Chopra
Yes. 

24:49
Dr. Linda Bluestein
What you're referring to right now okay, in case people have heard that word. 

24:53
Dr. Pradeep Chopra
So that brings to our second hack. You can't choose burglary as being a burglar as your profession. 

25:02
Jennifer Milner
You can or cannot because you're going. 

25:04
Dr. Pradeep Chopra
To be cracking your joints. 

25:06
Dr. Pradeep Chopra
You're going to be cracking your joints all the way. 

25:08
Jennifer Milner
It's not going to help people with burglary. 

25:11
Dr. Linda Bluestein
People with Eds don't make good burglars is what you're saying. 

25:15
Dr. Pradeep Chopra
Well, they can. I mean, they can sneak through those small spaces, but unfortunately, it's a cracking that gives them away. 

25:22
Jennifer Milner
Okay, so I feel like that's a zero sum balance then, because on the one hand, I can't sneak up on anyone, as my children say, because my ankles are snapping and popping the whole way. But on the other hand, once I'm in handcuffs, I can subluxate my thumb and get out of. 

25:40
Dr. Pradeep Chopra
Right, jennifer, let me just clarify one thing. 

25:43
Dr. Pradeep Chopra
Tell me about this incident when you were handcuffed and why were you handcuffed? 

25:47
Dr. Pradeep Chopra
Allegedly. 

25:50
Jennifer Milner
No, you know, speaking of that, though, with the thumbs, the reason I know that is because I have never unhooked a bracelet. To put a bracelet on my wrist, I hooked, and I just slide them over my hands, and I can just tuck my thumb in to slide it on. I didn't know everybody couldn't do that until I was an older teenager and somebody was like, what are you doing? And I was like, just tucking my thumb in so I can put my bracelet on. 

26:14
Dr. Linda Bluestein
That's funny. 

26:16
Dr. Pradeep Chopra
So we just went off topic. So the shoulder joint again, so we're talking about protecting your shoulder joint. There are really no great braces for. 

26:25
Dr. Pradeep Chopra
Shoulder joints except the body braid. 

26:29
Dr. Pradeep Chopra
And we talked about the body braid at one of our last podcasts. And again, the body braid looks like a bunch of tape put together, but. 

26:40
Dr. Pradeep Chopra
It'S a phenomenal piece of clothing, I. 

26:46
Dr. Pradeep Chopra
Think, or a brace that it was invented by a physician from Toronto, and you can get to the website and you can see how it works. 

26:54
Dr. Pradeep Chopra
And one of the things it really does well is to stabilize the shoulder joint. 

27:00
Dr. Pradeep Chopra
And there are two ways you can wear the body braid to stabilize the shoulder joint. Now, stabilizing means that keeping it from coming out subluxing, but at the same. 

27:11
Dr. Pradeep Chopra
Time being able to use it. That's the idea. 

27:14
Dr. Pradeep Chopra
You don't want to freeze a joint and you can't use it, then there's really no point. So the body braid does that very well. 

27:27
Dr. Pradeep Chopra
The next point. Now, let's say if the next thing. 

27:32
Dr. Pradeep Chopra
I wanted to bring up was the back pain, upper back pain, that happens in people with this. It can happen from your shoulder joint also. Now, one of the things about joints is when a joint subloxes, which means that when the joint slips out of its socket, then the muscles around a. 

27:48
Dr. Pradeep Chopra
Joint tend to tighten up in order. 

27:51
Dr. Pradeep Chopra
To it's a reflex thing. So it tightens up. The muscles tighten up. Trying to put the joint, stabilize the joint, and so that's when you feel patients will feel like something doesn't seem to be in the right place and it hurts a lot. 

28:04
Dr. Pradeep Chopra
And once you put the joint back. 

28:07
Dr. Pradeep Chopra
In place, everything feels right, the pain goes away. But the point I'm trying to make is that the pain that comes from a joint dislocation or a joint subluxation is not from the joint itself, it's from the muscles that are around the joint. So, for example, the group of muscles that control the shoulder joint is called the rotator cuff group. The rotator cuff group controls and manages the shoulder joint. And oftentimes when these patients are subluxing their shoulder joint ten times a day, it feels like their muscles are the most of their pain is from the muscles and not as much from the joint itself. And this is the problem. They show up at their provider's office and it looks like, oh, you've got muscle pain. Let me do something for the muscle pain and help relax that muscle. So it could be either doing dry needling, trigger points, massage, or medicines to loosen up the muscles. 

29:03
Dr. Pradeep Chopra
But you do not want to loosen up the muscles. You want to keep your shoulder joint in place. They help keep your shoulder joint in place. Once you loosen up those muscles, your shoulder is going to sublux even more. And this principle applies to all joints. So the concept that, oh, your muscles are very tight and they hurt, we should try and loosen them up with whatever device or whatever means is not a good idea. 

29:29
Dr. Pradeep Chopra
Because when you do that, then you're. 

29:31
Dr. Pradeep Chopra
Making the joint even more. You're taking away the one thing that. 

29:35
Dr. Pradeep Chopra
Keeps your joint stable, and that's the. 

29:39
Dr. Pradeep Chopra
Thing to be careful about. Obviously, there is a cut off point when the muscle pain is so severe that it's difficult to be comfortable. Then of course you can do something about it. But to a limit, do not get very aggressive about loosening the muscles. Because once you loosen the muscles too much, then your joint is going to sublux even more well, and it's a. 

30:01
Jennifer Milner
Great point to make. And that's something that I have to deal with a lot with my clients, is when they have so much tightness, they're like, I just want to release this. It just feels so tight. It just feels so tight. And for me, that's a signal to say, hey, what's not working? 

30:15
Dr. Pradeep Chopra
What is super loose? 

30:16
Jennifer Milner
If the front of their hips feel super tight, what's not working in the back of the legs? If their pecs in their chest feel really tight, why are the pecs working so much? What is not working? And what compensatory strategies have happened because of that? And I tell them, I can't loosen this up. It's like taking too many rocks out of a rock wall and then the rock wall is going to collapse. If we. Don't put something else in there to help hold that structure up. So we take a little out, we do a little strengthening of something else, and we kind of gradually replace the rocks in the rock wall, but we can't just take them all out at once. So that's a really great point. 

30:53
Dr. Pradeep Chopra
Right. 

30:55
Dr. Linda Bluestein
I'm sorry. Can I ask a couple of follow ups before we move on? 

30:58
Dr. Pradeep Chopra
Sure. 

30:59
Dr. Linda Bluestein
So the first thing is, could you comment about the concept that a tight muscle is a weak muscle? And then also a lot of my patients that come to me that have been seeing other clinicians, it's very common that they are taking daily muscle relaxants. They have been prescribed not for acute like you're talking about. Take this when you've acutely subluxed something, but they're taking every single day they're taking muscle relaxants. Would you comment on those two things? 

31:31
Dr. Pradeep Chopra
Okay, so on the first point, patients with Eds have inherently weak muscles because. 

31:40
Dr. Pradeep Chopra
Their connective tissue is weak. We know that. And the risk about having weak connective tissue means that your connective tissue is going to break down easily and takes much longer to heal. Which is why when we I think at some point we talked about exercise, and I said, you got to limit your exercise, your pace. It so that you're not causing enough too much of a damage to your wear and tear to your muscles. Now, when a muscle becomes tight in an Eds patient, and just as Jennifer mentioned, you have to look at why is your muscle so tight, there's a reason why your muscle is getting so tight. There's a reason your muscle is misbehaving. You don't just go for the muscle. You look at the joint that muscle is supporting, and is that joint loose? Is it subluxing? Is it not aligned? And therefore your muscles are tight. 

32:31
Dr. Pradeep Chopra
So then you work on the joint and you stabilize the joint by whatever. 

32:34
Dr. Pradeep Chopra
Means, and the muscle will let go automatically. 

32:38
Dr. Pradeep Chopra
Rather than sticking needles or doing all sorts of massage therapy and deep tissue massage and all sorts of things, you don't want to do that's going to damage the tissue much more. But there's one caveat to this. The caveat being that, of course, if it's excruciating pain and just for the time being, you can do something about it. Let's say you can put some magnesium lotion over it or even a gentle myofascial release to help sort of loosen up the muscle for the time being, then that's fine. It's better than going to the emergency room. But in general, look for the cause. 

33:17
Dr. Pradeep Chopra
Of the muscle tightness, which is usually. 

33:19
Dr. Pradeep Chopra
A misaligned subluxing muscle joint. Now, on the point on muscle relaxants so muscle relaxants is a misnomer. There are no muscle relaxants. The only muscle relaxants we have are what you use in the operating room. 

33:33
Dr. Pradeep Chopra
Linda okay? 

33:35
Dr. Pradeep Chopra
Trust me, you don't want to use them. 

33:38
Dr. Linda Bluestein
We're not paralyzing agents or anything like. 

33:42
Dr. Pradeep Chopra
That, you don't want to use don't. Those are paralyzing agents. So those are the true muscle relaxants. But drugs like Tyzanidine or Flexoril or soma and all these are not muscle relaxants. These are drugs that lower the tone of your muscles. So if you have a muscle spasm somewhere, let's say you have a muscle. 

34:04
Dr. Pradeep Chopra
Spasm in your calf and you take. 

34:06
Dr. Pradeep Chopra
Some Flexoril, it's not going to fix that muscle spasm. But what it's going to do is put you to sleep, and then the. 

34:11
Dr. Pradeep Chopra
Muscle will let go. But it doesn't do anything to release that spasm. 

34:17
Dr. Pradeep Chopra
There is one exception to the drugs. It's not classified as a muscle relaxant. And this is one of my favorite drugs for muscle cramps and muscle spasms, and it is called Carbidopa. 

34:29
Dr. Pradeep Chopra
It is marketed under the name of Cinemat. It's a combination of carbidopa and levodopa. 

34:35
Dr. Pradeep Chopra
This was something that I discovered years. 

34:37
Dr. Pradeep Chopra
Ago when I was just reading some. 

34:39
Dr. Pradeep Chopra
Literature, and I came across that patients with chronic muscle pain have low dopamine. 

34:44
Dr. Pradeep Chopra
Levels in their brain. And so I said, Wait, if you. 

34:47
Dr. Pradeep Chopra
Have low dopamine levels in chronic muscle pain, I know a drug that can. 

34:52
Dr. Pradeep Chopra
Increase that dopamine level. So why not try citimet? 

34:55
Dr. Pradeep Chopra
And we did try it, and we. 

34:57
Dr. Pradeep Chopra
Got really good results with it. So that's a drug. You can take half a pill, a. 

35:03
Dr. Pradeep Chopra
Full pill, doesn't matter. 

35:05
Dr. Pradeep Chopra
It does help with muscle cramps and pains. 

35:08
Dr. Pradeep Chopra
But in reality, there is no true. 

35:11
Dr. Pradeep Chopra
Muscle relaxant that can be used. But there's another option, is to use a magnesium lotion. 

35:21
Dr. Pradeep Chopra
Magnesium lotion applied topically does make a huge difference. 

35:25
Dr. Pradeep Chopra
Now, when I say we, I mean. 

35:28
Dr. Pradeep Chopra
Eds and non edsers. 

35:30
Dr. Pradeep Chopra
We are chronically magnesium deficient, and I don't know why. 

35:35
Dr. Pradeep Chopra
I mean, growing up in med school, magnesium was never a subject. No one talked about magnesium. And honestly, you cannot even check magnesium levels. If you go to the lab, they do a blood test, and that tells you magnesium levels. But magnesium tends to hide in bones and muscles. So a blood magnesium level is not going to tell you the true magnesium levels. But we all have low magnesium levels. It could be in the fruits and vegetables. 

36:04
Dr. Pradeep Chopra
They come from green leafy vegetables. 

36:06
Dr. Pradeep Chopra
It could be that you're not taking enough green leafy vegetables. It could be that the green leafy vegetables that are grown are not grown. They're grown hydroponically, and they're probably not getting enough magnesium. 

36:17
Dr. Pradeep Chopra
I don't know. This is just a guesswork, but when. 

36:20
Dr. Pradeep Chopra
You increase your magnesium now, magnesium orally does not work as well as topical magnesium. So magnesium lotion works really well. You can take some magnesium lotion, it's freely available online and everywhere, and you apply it, rub it over the muscles cramp area, and you should start to see some relief within a few minutes. 

36:46
Dr. Pradeep Chopra
There is one particular brand that has. 

36:50
Dr. Pradeep Chopra
Capric acid in it also, which is. 

36:51
Dr. Pradeep Chopra
Grapeseed oil, which helps with pain. 

36:54
Dr. Pradeep Chopra
So it's magnesium with capric acid. 

36:57
Dr. Pradeep Chopra
And the only company that makes it is Ancient Minerals. 

37:01
Dr. Pradeep Chopra
Ancient minerals. 

37:02
Dr. Pradeep Chopra
That's it. 

37:03
Dr. Pradeep Chopra
It's called ancient minerals. They have a few different models, I just realized that. But there is one that is just lotion you can get that don't get the oil. The oil is kind of irritating. Get the lotion and just apply it and it makes a huge difference. This goes for both Eds and non Eds patients. Oftentimes people get home after a long day at work. Their muscles are achy. They want to put their feet up and just let go and relax. 

37:30
Dr. Pradeep Chopra
That's the time to put some of this. 

37:32
Dr. Pradeep Chopra
Oral magnesium does not get absorbed well. And if you take too much of it trying to hoping to get some. 

37:39
Dr. Pradeep Chopra
Of it absorbed, you end up with diarrhea. So it's not worth it. 

37:44
Dr. Pradeep Chopra
The other magnesium form that you can use is called Epsom salt. 

37:48
Dr. Pradeep Chopra
Epsom salt has tons of magnesium in it. Did you know where the word Epsom salt came from? No. 

37:55
Jennifer Milner
And I wondered that. 

37:57
Dr. Pradeep Chopra
It came from a little town in UK called Epsom. 

38:02
Dr. Pradeep Chopra
That's where it was produced first or. 

38:05
Dr. Pradeep Chopra
I guess discovered first. I've always thought that it was an acronym or something, and then I sort of discovered it's from a town in UK where it came from. So in any way I digress. So this has magnesium in it. Two large cups of magnesium in a warm bathtub and you soak yourself in. 

38:24
Dr. Pradeep Chopra
It and you're good to go. 

38:27
Dr. Pradeep Chopra
Don't wash it, so don't take a shower after you've come out. Just let it dry on you. That's magnesium for muscle cramps and muscle spasms. 

38:40
Jennifer Milner
That's a good hack too. I think a lot of us already do Epsom salts, I think, especially in the athletic community. But it's a great tip to not wash off afterwards and to just kind of leave it there. 

38:53
Dr. Pradeep Chopra
There's one small warning on that part. 

38:56
Dr. Pradeep Chopra
Okay? If you have a dog, keep him. 

38:58
Dr. Pradeep Chopra
Away from you because he's going to lick at your legs because he's getting a lot of magnesium that they want. 

39:03
Dr. Pradeep Chopra
So he's going to lick all your. 

39:04
Dr. Pradeep Chopra
Epsom salt off your legs. Keep him off. But anyway, if you don't have a bathtub, you can put a few drops of water in the salt and make a little paste like thing and rub it over your legs. 

39:18
Dr. Pradeep Chopra
And that'll work just as fine coming. 

39:23
Dr. Pradeep Chopra
To the shoulder joint. 

39:25
Dr. Pradeep Chopra
The shoulder joint, remember I told you. 

39:27
Dr. Pradeep Chopra
There'S a big joint called the Glenohumural joint? That's where the big ball and socket joint is. And then you have the tiny joint where the collarbone meets the shoulder joint, which is called the AC joint or the Chromioclavicular joint. For purposes of our sanity, we'll just call it AC joint. And so this AC joint is a tiny joint that lives sort of near the shoulder joint. And it does get arthritic and it does get painful. And like every joint it becomes loose. So you've got to remember that in Eds, joints not only sublux or dislocate, but they also become loose. That means they don't sublux, but they are rattling around. 

40:07
Dr. Pradeep Chopra
And that's what happens to the AC joint, the collarbone. 

40:12
Dr. Pradeep Chopra
So on its outside it connects to the shoulder joint, but on the inside. 

40:16
Dr. Pradeep Chopra
It connects to the breast bone and. 

40:18
Dr. Pradeep Chopra
It forms a joint there called the menubrio sternal joint. It's very uncommon, but I've seen a few cases of where the Menubrio sternal joint is loose and it's kind of painful. But the problem with the collarbone is, and this is where I want to talk to you about a condition called thoracic outlet syndrome. Thoracic outlet syndrome. Let's talk about the symptoms. The symptoms are exactly upper back pain and pain going down the arm to specific fingers. It could be the thumb, the pointer and the middle finger, or it could be the ring finger and the pinky finger. So it exactly looks like it's coming as like a disc herniation from your neck going down your arm. So this pain originates in the shoulder and upper back and goes down the arm. And the way the reason it does that in thoracic outlet syndrome is that. 

41:13
Dr. Pradeep Chopra
The first rib is a very flat rib. It sits very flat just below the collarbone and the collarbone crosses over the first rib and there is a gap. 

41:28
Dr. Pradeep Chopra
Between the collarbone and the first rib. 

41:30
Dr. Pradeep Chopra
There's a very small gap. 

41:32
Dr. Pradeep Chopra
And in this gap live the nerves. 

41:35
Dr. Pradeep Chopra
That come down from your neck. 

41:37
Dr. Pradeep Chopra
They slide over the first rib and under the collarbone and go down your arm. 

41:42
Dr. Pradeep Chopra
And this is called the brachial plexus. 

41:45
Dr. Pradeep Chopra
So these nerves go over the first rib, under the collarbone, down to your. 

41:49
Dr. Pradeep Chopra
Arm, and then along with that you. 

41:51
Dr. Pradeep Chopra
Have the vein, also the brachiocephalic vein that goes down your arm. And then you have the brachial artery. 

41:58
Dr. Pradeep Chopra
That also goes down your arm. 

42:00
Dr. Pradeep Chopra
And then you have a few muscles in there. So there are a bunch of structures that live in this small gap between. 

42:06
Dr. Pradeep Chopra
Your first rib and the collarbone. 

42:09
Jennifer Milner
It sounds like you're saying, sorry to interrupt you and I just want to make sure I understand. It sounds like you're saying that thoracic outlet syndrome can sort of mimic or imitate like disc issues. And so you're saying this might be another possibility that people should look at. 

42:24
Dr. Pradeep Chopra
Is that correct? 

42:25
Dr. Pradeep Chopra
Absolutely. I'm sorry, I should have completed that sentence. That is what I was trying to warn people often. I've seen many times where people have had neck surgery just based on that. If you take an MRI of anybody's neck, there's going to be something there. There is no such thing as a normal MRI. 

42:42
Dr. Pradeep Chopra
And then they look at it and. 

42:43
Dr. Pradeep Chopra
They say, oh yeah, you've got a disc over there, let's operate. But it's really just thoracic outlet syndrome and it's common in Eds. It's common in athletes, and it's common in eds patients. So if you're an athlete with eds, you're in big trouble. Now, this gap is so small, it's between the first rib and the collarbone. Remember when I said that on the other end, on the outer end of the collarbone, it connects to your shoulder joint. Now, should your shoulder joint become unstable, then that makes your collarbone unstable. And when that collarbone bone becomes unstable, it shortens a gap between the rib. 

43:24
Dr. Pradeep Chopra
The first rib, and the collarbone. 

43:26
Dr. Pradeep Chopra
And so the collarbone then presses on the first rib. And in that process, it squeezes the nerve, the brachial plexus, the nerves that. 

43:37
Dr. Pradeep Chopra
Go down your arm, and that's why. 

43:39
Dr. Pradeep Chopra
They have an arm pain. 

43:40
Dr. Linda Bluestein
Did that also happen from the first rib being elevated from increased tension in the musculature, the scalines, or the sternocladomastoid? Can that contribute as well? 

43:51
Dr. Pradeep Chopra
Yes. 

43:52
Dr. Pradeep Chopra
So there are other reasons for having thoracic outlet syndrome. Like you said, remember I just said there are muscles connected to the first rib. So when these muscles tighten up, they pull up the first rib, and then that again shortens the gap. In some cases, there is an extra. 

44:08
Dr. Pradeep Chopra
Rib there, and that extra rib also causes problems. 

44:12
Dr. Pradeep Chopra
But these are exceptional cases. The more common causes of eds, thoracic outlet and eds is this. It's where your shoulder joint is loose, everybody's shoulder joint is loose, and that creates the gap between the first rib and the collarbone becomes lesser, which then presses on the nerve going down the arm. 

44:32
Dr. Pradeep Chopra
And that's called thoracic outlet syndrome. 

44:34
Dr. Pradeep Chopra
And there are three types. There is the neurogenic thoracic outlet syndrome. 

44:38
Dr. Pradeep Chopra
When the nerve is being pressed, when. 

44:41
Dr. Pradeep Chopra
The pressure becomes even more or the gap becomes even lesser, then it also presses on the vein, in which case it's called venous thoracic outlet syndrome. And then the other one, which is extremely rare, is when it presses on the artery. When it presses on the artery, it's called arterial thoracic outlet syndrome. The vein venous thoracic and the arterial thoracic outlet syndrome are not common. 95% of cases are neurogenic thoracic outlet syndrome. Venous and arterial thoracic outlet syndromes are. 

45:13
Dr. Pradeep Chopra
A bit of an emergency because you. 

45:15
Dr. Pradeep Chopra
Can get venous, thrombos thrombus there and all that stuff. But I think in my lifetime, I may have seen about 20 cases of that. 

45:24
Dr. Pradeep Chopra
But a lot of them are just. 

45:26
Dr. Pradeep Chopra
Neurogenic thoracic outlet where there's this nerve pain going down the arm, and it's not that hard to diagnose it. There are like three or four clinical tests that the doctor can do in the office, and it'll tell them there. 

45:40
Dr. Pradeep Chopra
Is thoracic outlet syndrome. 

45:43
Dr. Pradeep Chopra
The other test, there are other radiological tests that they can do where they can do an MRI and all that stuff. 

45:50
Dr. Pradeep Chopra
But here's the thing. 

45:53
Dr. Pradeep Chopra
Oftentimes they do an MRI in the normal position. So your arms are by your side, and that's your most relaxed position. That's your position where you have the least amount of pain. 

46:04
Dr. Pradeep Chopra
You want your arm sticking out away. 

46:07
Dr. Pradeep Chopra
From you, where your arm is actually hurting, where the space has shortened out, your arm is hurting. And that's when you need a picture. And that you can do only in a Cat scan. And so you need a Cat scan to do that. The treatment for thoracic outlet syndrome is relatively simple. What I do let me just tell you what I do. I'll do a couple of trigger point injections. I'm sorry. 

46:34
Dr. Pradeep Chopra
Let me just back up a little bit. 

46:36
Dr. Pradeep Chopra
When the nerve from your arm travels from your neck, travels over the first rib and under the collarboard, and as it's on its way down to your arm, it travels behind a muscle called the PEC minor muscle, or the Pectoralis minor muscle. 

46:50
Dr. Pradeep Chopra
That's that big chesty muscle that people have. 

46:54
Dr. Pradeep Chopra
And it goes behind that, and then it goes down the arm. And again, one of the exams that I'll do in my office is push on the Pectoralis minor muscle, and they'll. 

47:06
Dr. Pradeep Chopra
Tell you that the pain is going down their arm. 

47:09
Dr. Pradeep Chopra
Normally, it should not. If you press on the PEC minor muscle, the pain should not go into the arm. 

47:14
Dr. Pradeep Chopra
But if it does, it points more. 

47:17
Dr. Pradeep Chopra
Towards aneurogenic thoracic outlet syndrome. 

47:19
Dr. Pradeep Chopra
So if I see a patient with. 

47:21
Dr. Pradeep Chopra
Thoracic outlet syndrome in my office, I'll try and do some injections into the muscle, into the PEC minor muscle, into the scaline muscles. Those are the muscles that Dr. Bluestein just mentioned that are connected to the. 

47:33
Dr. Pradeep Chopra
First rib and can pull your rib up. 

47:36
Dr. Pradeep Chopra
So you do that. 

47:37
Dr. Pradeep Chopra
These are neck muscles. 

47:39
Dr. Pradeep Chopra
And then I see what the response is. And if the patient has some sort of a positive response, like, they'll come back and say, hey, doc, it helped for a few weeks, and now the pain is back. 

47:49
Dr. Pradeep Chopra
So now you know you're on the right track. 

47:51
Dr. Pradeep Chopra
And then the next thing is to botox these muscles. 

47:55
Dr. Pradeep Chopra
So when you loosen up these muscles. 

47:57
Dr. Pradeep Chopra
Then the gap between the first rib and the collarbone increases. And so you give some Botox injections into the PEC minor muscle, into the scalene muscles. Approximately. And this is not my figure. This is the data that's been shown that 70% of patients will respond to Botox injections. So the question is, how many insurances will approve Botox injections for thoracic outlet syndrome? 

48:25
Jennifer Milner
Well, it sounds like it should be a lot. Oh, my gosh. 

48:30
Dr. Pradeep Chopra
So 0% of insurances will approve Botox. 

48:33
Dr. Pradeep Chopra
For thoracic outlet syndrome, but those who. 

48:36
Dr. Pradeep Chopra
Do get Botox, 70% of them will respond to it. 

48:40
Dr. Pradeep Chopra
That's the thing. 

48:43
Dr. Pradeep Chopra
Obviously, if you've done all this and they're not responding, then it's time to investigate even further. Do they have an extra rib over there? And all of those things? And then it becomes a messy affair. If you have an extra rib or you're not getting any better, then it involves doing surgery. 

49:00
Dr. Pradeep Chopra
And as we all know that surgery. 

49:02
Dr. Pradeep Chopra
Is not a good idea, but this surgery is fine because it's more of a soft tissue surgery. Now, in the surgery, some of the things that they do is they release the PEC minor muscle. 

49:11
Dr. Pradeep Chopra
So they sort of cut it partially. 

49:13
Dr. Pradeep Chopra
And loosen it up, and then they release a scaline muscle. They'll even remove the first rib to increase a gap over there. 

49:21
Dr. Pradeep Chopra
And the results are pretty good, even. 

49:24
Dr. Pradeep Chopra
Though the surgery is this surgery, but the results are good. Well, I haven't seen too many patients with severe thoracic outlet syndrome that I need to send them to a surgeon for surgery. One exception is that if the patient has started to develop complex regional pain syndrome to their arm because of thoracic. 

49:44
Dr. Pradeep Chopra
Outlet syndrome. 

49:50
Dr. Pradeep Chopra
We'Ll talk about CRPS and Eds at some point, okay? But for those who don't know what CRPS or complex regional pain syndrome is, it's a brutal condition. It's a brutal, painful condition. Actually, it's rated as the worst pain. 

50:05
Dr. Pradeep Chopra
A person can feel. 

50:07
Dr. Pradeep Chopra
So that would be the only exception when I would say, all right, the botox isn't working. I've tried it twice. Time to go and see the surgeon. 

50:14
Dr. Pradeep Chopra
And release that because their arm is pretty useless now because of the severity of the pain. Those are the exceptions, and we've had. 

50:22
Dr. Pradeep Chopra
Some of those exceptions. We've seen that this is a common in the non Eds population, this is. 

50:28
Dr. Pradeep Chopra
A common athletic injury, especially in soccer. 

50:32
Dr. Pradeep Chopra
They get whacked hard, they land on their hand, and when they land on their hand, they cause thoracic outlet syndrome. So this is something to watch out for. The take home point I was trying to make here is just because you have pain in your upper back and neck and it's going down your arm, doesn't mean that it's coming from your neck. Have it checked by somebody who understands thoracic outlet syndrome. A lot of the vascular surgeons know thoracic outlet syndrome. Thoracic surgeons know vascular thoracic outlet syndrome. Some of the physical therapists know this, but not everybody knows how to diagnose it. So all of these kind of people would be the people to go to for getting a diagnosis or at least a suspicion. And I think that pretty much covers the shoulder itself, moving down to the elbow. The elbow joint is a pretty stable joint. 

51:25
Dr. Pradeep Chopra
It doesn't really sublux a lot or dislocate a lot. Even if it subluxes, it's not a problem. But what happens is if your elbow joint hyperextends. So hyperextends means that if you look at it from the side, it looks. 

51:40
Dr. Pradeep Chopra
Like a broken stick. 

51:45
Dr. Pradeep Chopra
What happens is now, this is where we talked, remember I talked about misaligned joints, subluxed joints, and dislocated joints. So this is where the joint is not subluxed, but misaligned. And because it's misaligned, it causes more of tendonitis. So they'll have pain on the inside of the elbow joint or on the. 

52:02
Dr. Pradeep Chopra
Outside of the elbow joint, commonly known. 

52:04
Dr. Pradeep Chopra
As golfer's elbow or tennis elbow, but. 

52:06
Dr. Pradeep Chopra
It is more from tendonitis because the joint is kind of unstable. 

52:12
Dr. Pradeep Chopra
There is one joint over there that does sublux, but it usually doesn't cause any problems. 

52:19
Dr. Pradeep Chopra
Moving down to the wrist. 

52:22
Dr. Pradeep Chopra
And hands and fingers. This is a common issue in eds. They do have pain there, and especially when they use it. So before I get into that, I just want to discuss a phenomenon that happens in the human body called proprioception, or otherwise known as joint position sense. There are senses in our joints, ligaments, muscles, skin that inform my brain exactly. 

52:46
Dr. Pradeep Chopra
Where the joints are. And based on that, the brain then. 

52:51
Dr. Pradeep Chopra
Decides how to balance yourself. So let's say, for example, you're walking first you put all your weight on the right leg so that your brain knows that your right leg is on the floor and your left leg is. 

53:02
Dr. Pradeep Chopra
Say, three inches above, or your left. 

53:05
Dr. Pradeep Chopra
Ankle is three inches above. And so it sends a message to. 

53:08
Dr. Pradeep Chopra
The right leg how to balance you. A common example I can tell you. 

53:14
Dr. Pradeep Chopra
Of understanding proprioception is if you have. 

53:17
Dr. Pradeep Chopra
An itch on your head, you can. 

53:19
Dr. Pradeep Chopra
Scratch that itch without even looking. Without even looking, you can pinpoint where exactly the itch is and you can scratch it. And the reason is that your brain knows exactly where the itch on your scalp is, and it sends a message to your arm and your knuckles, and it sort of redirects your hand right. 

53:38
Dr. Pradeep Chopra
Over to the itch. 

53:39
Dr. Pradeep Chopra
That's an example of proprioception. And we use that a lot on a daily basis. It protects our joints, it helps us move smoothly. So it's critical to have good proprioception. People with Eds don't often realize until and unless they diagnose with eds, they don't realize that they have poor proprioception. 

54:03
Dr. Pradeep Chopra
When you have they do have poor. 

54:05
Dr. Pradeep Chopra
Proprioception because their joints are loose. And because their joints are loose, their joints are not sending signals to the brain in time. 

54:12
Dr. Pradeep Chopra
And when they don't send it in time, then the brain cannot react fast enough. And I'll give you an example. 

54:19
Dr. Pradeep Chopra
When you're walking up the stairs, oftentimes people with Eds trip when walking up the stairs. 

54:24
Dr. Pradeep Chopra
And what happens is every step is. 

54:27
Dr. Pradeep Chopra
Supposed to be six inches. That's by law, all steps have to be six inches. And now, as you lift your, say you're walking up, your weight is on your right leg. You lift your left leg as you. 

54:38
Dr. Pradeep Chopra
Want to get six inches higher. 

54:40
Dr. Pradeep Chopra
You want to bring your foot six inches higher to the next step. But your brain doesn't know where you are, where your foot is. And it might just assume that your foot at three inches is at six inches, and you trip and fall. 

54:54
Dr. Pradeep Chopra
I don't think I explained that well. 

54:56
Dr. Pradeep Chopra
So as you're walking up the steps, your ankle has to move up by six inches. You may have moved your ankle only four inches, and the brain assumes that you've moved it at six inches and. 

55:09
Dr. Pradeep Chopra
Makes you take a step, and that's when you trip and fall. 

55:13
Dr. Pradeep Chopra
So that's an example of poor proprioception. And that's not just limited to ads. Poor proprioception is seen in the elderly because their joints have been damaged. It's seen after joint replacement surgery, it's seen in athletes, their joints have been damaged, and it's seen in toddlers, where they have not yet developed their joint position since. 

55:35
Dr. Pradeep Chopra
Well. 

55:36
Jennifer Milner
But poor proprioception is something that has been linked definitively to hypermobility and it is something that we have talked about on several discussions and it bears reintroducing and reminding people of. If your body doesn't have that awareness of where it is in space, then when we're talking about a joint that has a greater range of motion than usual, it may not be sure where is the most optimal place for that joint to sit. In the arm. There was a study that was released, oh, gosh, 1012 years ago, that was asking people with hypermobility to take their arms straight out to their sides, to abduct and to move them from front to side and then do it with their eyes closed and stop when their arms were straight out to the side. And the people with hypermobility had a much larger margin of error, I think it was like 23% of accurately figuring out what where straight to the side was than people who didn't have hypermobility. 

56:32
Jennifer Milner
So, as you pointed out with the stairs, it is an issue for every day. It's not just, can I balance better for my Olympic event or for my dancing on a world stage? It's something that applies to everyday life as well. 

56:47
Dr. Pradeep Chopra
Yes. 

56:49
Dr. Pradeep Chopra
Just to cover up the stairs issue. So the way to overcome that is to visually look at your feet and the steps where the stairs are and keep your hand on the railing. Now, on a day to day basis, here's the difference between dance and walking. When you're walking, you're not focused on your walking. 

57:09
Dr. Pradeep Chopra
You're focused on, I don't know, something. 

57:11
Dr. Pradeep Chopra
Else, where you're going or you're thinking about something. You're not thinking about your feet moving. When you're dancing, you are very focused on your feet. That's your main focus. And so in dancing, you may notice as much falling down or bumping into things because you are very focused on where your feet are, where your hands are. But when you're walking down the street, you may notice that. And this is one of the tests that I do in my office, is I have my patients walk up and down the corridor, and then I look at their gate. So I look at their gate for various reasons, but at some point while they're walking, I'll tell them suddenly, now close your eyes and walk. And they walk straight into the wall. And the reason is that they have no idea of their spatial sense in space. 

58:03
Dr. Pradeep Chopra
And they tend to walk into the wall. 

58:04
Dr. Pradeep Chopra
They get a little scary. So we haven't had any injuries, but still so proprioception or joint position sense is very critical. And we'll cover this again and again at different steps. But one of the things about the hand is that when you hold a pen or a pencil to write, children with Eds or people with Eds tend. 

58:30
Dr. Pradeep Chopra
To hold the pencil really tight because. 

58:33
Dr. Pradeep Chopra
They'Re not getting any signals from their knuckles. So the brain overcompensates by making them hold their pencil really tight. They may even hold it in a very different way. They might wrap like three or four fingers around a pencil differently. And the other thing that they do is they press down hard when they write. 

58:55
Dr. Pradeep Chopra
That's called haptic feedback. 

58:56
Dr. Pradeep Chopra
So when you press hard, you get a sense of where you are. The scratchiness of writing with a pencil. 

59:03
Dr. Pradeep Chopra
On paper, it's called haptic feedback. 

59:05
Dr. Pradeep Chopra
That's what iPhones have. When you press the button, you get. 

59:08
Dr. Pradeep Chopra
This little buzz that's called haptic feedback. That means signal received. So they don't get that haptic feedback. 

59:16
Dr. Pradeep Chopra
And they don't exactly know how tight they're holding their pencils, so they overcompensate by holding it really tight. Now, there are two issues with that. One is they're making their muscles, their tiny muscles in their hands, work harder than needed. You don't really need a whole lot of energy to hold a pencil. But these kids are holding, or even adults, whatever they're holding it very tight. So they're using their muscles a lot. That's number one. Number two, their joints in their fingers, the finger joints are lax. And in order to hold something, we need to make our fingers rigid. And they have difficulty making it rigid. 

59:51
Dr. Pradeep Chopra
Because their fingers are lax, so they hold it even tighter. 

59:57
Dr. Pradeep Chopra
Eventually, kids or even adults will complain of hand pain after having used it for something like in writing or cooking, for example, when you're chopping food or stirring food, or in people who are doing work with their hands, like artists and all, they'll find that their hands start to hurt after some time and it's mostly muscle pain. 

01:00:19
Jennifer Milner
And that's a great point. That's one of the things that don't seem to have anything to do with hypermobility, that I use as a hack when I'm doing an intake for a new client, is how do you hold your pencil? Do you enjoy writing physically? Do you not enjoy writing? And it was a new area for me to learn about. One of my kids went through occupational therapy for hands and for grip issues. And I learned that the way that people hold their pencil and have that finger kind of over. Of course, nobody can see this because it's a podcast, but if you're hypermobile, you can really hyperextend those joints, which doesn't feel good. So then you start to change your. Hand grip and do different things with it to try to make it feel better. And so that's one of those little things. And I read an article on it just a few years ago that a medical professional was saying, hey, for people with hypermobility, we need to look at their writing skills and their fine motor skills with their hands, because a lot of them are being done a disservice by not looking at that and not checking into it. 

01:01:21
Jennifer Milner
Because, again, we're copers. We're adaptable, right? And we figure out how to make it work. If your purse pulls your shoulder out of the socket, you figure out a different way to hold it or just sling it up your shoulder, up to your ear or something. So we're nothing if not flexible. 

01:01:36
Dr. Pradeep Chopra
Bring your shoulder to your well, yes. 

01:01:39
Jennifer Milner
Like when I was carrying a purse in New York and it literally pulled my shoulder out of the socket, I would just put my purse on my shoulder and then just hold my shoulder up by my ear to help carry the purse. And I was like, Why doesn't everybody do this? And then you have a whole host of other issues from that. So compensatory strategies. I feel like we could win Olympic medals for our compensatory strategies. 

01:02:03
Dr. Pradeep Chopra
Yes, that is true. 

01:02:04
Dr. Pradeep Chopra
So when it comes to holding a. 

01:02:07
Dr. Pradeep Chopra
Small object like a pencil, okay, firstly in kids let's talk about kids first, and then we'll talk about adults. In kids, if they're holding the pencil in a quote unquote, weird way, do not correct it. There is normal way of holding a pencil. There's no handbook on holding pencils. As long as the job is being done, let them do it. They've discovered that's the best way to hold it. If they need four fingers to hold. 

01:02:35
Dr. Pradeep Chopra
A pencil, so be it. 

01:02:37
Dr. Pradeep Chopra
So don't make their teachers try to correct it to the right way. I'm showing air quotes for those who can. 

01:02:44
Dr. Pradeep Chopra
The second thing is that they do. 

01:02:48
Dr. Pradeep Chopra
Press hard, and they do, of course, hold their pencils very tight. 

01:02:52
Dr. Pradeep Chopra
And that's the issue. 

01:02:55
Dr. Pradeep Chopra
So that's the proprioception issue. So how do you correct proprioception in this case? Now, here's the thing. In proprioception, what you do is first things is to, if they have hypermobility of their fingers, correct that, okay? And that's an easy thing to do. In girls, especially, you get these ring. 

01:03:14
Dr. Pradeep Chopra
Splints that literally look like rings, and. 

01:03:16
Dr. Pradeep Chopra
You can put these around your around the joints that are loose. 

01:03:19
Dr. Pradeep Chopra
Now, you only need to do that. 

01:03:22
Dr. Pradeep Chopra
For three fingers, the thumb, the index finger, and the middle finger. The other two fingers are really useless. The ring finger and the pinky, they. 

01:03:29
Dr. Pradeep Chopra
Don'T really do anything. 

01:03:30
Dr. Pradeep Chopra
So for these three fingers, just make sure that the loose joints are stabilized. 

01:03:36
Dr. Pradeep Chopra
With ring splints, okay? 

01:03:39
Dr. Pradeep Chopra
Once you've got those stabilized, the second thing is to look at the pencil, the writing instrument. You can get a thicker version of that. 

01:03:47
Dr. Pradeep Chopra
Or you can get rubber thingies that. 

01:03:50
Dr. Pradeep Chopra
Go on these pencils that make them thicker so that when they are clamping their hand on the pencil, they're not clamping onto something really hard which is going to affect their muscles. 

01:04:03
Dr. Pradeep Chopra
So they're rubber things you can buy. 

01:04:05
Dr. Pradeep Chopra
At any store and that helps them. 

01:04:08
Dr. Pradeep Chopra
That is one way to do that. 

01:04:10
Dr. Pradeep Chopra
Oftentimes occupational, therapies therapists do have something around for that. 

01:04:14
Dr. Pradeep Chopra
Also once they have that, now for. 

01:04:20
Dr. Pradeep Chopra
The non writing portion. So let's say you're cooking and you're using you're chopping food or stirring food. In that case, buy knives or ladles or spoons that have a thick big handle. 

01:04:35
Dr. Pradeep Chopra
And there's only one company I know. 

01:04:37
Dr. Pradeep Chopra
Of that does that and that's called. 

01:04:41
Dr. Pradeep Chopra
Can. It's very popular. 

01:04:43
Dr. Pradeep Chopra
You can get them at I've seen them in Target, I've seen them on Amazon. They make their kitchen utensils in a very intelligent way. The handles are very big, they are. 

01:04:53
Dr. Pradeep Chopra
Very thick and they're soft, they're not very hard. 

01:04:58
Dr. Pradeep Chopra
And that's another way to work around that. Now, if you're doing something that's let's say it's not cooking and it's none of this let's say you're gardening or doing something else, you can wear a. 

01:05:09
Dr. Pradeep Chopra
Fingerless compression glove and that'll help. 

01:05:12
Dr. Pradeep Chopra
Also, they're often sold as arthritis gloves. And these gloves here's the thing. When the brain isn't getting any signals from the joints as to their position, then it uses contact of the fabric. 

01:05:25
Dr. Pradeep Chopra
Over the skin of the joint as. 

01:05:28
Dr. Pradeep Chopra
A way of figuring out where the joint is. So when you wear a glove, the glove, when it comes in contact with that particular joint on your knuckles, that tells the brain exactly where the knuckle. 

01:05:42
Dr. Pradeep Chopra
Is, the position of the knuckle. 

01:05:44
Dr. Pradeep Chopra
And that helps people understand or the brain understand where your joints are at any given time. So this would come in handy in other things like non writing thing or non cooking things like you're doing some painting or you're doing some yard work and things like that, you can wear them at those points. By the way, this concept of proprioception had not been proven for a very long time. We knew that this was a problem, but it was eventually proven in 2021 and the person who did that actually. 

01:06:19
Dr. Pradeep Chopra
Got the Nobel Prize and he was. 

01:06:22
Dr. Pradeep Chopra
The one weren't able to prove it, definitely. We knew that there's proprioception, we knew that, but we couldn't really prove it. And he was the one to first prove it in 21, as recent as 21, and he's at Scripps in California and he shared the Nobel Prize for physiology and this was his work anyway. So for the hand, you can either wear a fingerless compression glove, stabilize the joints on your fingers with ring spins. Now just want touch base on the ring spins. That's a pretty difficult issue. There is a company that makes them. 

01:07:00
Dr. Linda Bluestein
Isn'T it silver rings, the name of. 

01:07:01
Dr. Pradeep Chopra
The company right now. 

01:07:02
Dr. Pradeep Chopra
But yes, silver ring. 

01:07:06
Dr. Pradeep Chopra
They're kind of difficult to work with. They have their own measuring method and it's hard to work with them. Let's just get to that end. It there. There are some people, some really nice creative EdsRS who make them at home and they'll create it for you at home. One of them that I know is. 

01:07:28
Dr. Pradeep Chopra
Again, let me shake my head, zebra Sprints. 

01:07:34
Dr. Pradeep Chopra
This lady is Zebra Sprints. I believe she's on Etsy and I believe she is on her own website. Also, the advantage of going to a person like that versus going to a. 

01:07:44
Dr. Pradeep Chopra
Company is that these ring sprints need constant adjustment as you grow or as. 

01:07:51
Dr. Pradeep Chopra
Your hands change shape and all that. And if you're a relationship with the person, then they can adjust it again and fix it. So anyway, ring spins, stabilize your rings. 

01:08:03
Dr. Pradeep Chopra
Your fingers wearing a big old brace. 

01:08:12
Dr. Pradeep Chopra
There are two downsides to it. One is that they don't really do a good job and they get very sweaty and it's hard to wear them. Plus they look really ugly. 

01:08:23
Dr. Pradeep Chopra
Listen Jennifer. 

01:08:28
Dr. Pradeep Chopra
There is an aesthetic value. 

01:08:30
Dr. Pradeep Chopra
To it and you cannot tell a. 

01:08:33
Dr. Pradeep Chopra
Teenager to wear an ugly hand brace, but you can convince them to wear a ring splint. 

01:08:38
Dr. Pradeep Chopra
You don't even have to convince them. One look at it and they're all for it. But if you tell them, I need. 

01:08:44
Dr. Pradeep Chopra
You to wear this leather thing and strap it up and tie it up. 

01:08:47
Dr. Pradeep Chopra
You'Re not going to get any results from it. 

01:08:50
Dr. Pradeep Chopra
So you got to look at non medical compliance factors anyway. So that's the one about the hand most commonly this issue. The bigger problem is with the thumb. The thumb is not exactly a very stable joint in some forms and oftentimes you'll see thumb issues. There's also a tendon that goes to. 

01:09:11
Dr. Pradeep Chopra
The thumb and that tendon. So if you look at your hand. 

01:09:16
Dr. Pradeep Chopra
With the thumb up it's on the edge of the hand wrist, there's a tendon that goes to the thumb and it's a condition called decorabians or DQ. The tendon gets inflamed and in that case just stabilizing the thumb makes a difference. So these are some of the things that you can use. These are the issues that you have with your arms that I can think of right now. 

01:09:41
Jennifer Milner
I'm just thinking through issues I've had or I've seen other people had. What about the radial ulnar joint? Because I've definitely run into people who have that. It can sublux easily, especially the ones who are like, please don't pull on my hands because I can feel it slide in and out. 

01:09:58
Dr. Pradeep Chopra
Yes. 

01:09:59
Dr. Pradeep Chopra
So you're talking about the distal radio ulnar joint. The wrist is made up of well, the end of the wrist has made up of two bones, the radius and the ulna. And they meet up there at the wrist and oftentimes the joint at that point splits open that's the only place you would need to wear a brace. 

01:10:23
Dr. Pradeep Chopra
Because like I said, once it splits. 

01:10:25
Dr. Pradeep Chopra
It'S not going to heal up on its own. And that's the only place you would want to wear a brace to keep that in place. And it doesn't have to be a big brace. It can be something as much as an elastic brace that just holds it. 

01:10:38
Dr. Pradeep Chopra
Like a wrist, like one of those. 

01:10:39
Dr. Pradeep Chopra
Wristbands that tennis players wear. Something like that might be enough to hold that Radio Ulnar joint in place, but avoid separating the Radio Ulnar joint. And the way you can do that. 

01:10:51
Dr. Pradeep Chopra
Is I'll give you an example. 

01:10:54
Dr. Pradeep Chopra
When you're brushing your teeth, you've got the brush in your hand and you're brushing your teeth and you rest your. 

01:11:00
Dr. Pradeep Chopra
Left hand on the sink and you're. 

01:11:03
Dr. Pradeep Chopra
Putting all your weight on that, and that's where the Radio Ulnar joint splits. That's the best example I can give you right now. Surgery does not help because you need some movement at that joint. There's a reason why God made a joint over there, because you need movement, however slight, but you need movement there. If you put screws and you fuse. 

01:11:24
Dr. Pradeep Chopra
It, it's not going to help. It's going to make things worse because then that pressure, the pressure is then. 

01:11:31
Dr. Pradeep Chopra
Transmitted to the elbow where the radialna joint meets up again. 

01:11:35
Jennifer Milner
And I think that's just another great example of how prevention is so important in educating children or parents. If your child already seems loose and hypermobile, don't grab them by the hands and swing them around. You can dislocate their shoulders, elbows, wrists, all the fun things. So be careful and not getting to the point where you start to have it slip out. 

01:11:58
Dr. Pradeep Chopra
And while we're on the topic, no party tricks. 

01:12:05
Jennifer Milner
Dr. Bluestein is cheering you on right now. 

01:12:07
Dr. Pradeep Chopra
No party mean, just make it sound serious. 

01:12:13
Dr. Pradeep Chopra
And again, one of the problems is that when patients with Eds go to a doctor who has probably never seen Eds, gets all excited about it and says, hey, show me what you can do. That's when you say, no, I'm not going to show it to you because it's not going to help me in any way. It's just going to entertain you. I'm not doing it. Well, remember, stretching your joint will stretch the ligament and that's going to damage it forever. 

01:12:38
Jennifer Milner
And I think this is where Dr. Bluestein has a hack of her own for that topic. Yes, Dr. Bluestein. 

01:12:44
Dr. Linda Bluestein
Oh, yes. I'm like my hack. Yes. I have patients. When I'm evaluating them, I have them show me, or I'll say do it at home one last time. Have somebody videotape you, take pictures, whatever. Store those in a secure place, email them to yourself or whatever so you can find them easily. And that way you have documentation because later on, when you have historical joint hypermobility and your bite and score is zero or one or two or something. You can at least have this documentation on hand. 

01:13:20
Dr. Pradeep Chopra
Yes. 

01:13:20
Dr. Linda Bluestein
Is that the hack you were thinking about, Jen? 

01:13:22
Dr. Pradeep Chopra
Yes. 

01:13:22
Jennifer Milner
So that the doctor says, Show me, and you're like, yes, let me get out my phone and I will show you, rather than doing it ten times? 

01:13:28
Dr. Pradeep Chopra
Yes. Even with the bite and score, I get really leery about doing it. And sometimes I'll say especially the last one where you have to bend over. 

01:13:36
Dr. Pradeep Chopra
And touch the floor. 

01:13:39
Dr. Pradeep Chopra
I'll ask them, can you do it? And they'll say yes. 

01:13:41
Dr. Pradeep Chopra
And I take their word for it. 

01:13:43
Dr. Pradeep Chopra
Because it really makes me very nervous doing these hacks, the bite and score, where you have them push pull their joints, the thumb also, I'll just do one side and I'll see if they can touch their forearm. I'll ask them, have you done it in the past? Has it done it on your left side also? And if they say yes, then I'll say I'll take their word for it. 

01:14:02
Dr. Pradeep Chopra
Obviously, but I try not to do it. No, go ahead. 

01:14:09
Dr. Linda Bluestein
I was going to say, I think the challenge with the party tricks is when I've had people bend back the fifth finger if I'm doing the bite and scorn, and I've had ones where they literally can touch the finger to the back of their hand and I'll scream sometimes and I'll be like, what? That doesn't hurt. And the difficulty is it doesn't hurt. It doesn't hurt until it does. Right? So that's why we're trying to encourage people to be thoughtful about what it is that they're doing and being proactive. And I sure wish I had worn my ring splint before I got a lot of arthritis in my fingers. Until it does, I had difficulty getting them to fit. So it can be really hard to do those things, especially if something's not hurting. If it's hurting, pain is a really good motivator, right? So if something is hurting, we can be very motivated to make change, but otherwise, if it's not hurting, somebody can tell us to the cows come home. 

01:15:06
Dr. Linda Bluestein
But I feel like it can be really hard to make any change. And Jen pointed out once that with her dancers, it's the dancers who have already been injured that listen to her the most and take her advice. Is that true, Jen? Is that what you said? 

01:15:20
Jennifer Milner
Yes, I was saying the people that take an injury prevention class are the people who have already been injured because people think it's never going to happen to me, I don't need to deal with it. And I'm sure that if we offered a hypermobility injury prevention or issue prevention musculoskeletal issue prevention class, the people who would take it would be the people who had already had dislocations or who were already experiencing pain and didn't want to have it again. Right, but up until that point you're like, I feel great, I'm funny to my friends. I'm a really good baseball player or a rollerblader or whatever the thing might be. And then once you've experienced it, you're like, I don't want to experience that again. And that's when you start trying to address it. 

01:16:03
Dr. Pradeep Chopra
And that's what 6000 motorcyclists in the United States thought, that nothing would happen. 

01:16:08
Dr. Pradeep Chopra
To them till it happened. And now they're dead, right? 

01:16:13
Dr. Pradeep Chopra
Every year, every single year, approximately 6000. 

01:16:18
Dr. Pradeep Chopra
Motorcyclists die in the United States. 

01:16:21
Dr. Linda Bluestein
6000 or are there more zeros on there? Because 6000 honestly sounds low. 

01:16:27
Dr. Pradeep Chopra
I mean, I have the 21 motorcyclists. 

01:16:30
Dr. Linda Bluestein
Interesting. 

01:16:30
Dr. Pradeep Chopra
Okay, 6000, it's a self serving prophecy because once they died, then other people are going to look at it and say, no, yeah, no thanks. But 6000 as compared to the number of people died during 911, which is about 3000. 

01:16:47
Dr. Pradeep Chopra
And yet we all think motorcycles are cool until it happens. 

01:16:54
Dr. Linda Bluestein
Some of us don't. 

01:16:55
Dr. Pradeep Chopra
Until they have to scrape you off the road, right? So we talked about the arm and hand and I'm pretty sure as soon as we sign up from the podcast, I'll remember a few things that I forgot to tell you, which we will. 

01:17:10
Jennifer Milner
Next podcast and, you know, happens. If that happens, we will just pop you back in to do another little mini conversation. Maybe we'll throw it up on our YouTube videos. You guys never know where Dr. Chopra is going to show up for a little guest appearance. Today's conversation was such an important one because as you pointed out at the very beginning of this discussion, the upper extremities are the part of the body that we use the most for our everyday life, for cooking and feeding and getting dressed and moving and doing work and all those sorts of things. So it's really important to understand some of the common things that could occur for people with hypermobility for the upper extremities, and way to pursue maybe getting some relief or even better prevention for those issues. So we really appreciate you taking the time to dive into these topics with us, Dr. 

01:18:03
Jennifer Milner
Chopra. We are so grateful for your expertise on this subject. 

01:18:07
Dr. Pradeep Chopra
Thank you. And thank you for inviting me. 

01:18:09
Jennifer Milner
Absolutely. We always enjoy having you. 

01:18:12
Dr. Linda Bluestein
Yes, we do, most certainly. And we look forward to seeing everybody next time on the Bendy Bodies podcast. 

01:18:19
Dr. Linda Bluestein
Thank you for listening to this week's episode of The Bendy Bodies with the Hypermobility MD podcast. Help us spread the word about joint hypermobility and related disorders by leaving a review and sharing the podcast. This helps raise awareness about these complex conditions. Visit bendibodiespodcast.com and follow us on Instagram at bendy bodies. We love seeing your posts and stories, so please tag using hashtag bendybuddy. You can also find me Dr. Linda Bluestein on Instagram, Facebook, Twitter and LinkedIn, all with the ID hypermobility MD. This podcast is for general informational purposes only and does not constitute the practice of medicine or other professional healthcare services, including the giving of medical advice. No doctor patient relationship is formed. This is not intended to be a substitute for medical diagnosis or advice. Do not disregard or delay obtaining medical advice for any medical condition you have. The opinions shared are that of the guest and do not necessarily represent the views of the hosts or any particular organization. 

01:19:24
Dr. Linda Bluestein
Thank you for being a part of our community and we will catch you next time on The Bendy Bodies Podcast.