The real perfect push-up

I was talking with a friend of mine earlier this week who had used the Perfect Push-up. He liked it. He also made a great comment that really summarizes the use of exercise gadgets- "Hey Chimes, you know what the real perfect push-up is? Actually doing them."

I think that is perfect. Just like the old Nike commercial says- "Just do it!"

Cushioned running shoes for feet with high arches

The choice of which running shoe a runner should use is largely determined by their foot arch and the type of motion the foot makes through the stance phase (the portion of the running cycle when the foot is in contact with the ground).

There are two common subsets of foot and motion patterns seen in runners. The most common pattern is the overpronator, which is often associated with a flat arch. The second and less common category is the high-arched underpronator, which happens to be the category I belong to.

To understand how these foot mechanics influence choice of footwear, it is important to understand foot pronation. Foot pronation is a natural roll of the foot that occurs during stance phase that serves to help absorb some of the force of impact. When the foot first contact the ground, most people start to roll almost immediately to the outside of their foot (this is why, if you look at the shoes of most people, you see greater wear on the outside of their heel than the inside of the heel). What happens in the middle of stance phase is that weight stays along the outside of the foot arch as the runners body weight is transferred over the middle of the foot.

The main distinction between over- and under- pronators occurs during the end of stance phase. Underpronators start rolling toward the big toe, and keep on going. This pronation is useful, as it helps absorb the force of landing, which is several times bodyweight. The problem with overpronating is that as the foot keeps rolling without control, it drags the rest of the body with it, which causes excessive strain up the kinetic chain (e.g., the excessive pronation can pull the leg bone, the tibia, with it the foot, which can cause strain at the knee). Therefore, runners with excessive pronation are often advised to wear motion control shoes.

The underpronator, like me, has the opposite problem. In their feet, the foot does NOT roll sufficiently toward the big toe. Remember- pronation is an important shock absorbing motion. Therefore, in runners with high arches and underpronation, the general recommendation is to avoid motion control shoes and use running shoes that have extra cushioning (to compensate for the lack of absorbtion from the natural pronation motion).

A recent study from the American Journal of Sports Medicine confirmed the shoe recommendations for high-arched runners.

Caleb Wegener, Joshua Burns, and Stefania Penkala Effect of Neutral-Cushioned Running Shoes on Plantar Pressure Loading and Comfort in Athletes With Cavus Feet: A Crossover Randomized Controlled Trial , Am J Sports Med 2008 36: 2139-2146

In short, this study confirms the recommendations above for the high-arched runner.

For the record, the cushioned shoes that were examined were the Asics Nimbus 6 and Brooks Glycerin 3, and the control shoe that was examined was the Dunlop Volley. This was a well designed study that used a cross-over study design, meaning that each participant started with either a cushioned shoe or the control, and then switched groups. The examiners also assessed both pressure distribution and comfort level of the runners.

Based on this study, the recommendations listed above still apply. Based on my personal anecdotal experience, it is important for runners with high arches and underpronation to look for a shoe that is BOTH heavily cushioned AND not motion control. My experience has been that it is hard to find running shoes that do not have some component of motion control built into the shoe. Since overpronation is the more common foot problem, most shoe manufacturers tend to build some motion control into almost all of their shoes, even their heavily cushioned models.

As a practical matter, this can be a challenge. If you go to many running shoe stores, the clerks sometimes will not know the properties of the individual shoes. My recommendation is to first scout out the shoes you are looking for on a good running shoe site (I tend to use RoadRunnerSports.com), and then look for shoes that fit your category. Once you find a shoe you like, stick with it. Stores that specialize in running shoes (e.g., in Chicago and Pittsburgh, Fleet Feet is a good store) tend to have experienced sales people with good knowledge of what type of shoe is right for you.

Iron Gym Pull Up Bar

I am doing another product review. One of my readers (that is, one of my grand total of 5 readers) pointed out "for a guy who claims not to be commercial, you sure have a lot of product placements. And while I'm at it, exactly how many mentors do you have?"

Addressing the second question- I have a lot of mentors. I've been very fortunate that many people have cared enough to invest their time in my success. The only payback I can give them is that I try to take their advice to heart and pay it forward to the next group of trainees.

As for the product reviews, let me clarify- I do not take any money or compensation from any sponsor. That may change in the future- I can only hope that I am successful enough that people will pay me for my time. What I can promise is that I will fully disclose any financial relationships I have with any products.

Now, then ...

I am reviewing the Iron Gym Pull Up Bar. Right now, they are selling them for $29.99 at Bed Bath & Beyond.

I will first make a quick plug for Bed Bath & Beyond. You have to love their ubiquitous coupons that never expire, so you never pay list price for anything. Even better, though, is their return policy. I go through blenders fairly quickly- I use mine every day for protein shakes, and occasionally burn out the motor. I used to buy them from other vendors, but because the return policy is so good at BBB, I don't think I will ever buy a home appliance anywhere else. Great customer service goes a long way in building loyalty.

Back to the Iron Gym- it's basically a pull-up bar that can be attached without hardware. It claims to be used for other purposes, but I suspect that 90% of the people who are buying it just for pull-ups.

It does exactly what it says it does- I really like it. I am a big man (well over 200 pounds), so I am skeptical that any bar can really support my weight. But the Iron Gym feels pretty sturdy, and is easily attached to a door in under a minute. I don't see any issues at all with structural integrity of the door, and it has not marred the doorway at all.

Additionally, it allow for multiple grips- I use 2 chin positions, 1 neutral grip (which most bars don't allow for), and 2 pull up positions. I am 6'3", so a concern with some bar designs is that there is not enough clearance, but the bar only extends 5" below my door, so I can easily do pull ups with my knees bent.

So, I am probably the perfect demographic for someone who will benefit from this bar in that:
1. I am able to do a pull up
2. I don't want to permanently install a pull up bar
3. My gym doesn't have a pull up bar, which is a shame, since it's one of the most important resistance exercises one can do

It is perfect for me. On the days when I do upper body weights at the gym, I'll do pull ups on the Iron Gym at home. I usually work for several hours at my computer every day, so I periodically get up anyway for some other reason. When I get up, I make a point of doing as many pull ups as a I can on the bar. Since I, like most people, can't do to many at one time, this is a way to make sure I get in a fair number of repetitions over the course of the day.

There are some people who should avoid this product:
1. If you cannot do a pull up- you should be able to do at least 1 in at least 1 grip position to really benefit from the bar.
2. If you are over 30o pounds- at some point you may damage the door frame. I don't feel like I am approaching that limit, but the product label recommends 300 pounds as a weight limit.

Overall, I think it's a terrific product that fills a real need, and is reasonably priced.

Medical perspective on Mixed Martial Arts (MMA)

I am a big fan of mixed martial arts, also known as MMA, most commonly associated with the world's largest MMA organization, the UFC (Ultimate Fighting Championship).

Max Kellerman, the great sports commentator and noted boxing fan, frequently notes that fighting is the most intrinsically interesting of all sports. A thought experiment he likes to make is to imagine that you are in the middle of an intersection of two streets with a crowd of people. Imagine that on three of the street corners there is a different sporting event going on- one street corner has a baseball game, another a basketball game, and on the third a football game. The crowd at the intersection would likely have their attention split amongst the basketball, football, and baseball games- none would dominate interest.

Now imagine that on the 4th street corner a fight breaks out. Nearly everybody would stop watching whatever they were watching and turn to watch the fight. It's simply more interesting- fighting is, at it's essence, the most purely interesting of all sports.

Max Kellerman made this argument in defense of boxing, but I think it applies even more to MMA. In recent years, MMA has become the dominant combat sport in America. The stars of the UFC- Brock Lesnar, GSP, Fedor, Forrest Griffen- are now bigger stars than the boxers. UFC fights dominate on pay per view, and the UFC fight cards draw bigger crowds in Las Vegas than do boxing cards.

Senator John McCain famously referred to the early sanctioned MMA fights as "human cockfighting." I have tremendous respect for Senator McCain, and there is some truth in his assessment of early MMA- the rules were not clearly established, and the early cards often seemed to promote the brutality of the exhibitions rather than the elgance and athleticism. It was being marketed as show rather than a sport.

I also think that, at least in part, McCain was speaking as a boxing fan. He loves boxing, and was bothered by a newer sport supplanting boxing. I love boxing too- like most people of my generation, some of my favorite sporting moments as a fan are the great Sugar Ray Leanord/Marvin Hagler/Thomas Hearns/Roberto Duran middleweight bouts, or the Evander Holyfield/Mike Tyson era.

But, I am a much bigger fan of MMA now than boxing, for 3 major reasons:
1. As a sports fan, I think the matches are far more entertaining.
2. As a biomechanists, I think MMA is more elegant. Watching a great multidisciplinary fighter, like Georges St Pierre, is like watching a text book on human movement. It is similar on some level to watching a great dance troupe like Alvin Ailey or great gymnasts like Cirque de Soleil, only with a greater sense of urgency because it is taking place in the context of a fight.
3. As a physician, I think MMA is safer than boxing.

The last point is the major one that inspired me to write this posting.

I don't think it has always been true that MMA is safer than boxing. The early sanctions to clean up the sport, though, have been very successful. There are a few things that make the sport safer now:

1. Most importantly, encouraging a referee to step in quickly when an opponent cannot defend themselves.
2. Rules changes to minimize things like small joint manipulation and kicking an opponent in the head when they are on the ground, that remove some of the most dangerous elements.
3. Creating weight classes, which minimizes the risks of greatly mismatched opponents
4. Moving away from tournaments, which increase the risk of cumultive trauma
5. Increasing popularity, which places an impetus on keeping stars healthy, and creating enough stars that they can alternate on who the headliner is for the card. A top fighter may only have 4 fights in a year

There have been several studies in the past few years that have tried to assess the risk of MMA, both overall, and in comparison to boxing. I don't think the data is conclusive, but my impression is that MMA is safer.

The big difference, in my opinion, is concussion rate. Concussion, or mild TBI (traumatic brain injury), is in my opinion the most serious risk of combat sports. I think the risk of concussion is significantly higher in boxing for several reasons:

1. In MMA, there are many other ways to win, including submissions. In boxing, the main goal of the sport is to give your opponent a concussion and knock them unconscious.
2. The gloves: The thick padded gloves in boxing probably increase the rate of concussion by several mechanisms. I think the most important one is that they protect the hands, so there really isn't much disincentive from punching your opponent in the head. In MMA, the thinner padding of the gloves results in punches hurting the fighter's hands more. This often results in fighters trying alternative approaches, including takedowns and submissions, rather than just punching. Of course, in boxing those options don't even exist. Furthermore, the padding of boxing gloves widely distributes the force, which may minimize the knockout potential of any one punch. This can lead to greater cumultive trauma over the course of a fight.
3. Quick stops. Right now, refs in UFC and most of the other sanctioning organizations are quick to stop fights when fighters cannot defend themselves. Sometimes this is frustrating to viewers, but I think it is one of the most important safety factors for the sport, and it is the one variable that could dramatically change the sport. If UFC wants to continue as a mainstream sport, they MUST continue to protect their fighters.

Enough with medical talk ....

I am very excited about the sport of MMA right now. There are some huge, huge fights on the horizon. UFC has done a tremendous job of promoting their fighters, and I don't know an MMA fan who isn't simply giddy in anticipation of the December 27 card coming up, with 3 fights fully worthy of main event status.

The one major logistical issue that I see right now is that 2 of those most appealing fighters on the planet, Fedor Emelianko and Gina Carano, are not under UFC contracts. I hope that changes. Fedor is, in my opinion, the best fighter who has ever lived, and I want to see him fight all of the best competition available. Gina Carano is a phenomenon in her own right- a legitimately terrific fighter whose marketability is off the charts. A series of fights between her and Cris Cyborg and Tara Larosa would easily be the most heavily anticipated fights in female fighting history. I hope they happen.

Where's the sun?

Now that I've lived in Pittsburgh for a few months, one of the most striking things to me is the absence of sun.

I had heard that Pittsburgh was similar to Seattle in terms of cloud cover. During the summer, it wasn't an issue, and indeed summer in Pittsburgh was beautiful. But once the time change happened, it was striking how little sunlight I saw every day. It is not uncommon for me to see no sunlight the whole day.

I think this has several health implications for the people living in western Pennsylvania. First, people like sun, and the absence of sun makes it less likely for people to be active outside. I am curious which is a bigger deterrent for outdoor activity- weather, or sunlight. Anecdotally from speaking to work colleagues, I think it's sunlight. And this can lead to less exercise.

The second issue is Seasonal Affective Disorder (SAD). I am starting to believe this is much more common than has been commonly realized. In particular, I see many patients with musculoskeletal pain, and I believe there is a high comorbidity with SAD in my patients.

I suspect that one of the changes we will see in the coming decades in the management of musculoskeletal conditions is the realization of the extent to which external environmental factors, including sunlight, contributes to our sense of well being.

fitness gadgets

I don't want to specifically endorse any commercial products. However, I know that most people are familiar with a variety of fitness gadgets on the market- for example, Sunday morning TV is filled with infomercials for all sorts of exercise gadgets.

In general, the best form of exercise is something that you do regularly, so anything that inspires you to exercise more is good. One of my medical school professors liked to say "The best exercise for you is the best exercise for you," meaning that there is no one perfect form of exercise that is universal.

In general, I am not a huge fan of machines that are designed to target one body part, for several reasons. First, it is not possible to spot reduce fat in one region of the body, so machines that market themselves as "hip and butt machines" or the latest and greatest ab machine tend not to be great purchases. Additionally, they tend to be expensive and bulky.

The one targeted machine that I do like is the ab wheel, shown to the left. It's a cheap item (it should certainly be less that $20, and you may be able to get one for as little as $5), small, and does work very well for strengthening the abdominal muscles.

As I discussed in an earlier post, I like anything that makes exercise easy and more convenient. Therefore, little gadgets that allow you to exercise during small windows of time are great. One example is "The Perfect Pushup." It's a $20 item that makes pushups more fun, and probably more effective. The rotation of the handles does place less strain on the wrists, and in my personal testing, I do find that my push-ups seem to be more effective when I use it. I keep mine near the television, which is also a useful reminder for me. When I see them while I am watching TV, it is a useful cue to do some push-ups during the commercial break.

Incidently, a pair of dumbbells serves a similar purpose, and may be an even better choice. The great thing about dumbbells is that they are so versatile- you can do many different exercises with them.

If one were to look into more expensive products that target more total body exercises, there certainly is not a shortage of devices available. Of the large, bulky devices, my personal favorite is the Total Gym, which is an infomercial staple with Chuck Norris and Christie Brinkley. It's a great machine, the main drawback being that you need a large enough space to use one.

Amongst smaller gadgets, one that I really like is the BodyBlade. It's basically a stiff flat blade, that somewhat resembles a very thin ski. The idea behind the BodyBlade is that by rapidly vibrating the blade in different positions, you can strengthen a variety of muscles through repeated contractions. I wouldn't recommend it for the novice exerciser, for those who are looking for a great way to add variety to their routine, it can be terrific. It is commonly used in physical therapy, so it is ideal for people who are using the BodyBlade in therapy, and want to extend it's use to the home. I like to collect fitness gadgets to play with so that I am familiar with them for my patients, and the BodyBlade is the one that I find myself using the most often. The main downside of the BodyBlade is that it can be quite expensive (usually over $100, depending on which size you get).

Again, my goal of discussing these gadgets is not to endorse any specific product. But I do think that anything that helps cue people to be more active is helpful, and these gadgets can be useful as part of your healthy lifestyle so long as you actually use them.

Accidental Exercise, Reversal of Flexion

One of the challenges of most working people is finding sufficient time to exercise. Because of the multiple obligations that most working people have (work itself, family, shopping, paying bills, keeping in touch with friends, etc), exercise is often the first thing that goes, usually with a pledge of "well, I'll fit it in later."

As one of my mentors in NJ used to say, later never comes.

One of the keys, then, is to find ways to sneak exercise into every day life.

One common strategy that has been discussed commonly is to find extra opportunities to walk. For example, you can park far from the entrance to your office, or make a point of using the stairs to work.

Another useful strategy is to turn seemingly mundane activities into exercise. I try not to endorse products, but I am going to make an exception for a book my friend and mentor, Joel Press, called the Couch Potato Workout.

http://www.amazon.com/Couch-Potato-Workout-Exercises-Home/dp/192998815X

In it, he describes some useful exercises that you can use while at home to get in a little bit of extra exercise. I don't want to steal his thunder (and I suppose his profits), but one of my favorites is to stand on one leg while brushing your teeth. This is a particularly effective exercise as the mini-perturbations from brushing stimulate the proprioceptive system to maintain balance at the hip and ankle. It sounds easy, but it's surprisingly challenging at first. Once you get good at it, try it with your eyes closed. For the super advanced toothbrush-exerciser, you can try it with your eyes closed while standing on a towel (to give your foot an unstable platform).

This is just an example of fitting exercise into your day. You can do a simple variation on the toothbrush exercise while shopping. When you are waiting on line, simply stand on one leg. Once you get the hang of that, you can progress by lightly twisting while standing on one leg.

An important time to fit in exercise is when sitting for prolonged periods. Sitting for prolonged periods can put significant strain on the disks in the lower back, especially if you sit with poor posture (which many of us do). It's important to reverse the flexion of sitting periodically. Here are some approaches to reversing that flexion:

1. Stand up. The simplest is to simply stand up and walk for a few minutes. I advise that office workers should (if their bosses will allow it) print all documents to a printer on the other side of the office. This will force you to periodically stand up to walk to the printer.

2. Upward facing dog. If you are in an environment that provides sufficient modesty (e.g., at home, or in an office with a closed door), a great exercise to reverse the flexed position of sitting is the upward facing dog exercise, common in the sun salutations from yoga. An example of this exercise is shown at the following link (http://www.yogajournal.com/poses/474). The upward facing dog exercise is very similar to the Prone Press-Up, which is one of the corner stones of McKenzie Physical Therapy, a form of physical therapy that is particularly effective for low back pain. I recommend doing this exercise at least every 30 minutes if your work environment allows to reverse the flexion of prolonged sitting.

3. Standing back extensions. Another great exercise, which may be able to do logistically, is to stand up and extend your back. It may be easier to place both of your hands in the small of your back as you arch backwards.

4. Push-ups. Another good exercise. In addition to strengthening the chest and shoulder muscles, the posture of the push up (a plank position) requires tightening your innermost abdominal muscles (the transversus abdominus), which is important for maintaining balance across your lower back. Push-ups are great for fitting in periodic exercise throughout your day- crank out a quick 5-10 pushups when you get out of your chair, during commercials while watching TV, or just before sitting to eat dinner.

I hope these exercises serve as useful examples for how you can fit small bits of exercise throughout your day.

Uncle Garii

My brother was kind enough to take a snapshot of my "Mii" that I used when playing my nephews on the Nintendo Wii. This is Uncle "Garii." Cute.

Wii

I try not to officially endorse products, but I was at my brother's this past weekend, and played the Nintendo Wii, so I wanted to give a few comments on it from the perspective of a physician and biomechanist

Overall, I really liked it. I'll list my essentially random observations, just to give some semblance of organization:

1. It's fun. It's entertaining for both adults and young children.

2. It's a better way of doing video games. There has been a trend over the past decade to find new ways to make videogames interactive- for example, the many dance oriented games like Dance Dance Revolution and Guitar Hero. The Wii clearly takes things to a new level- the controller is innovative and worthy of the hype.

3. You can get a great sweat playing. After boxing, playing tennis, or hula hooping on the Wii, my shirt was drenched with sweat. You can get a legitimate workout, if that is your aim, from playing the Wii. My nephews, however, did find ways to move the controllers less aggressively, so I suppose over time the workout may not be as intense as it was for me using it the first time.

4. Good motivator for kids. One of the highlights for me was watching my brother use a boxing game. His youngest son mimicked his dad's movements, and was getting exercise himself. One trend that has been noted in much of the pediatric exercise research is the importance of kids watching their parents be active. We spent a few hours as a family exercising on the Wii, and I think that beyond being fun, it helps establish to the kids that exercise is something that you should do.

5. Real exercise is still preferred. We also took a hike as a family, and that was still a better form of exercise. The Wii is ideally an adjunct to other forms of exercise. If your kids are going to be playing video games, though, it's probably better to do it on the Wii, where they are active, than on other forms of video games.

6. The Wii Fit is pretty awesome. I enjoyed playing the balance, yoga, and exercise games that are part of the Wii fit. I found the additional feedback of the Wii Fit helpful for giving feedback on my balance and stability, and for the most part thought the exercises were well designed and fun. My biggest complaint is that the Wii Fit board is a bit narrow for larger framed individuals like my brother or myself.

7. The Mii are a nice touch. My nephews made an avatar for me (they are called Miis, and they called my avatar Garii). It's amazing how detailed they are- Garii looked disconcertingly like the real me, which was especially concerning when my nephew wacked me in the face when playing the boxing game. It also took a little joy out of beating my nephew in boxing, as Garii knocked out a Mii that looked just like my little nephew.

8. There is some translation from real skills. On games I've never played before, my nephews beat me pretty easily. But I was able to occasionally beat my nephews on some of the activities that I do in real life, like boxing, yoga, tennis, or baseball. If I get a Wii, I think I would probably play the tennis game quite often, since it's certainly easier to turn on the video game system than find a similarly skilled partner.

Overall, I really enjoyed the Wii. For adults in particular, I thought the Wii Fit was great, and could be a enjoyable way to work on balance and strength exercises.

Ramblings: Externalities

I would like to discuss the concept of externalities. It may be a term that is used elsewhere, but I use it to mean the extent to which we rely on external factors to define ourselves.

The Olympics are, viewed through a certain filter, all about externalities. Athletes all want to know how good they are, but it’s impossible to define your success in athletics based on some intrinsic sense of self- the athletes need to compete against other athletes to get a sense of good they are.

Some images from the Olympics endure because of this sense of an athlete competing against others. For example, probably the single most impressive image of the Olympics was Usain Bolt in the 100m sprint, looking around and thumping his chest as he raced toward the finish line. What made it so impressive was that he was looking for peers to judge how fast he was going, and he couldn't find any. He was without peer.

I thought about this quite often when I biked in Little Rock this past year. My favorite ride was along the river trail along the Arkansas River which separates Little Rock and North Little Rock. During the Little Rock winter, I tended to ride on Saturday afternoons. Within the context of the Saturday afternoon crowd, I was very fast- I was almost never passed by another rider, and would regularly pass others.

However, as the weather heated up in the spring, I started to ride in the morning before work to avoid the heat. The cyclists on Monday morning at 5:30am were a dramatically different group than the riders on Saturday afternoon. Basically the only people who would wake up that early on a weekday morning to ride their bike were hardcore riders, and me. I had felt strong about my cycling ability based on my weekend rides, but all of a sudden everyone was passing me.

This is a good example of an externality- my sense of self as a cyclist was completely defined by the people I was riding alongside. Am I a good cyclist? I have no idea- it depends on the context.

Getting back to the Olympics …. I enjoyed the interactions between Mark Spitz and the media. For most of Mark Spitz’s life, it has probably been close to impossible for anyone to grasp what he did in winning 7 gold medals at the 1972 Olympics in Munich. No one else had done it before, and no one had been particularly close. But Michael Phelps’s pursuit now gave perspective for Spitz’s accomplishment. That Phelps tried and failed to match him at the 2004 Olympics, and that Phelps needed a strong leg by Jason Lezak in the relay and a dramatic touch in the 100m butterfly emphasizes just how hard it was to beat Spitz’s record. Spitz’s accomplishment now has meaning- Phelps’s performance is an externality that gives perspective to what Spitz had done.

A similar phenomenon exists in how I (and I imagine many others) view Roger Federer. I was never a big fan of his until he lost to Rafael Nadal at Wimbledon. It is only now that Federer has been supplanted as the #1 player in the world that I have perspective on how dominant he was prior to losing. I needed the externality of Nadal to appreciate Federer’s greatness.

As another example in another medium, one of my all-time favorite movies is Unbreakable by M. Night Shyamalan. I don’t want to spoil the movie for those who haven’t seen it, but it involves a struggle by both Bruce Willis and Samuel L. Jackson to define who they are, for which they both require the externality of the other man. I found that message extremely powerful.

Externalities play a role on a social level as well. For example, three top 3 tennis players have emerged from Belgrade, Serbia, within a span of one year of one another (Ana Ivanovic and Jelena Jankovic are the top 2 players on the women’s side, and Novak Djokovic is #3 on the men’s side. Both Ivanovic and Jankovic have been ranked #1, and Djokovic will presumably at some point in the next 2-3 years). The odds of this happening are actually quite good- all three were in formative years when Monica Seles, also from Belgrade, was the #1 player in the world, but beyond those influences, it helps to have a peer for comparison. All three actually trained substantially outside of Serbia for portions of their development, but they were compared. In the case of Ivanovic and Jankovic in particular, I think having a direct comparison with someone with a similar skill set and the same age can be a driving force to bring them to a higher level. Similar pairings are actually fairly common in tennis- Kim Clijsters and Justine Henin from Belgium, Venus and Serena Williams in the US, Marat Safin and Dinara Safina from Russia, and John McEnroe and Patrick McEnroe and Mary Carillo (who grew up with them). Other famous pairings are ample in sports- one of my favorites is Yogi Berra and Joe Garagiola growing up playing baseball in St Louis (the Cardinals chose Garagiola to be there catcher. They should have chosen the uglier guy).

I know it has for me in the past. I have a brother Mike 5 years older than me, and a twin sister Jill. We were all swimmers, and Mike was clearly the best of all of us. Both Jill and I started swimming competitively at age 5, and my drive was always to try and be as good as my brother. In addition to having the role model as an externality, I had a constant base for comparison, in my sister Jill. This was particularly a driving force when we were in our young teens, since she was faster than me for a few years in the time when she had undergone puberty and I had not. Even though I was nothing special as a swimmer, to the extent I was decent, a major factor was having Mike and Jill as externalities that helped me judge my progress.

Why do I bring this up idea of externalities in the context of a Kinemedics blog?

I think it matters in working with patients with musculoskeletal conditions. Understanding externalities is important in understanding that a person’s sense of self, a sense of who they really are is largely governed by phenomena that are external to themselves. Even more important, though, is that we can choose which of these external phenomena we will allow to define us, and that we can choose how these phenomena define us.

In the case of Michael Phelps and Mark Spitz- Michael Phelps was able to use the accomplishments of Mark Spitz as a goal to drive him to higher levels of performance. Mark Spitz, much to his credit, was able to graciously accept Phelps surpassing him as a sign of how hard he was to pass, and admire the inspiration he helped create.

The Williams’s sisters and Ivanovic/Jankovic have chosen to raise their games in face of competitors in their immediate peer group, and the game of tennis is better for it. Rafael Nadal has forced Roger Federer to redefine his greatness in the context of a new external force he cannot dominate, and in the process has allowed us to appreciate how great he was all along.

The same is true for patients. Many of patients see me to address an internality- they feel pain somewhere, whether it be their back, neck, knee, hip, shoulder, or elsewhere. I find that one of the most effective things I can do in helping the patients I work with is reframing their problem- rather than defining their problems by an internality, define it by an externality- what is it that you actually want to do?

I’ll use a personal example from my life to highlight what I mean. At the tail of end of my college career at the University of Wisconsin, I was involved on the UW triathlon team and had a long term goal of completing my first Ironman triathlon. On a training ride in May of 1995, I wiped out and tore the PCL in my left knee.

I spoke with multiple orthopedic surgeons in Wisconsin, New Jersey, and New York, and they all took a similar approach to my knee injury- they address the internality of my knee injury, and made a determination of whether I needed reconstructive surgery (I didn’t). But for me, they never addressed my externality- I was defining myself by my ability to race in an Ironman triathlon. They were answering a different question than the one I was asking- they were answering the question “do I need surgery,” when the question I was really asking was “what do I need to do to enjoy, compete, and excel in the Ironman?”

I’ve devoted my life to answering that question, both for me and my patients. It may not be the approach for everybody, but I think it helps many. Some examples:

Patient #1:

Internality: Initially comes in talking about her back pain

Externality: What she really wants to know is what does she need to do to pick up her granddaughter and play with her

Patient #2:

Internality: Comes in bothered by hip pain

Externality: What he really wanted to know is what he needs to do to finish a marathon he is training for with his brother

So- what is your externality- what is it that inspires you? What motivates you? What excites you? What is that makes you the best version of yourself? What can we do to help get you there?

The Stretching Trial

There is ongoing trial that is recruiting athletes to assess the effectiveness of stretching. I encourage those interested to take a look:

http://stretchingstudy.nokc.no/study-stretching-web/innhold/welcome.faces

US Open Preview- Women's Draw

As is often the case for me, I am more interested in the women's draw, particuarly because of one player. My predictions, in order:

1. Dinara Safina. I am very much excited about her chances. She's had a pretty dominant run the past 6 months:

Won 2 Tier I Tournaments: Berlin (clay), Montreal (hard)
Won 1 Tier II Tournament: LA (hard)
Lost in a Slam Final: French (clay)
Won Olympic Silver Medal: China (hard)

She's ascended from the number 15 last year to number 7 now. She is only 535 points outside of first place, and 297 points outside of first in the points race for the year.

For all these reasons, I think Safina is currently the best player. I think she's the strongest woman on the tour (I would love to see a "World's Strongest Man" type event featuring Safina, Serena Williams, Lindsey Davenport, and Ana Ivanovic. I'd put my money on Safina). She has superpowerful strokes from both the forehand and the backhand, and she's the most intense player on the tour. I could also see the NY crowd getting into her intensity (I could see them tearing into to her).

So, even if everyone wasn't injured, I'd be picking Safina. But everyone is injured. This makes it an even easier call. I give Safina a 35% chance of winning, which is pretty high- it's higher than I picked for Djokovic in the men's draw, for example

If she does win, by the way, I put the odds of her brother showing up to watch her also at 35%. You can never predict anything with the Safin/Safina family.

2. Elena Dementieva. I've never loved her game, but she is admittedly doing well recently, and did beat Safina for the gold medal. The main strength to her candidancy is a solid all around game, an improving serve, and a depleted field.

3. Serena Williams. Just on talent alone. I think I was premature in thinking Ana Ivanovic had surpassed Serena as the most talented player on the tour- at least until Ivanovic gets over her injuries. When Serena plays on her A game, she's going to beat everybody. I have no idea if she brings her A game- she should in NYC, but she actually hasn't been much of a world beater at the US Open.

4. Ana Ivanovic. I can't be completely neutral on her- she's my favorite player, so I want her to win. I don't know what to make of her injuries. I assumed that her hip abductor strain going into Wimbledon was a fake or minor injury to give her more time to rest after winning the French. But she was lackluster at Wimbledon, and would have been eliminated earlier if not for a lucky let cord shot. And her thumb injury has been limiting her substantially, including pulling out of the Olympics. A thumb injury could be very limiting, especially how important her rotation and top spin is to her dominant groundstrokes.

If Ana is healthy, though- well, I still might put her #2. She had a mental edge coming out of the French, but Ana's been playing so poorly that I think she will have issues getting her mental game back. If she starts off with a few dominant straight set wins, then she goes right to the top of the list with Safina. Otherwise, we may have to wait a few more months to let her thumb and confidence heal.

5. Venus Williams. Just too talented and too erratic to ever predict accurately.

6. Jelena Jankovic. Again, injuries are the main issue here. Clearly talented enough to win. If she gets rolling, her engaging style of play and ebullient personality will make her a crowd favorite in NY- she's just too darn likable. I'll be rooting for her.

7. Alize Cornet- my "what the heck" pick. She's been playing well, and shown she can hold her own with the big name players. I wouldn't be shocked to see her make the semi-finals

US Open Preview- Men's Draw

Here are my thoughts on the likely winners for the US Open, in order of likelihood:

1. Novak Djokovic
2. Rafael Nadal

I've gone back and forth on these two, who I consider co-favorites. It's certainly been Nadal's year. There are a few reasons, however, I am leaning toward Djokovic:

a. I think Djokovic's track record is still better on hard court
b. They've played each other pretty closely. Djokovic is one of the few players to have convincing wins over Nadal this year. Djokovic is probably the only player on the tour who thinks he should beat Nadal, and I include Federer in that comment.
c. Health. I think Nadal's style makes him a bit of walking time bomb, and I could see him running himself down over the course of the hard court tournament
d. Crowd response. The US Open is my favorite live event in any sport, and the main reason is the crowds- it is the one tennis event where the crowds can really rally a player. Of the top players, Djokovic has the most engaging personality, which definitely benefited him last year.

I think these are all very real advantages for Djokovic. Maybe I am just trying to convince myself to go against the best player, who is clearly Nadal.

I would probably say 27% chance for Djokovic, 23% chance for Nadal, and 50% for the rest of the field.

3. Federer. Still great, even if his not playing at a "greatest of all time" level. I am one of those people who appreciates Federer more now that his is mortal.

4. James Blake. Inconsistent, but I think he's the American most likely to have the crowd rally behind him and carry him to victory.

5. Andy Murray. The most talented player outside of the Big 3.

6. Marat Safin. I was impressed by his Wimbledon run, and I think it would make an interesting story to add to my predicted winner for the women's draw.

Michael Phelps

While Usain Bolt has certainly been incredibly impressive, this has clearly been Michael Phelps's Olympics.

Michael Phelps was already the greatest swimmer of all-time prior to the Olympics. What this Olympics did was put distance between him and #2, whoever that is (Mark Spitz presumably, although I suppose their are other people in the mix, like Matt Biondi, Ian Thorpe, Tracy Caulkins, and Jenny Thompson).

Michael Phelps's real peers now are people like Tiger Woods, Roger Federer, Michael Jordan, Jim Brown, Barry Bonds, Lance Armstrong, Babe Ruth, and Jim Thorpe- whether he is the greatest athlete of all time.

If I were his career adviser, I would recommend against trying to repeat in the same events he has already been swimming. I think there is limiting returns in trying to dominate 200 free, 200 and 400 IM, and 100 and 200 fly. He's already proven he can win these races, and it won't alter how he is perceived historically.

So what events would I like to see Phelps swim:

100m and 200m Backstroke: I have seen some talk that he is considering racing the backstroke as an individual. I think that would be a great choice. It would certainly add to his legacy if he could start beating Aaron Piersol regularly in the backstroke, since Piersol is arguably the greatest backstroker of all time. I think it would also help his dominance in the IM, since his closest competitor is Ryan Lochte, and Lochte is the current 200m record holder and gold medal winner.

100m Freestyle: I think he would also benefit from taking on the 100m freestyle as an event. I suspect that as he ages, he will be able to maintain his speed more easily than his endurance. His best time is 47.51 seconds, and the current world record is 47.05, which was just set at this Olympics by Eamon Sullivan. Phelps's time of 47.51 seconds would have been a world record as recently as March of 2008, and only Sullivan and Alain Bernard have swum faster. I suspect that if Phelps were to concentrate on the 100m freestyle, he would be very much in the mix for the best in the world.

200m Breaststroke: This is the event that would truly cement Phelps's place in history. Currently, the record of 2:07.51 is held by Kosuke Kitajima of Japan, who is probably the greatest breaststroker of all time. Breaststroke is most peculiar of the swimming strokes, and so it is unusual for great swimmers in the other strokes to also be great breaststrokers. If Phelps were able to take down Kitajima, he would dominate over the sport of swimming more than any other athlete in any sport.
I think he could do it. In the IM, Phelps held his own in the breastroke against the other IM'ers. I don't think he could beat Kitajima using his current stroke- I think he would have to evolve the stroke to better fit his body type. It would probably continue the progression of breastroke, which has over time has increasingly evolved to look more like butterfly. Phelps is the greatest butterflyer of all time, and if he could modify the breastroke to take advantage of his poweful dolphin motion and elongate the glide even more than is already case in the breastroke, I think he could beat Kitajima.

If Phelps were to become a world record holder in the 100m backstroke, 200m backstroke, and 100m free, then I think he would clearly be in the discussion for the greatest athlete of all time. If he were to beat Kitajima and break the world record in the 200m breastroke, then I think that more than being in the discussion for the greatest athlete of all time, he would become the starting point in the discussion.

Go for it Mike.

Kinesiotape- part II, and some related thoughts on doping

A reader posted a follow-up question regarding my post on kinesiotape:

"Let's say I'm a perfectly healthy athlete who decides to put kinesiotape on my shoulder to help with proprioception during my tennis match against Lindsay Davenport. Would you say this is more equivalent to me (a) wearing an Ace bandage around my prone-to-spraining ankle, (b) wearing a sweatband to keep my hair, sweat, etc. out of my face, or (c) me taking steroids to help improve my performance? Or (d) none of the above. I guess my more general question is, could kinesiotape be used to give injured and/or non-injured users any kind of advantage (beyond the band-aid type functionality)?"

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I'll address the specific question asked here at the end of this post.

As for the more general question, and it's a good one- how should we view the benefits of kinesiotape- is it within the realm of clothing, or should it be considered a form of doping. These types of questions are tricky to answer, but they are becoming more important in the realm of sports. Before I give an answer, I'll provide a few more examples of things like kinesiotape, that are things that athletic boards need to consider:

1. Carbon fiber or other alloys in athletic equipment (including obvious things like bikes and tennis racquets, but also less obvious things like the soles of athletic shoes, where it could augment the propulsion of runners)

2. Nutritional supplements

3. Sleeping chambers to simulate sleeping at altitude

4. Anabolic steroids

5. Birth control pills and corticosteroids- both are also forms of steroids, also with multiple systemic effects, including some significant side effects, and both which are sometimes prescribed for athletic performance. For example, birth control pills are sometimes prescribed to help with menstrual irregularities associated with the training from female endurance athletes. As another example, corticosteroids are amongst the most commonly prescribed drugs in athletes, such as in inhalers for asthmatics, or joint injections for joint pain. These are interventions that are not without significant risks.

6. Prosthetics for lost limb segments.

7. Caffeine

8. Water- this may seem obvious, but some sporting events used to ban water, and it does offer some performance advantage. Should this be banned?

9. Weight training
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These are just a few examples. I think it is valuable, before making an arbitrary decision on whether to allow something like kinesiotape in recreational tennis matches or Olympic beach volleyball matches, to have a set of criteria by which that decision would be reached.

In my opinion, in order to ban an intervention, it should be meet both of the following criteria:

A. The intervention confers a definite performance advantage
B. The intervention causes a reasonable expectation of harm to the athlete who uses it

In my opinion, an intervention needs to meet both of these criteria for it to be banned. This discussion is explicity assuming that the reason to ban something is for the safety of the athlete (below, I will discuss other aesthetic considerations). To give a few examples:

1. Water. Water almost certainly meets critieria A (confers benefit), but doesn't meet criteria B (reasonable expectation of harm). Therefore, there is no need to ban it, since there is no significant harm in athletes using water. Athletes should use water. I would probably make a similar argument for caffeine.

2. Beer. Beer probably meets criteria B (reasonable expectation of harm), but it is unlikely to meet criteria A (confers benefit), so there is no reason to ban it, since athletes aren't going to use it anyway.

3. Cutting off your nose. I use this as a trivial example. Some may argue that for beer- "well, it's not likely to be beneficial, but since it can harm athletes, we want to ban it to protect the athletes." But it's not reasonable to ban everything that can harm athletes- the purpose of governing athletic bodies is to protect athletes within the context of their sport, not life in general. It may seem obvious that athletes shouldn't have to be reminded not to cut off their nose, but athletic bodies frequently ban interventions with no proven benefit, and in my opinion they are extending themselves into the personal lives of the athletes and no longer protecting the sport. As an example, I don't think regulatory agencies have any business regulating marijuana or alcohol consumption, since they are not directly related to athletic performance.

4. Cocaine. Cocaine probably does meet criteria A (it is a stimulant, and probably confers a performance advantage) and also meets criteria B (it has many well documented harmful side effects). This, to me, is the very kind of substance that should be banned- if it was not banned, athletes might feel a selective pressure to take cocaine in order to compete, and therefore put themselves in harms way.

Getting back to the initial question regarding kinesiotape- it is possible that it meets criteria A (offers a performance advantage), but it is highly unlikely that it meets criteria B (reasonably would expect harmful side effects), so I can see no reason to ban it for players, whether they are injured or otherwise.

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The other reason for banning an intervention, beyond protecting the safety of the athletes (which is what I was really getting to above) is protecting the aesthetic and performance standards of the sport. There are certain equipment changes which have fundamentally altered the nature of their sports. These include:

1. Composite materials. Materials such as graphite, titanium, and carbon fiber have revolutionized sports like tennis, golf, and cycling. There is frequent discussion about whether these changes have ruined their sports. I think the difference is most striking in tennis, where the advent of new materials has probably been the dominant factor in the shift from serve-and-volley to power baseline as the dominant playing styles. I happen to like this shift, but some people hate it.

2. Aerodynamics/hydrodynamics. Examples include aerobars and disk wheels in cyling and the much-talked about LAZR swimsuit from Speedo have played large roles in rewriting the record books.

3. Altered techniques. Probably the best examples I can think of are the Fosbury Flop in high-jumping (the technique of going over backwards, developed by Dick Fosbury) and the Berkoff Blastoff in swimming (David Berkoff would swim nearly the entire lap of backstroke underwater using a dolphin kick. This has since been banned- an example of outlawing a technique to preserve the aesthetic of a sport, even if the new technique is faster).

As an aside, the concept of altered techniques altering a sport became very apparent to me in my marginal high school swimming career. When I was in high school, one of my teammates was a guy named Keith Rizzi. We came up swimming together in youth programs, and while he was always good when we were younger, he didn't become truly outstanding until late in our high school careers.

I think two things occured during our junior year that led to rapid improvements. The first factor was puberty, which is always a difference maker in high school sports. The second is that when we were juniors, they made a seemingly small change in the rule for backstroke flip turns, allowing what was called the cross-over turn. Until our sophomore year, it used to be required that a swimmer touched the wall while still on their back before starting their turn. They changed the rule to allow a "cross-over" turn, where the swimmer was allowed to flip onto their stomach for one stroke prior to initiating their turn. This allowed the swimmer to gain momentum from twisting from their back onto their stomachs and use that to propel their turns, which was faster for everybody.

However, Keith Rizzi was better at this turn than anybody else, and it made him unbeatable. Furthermore, he was able to use the technique he refined on his turns in backstroke and use that on his freestyle flip turns, and he became unbeatable in freestyle sprints as well. This made a big impression on me as a young swimmer, because I was overwhelmed with how a seemingly small change in a rule could make such a large impact in the outcome of the race. I think about this often when assessing the biomechanics of athletes or my patients- small changes in movement can make dramatic changes in outcome.

4. Altered equipment. Sometimes equipment dramatically alters. Examples include shapes of the modern putter in golf. Another example, which hasn't particuarly caught on, is two-handed tennis racquets.

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So, should kinesiotape be banned from volleyball, tennis, or other sports for aesthetic grounds?

In my personal opinion, no.

Beach volleyball and tennis, though, provide interesting counterpoints to the extent to which they regulate their aesthetics. Beach volleyball promotes the aesthetics of their athletes more avidly than any other sport. Tennis, particuarly the women's game, probably goes more out of their way to downplay the aesthetics of their athletes than any other game. It wouldn't surprise me if tennis outlawed kinesiotape because they found it "off-putting." At the very least, I would imagine that at Wimbledon players would have to make sure their kinesiotape was white.

Anyway, let me get back to directly answering the readers original question. I would consider using kinesiotape most equivalent to using an ACE bandage on your prone-to-spraining ankle. And I still don't think you'd have any chance of beating Lindsay Davenport.

My good friend, the late Jim McLean, applying kinesio tape to his knee in the middle of a marathon. He attributed the kinesio tape to being one of the keys for him overcoming the pain of his patellofemoral syndrome and finishing the marathon

Kinesiotape

I am on vacation at the moment, and have been avoiding posting while away, but someone asked a very good question that I've been thinking about myself while watching the Olympics- how beneficial is kinesiotape?

Probably the athlete who has stimulated the most questions is Kerri Walsh, the star beach volleyball player who, along with Misty May, is the favorite to win the gold medal in beach volleyball. She has been playing with kinesiotape on her shoulder throughout the Olympics, although she notably did not have any on last night during her semifinal match against Brazil.

Before researching the answer, my anecdotal experience from residency training was that while kinesiotape is limiting in it's ability to actually restrict motion, but it is useful as a proprioceptive cue. The theory behind this is sensory substitution. In this case, it is substituting tactile sensation to compensate for inadequate proprioception, which I will elaborate on below.

Proprioception refers to the ability to know where your body is in space. For example, if you close your eyes, you can flex and extend your elbow and know the position of your elbow- that's proprioception. Proprioception is important in sports activities, because to function at a high level, an athlete needs to properly place their limbs in a location to optimally contract their muscles to deliver a movement quickly and forcefully. A few examples where this can be especially important:

1. The knee- when an athlete lands, the knee needs to be optimally located to allow for smooth tracking of the patella (knee cap) along the groove of the femur (thigh bone). Improper positioning (usually of the femur) can cause abnormal tracking of the patellofemoral joint, causing patellofemoral syndrome.

2. The shoulder- the shoulder is one of the most mobile joints in the body, and requires an intricate interaction between multiple muscles (including the rotator cuff muscles, serratus anterior, trapezius, levator scapula, and several others). A typical pattern may include using the rotator cuff muscles to pull the head of the humerus into the glenoid fossa of the scapula (shoulder blade), co-contracting the serratus anterior and lower trapezius to position the scapula into the optimal position, and then contracting the teres major and latissimus dorsi to position the humerus throughout the range of motion. From just that description, one could see how the coordination of the muscles at the optimal time and in the optimal proportions could be challenging.

So, how does kinesiotape theoretically help? Well, the tape is a semi-rigid tape that stays relatively loose and comfortable when the joint is moving throughout the proper range of motion, but becomes uncomfortably tight when moving the joint outside of that ideal range, creating tension on the skin. This helps use the tactile sensation of the pulling on the skin to substitute (or reinforce) the proprioception of the joint. In combination, this helps reinforce the optimal positioning and movement of the joint.

So, back to the readers question- does it work?

Anecdotally, it is a useful reminder to maintain posture. I've used it experimentally, just for kicks, to see if I could remember to keep my back straight while lifting. It did help, although it could also be annoying every time I tried to sit down. So, there is the balance between reminding one of proper positioning, and an annoying tugging of the skin.

What is the evidence?

A search on pubmed on the term "kinesiotape" yields one article:

Res Sports Med. 2007 Apr-Jun;15(2):103-12.
The effect of kinesio taping on lower trunk range of motions.
Yoshida A, Kahanov L.

This article looked only at range of motion, not the more complicated question of athletic performance. It found it helped to some extent.

I then checked out the kinesiotape website: http://www.kinesiotaping.com/

To their credit, they have a grant process available, where they will supply tape to interested researchers to help conduct studies. They also have links to a few studies that are germane to the reader's questions:

J Orthop Sports Phys Ther. 2008 Jul;38(7):389-95. Epub 2008 May 29.
The clinical efficacy of kinesio tape for shoulder pain: a randomized,
double-blinded, clinical trial.
Thelen MD, Dauber JA, Stoneman PD.

This study looked at 42 participants with presumed rotator cuff pain, and randomized them into 2 groups, one of which used kinesiotape. The results aren't overwhelming, but the kinesiotape group did have some increased range of motion.

There are a few other studies cited for other conditions listed on the website.

So, back to the key questions:

1. Does kinesiotape work, in general?

Maybe. I don't think the evidence is overwhelming, but absence of evidence is not evidence of absence. I think it probably does offer some sensory substitution that is useful as part of an integrated physical therapy program in training an athlete to use their joint through an optimal range of motion.

2. In the specific case of Kerri Walsh, does it help?

Maybe. She's been playing pretty well, although it is interesting that many of the teams have aggressively challenged her defensively. Also, she ended up pulling it off for her semifinal match against Brazil. With an athlete like Kerri Walsh, who may be the best ever in her sport, it is difficult to attribute any one component of her success to any one intervention. Probably the largest benefit is providing her the confidence to play all-out.

3. Would I prescribe it?

Yes. I have prescribed it. My closest friend from training (the late Jim McLean) used it regularly for his patellofemoral syndrome, and he attributed it to being of the keys to him running marathons again.

Please share with me your thoughts.

Gary

The Benefits of Sun

For today's post, I want to write about the benefits of sun. Before I get to that, however, I should probably touch upon the downside of sun.

There are real downsides to sun- mainly skin cancer. I take this seriously.

Back when I was a medical student, and not yet familiarized with death, one of the most traumatic experiences I had was when the young wife of one of my friends, Sabra, was diagnosed with melanoma. She was in her early 20s, and was a wonderful woman. Ever since then, I have been somewhat hypervigilant to the risk of skin cancer.

To that extent, I want to mention a non-profit that was dedicated to Sabra's honor, called Be Sun Sensible.

http://besunsensible.org/

What I would like to discuss, though, is the upside to sun. I think at this point, my perception is that my patients are now more aware of the downside to sun exposure than they are to the upsides.

For example, I have a friend who wears a solar-powered watch. It only requires 7 minutes of sun exposure every 6 months to remain operational, but periodically it stops. That is a pretty vivid example of just how little sun exposure many of us get. As sympathetic as I am to the very real risks associated with excessive sun exposure, we also do need sun.

So, here are some of the benefits of sun:

1. Being active. In my opinion, by far the best reason to have sun exposure is because it gets you outside, and if you are outside, you are more likely to be active, and probably the single biggest thing that most people can do to improve there overall sense of health and well-being is to stay active.

2. Staying happy. One of the unfortunate effects of limited sun exposure is Seasonal Affective Disorder. Our mood is largely regulated by external cues, and one of the most potent of these cues is sun exposure. This is most obviously true in northern regions of the world, where they have very limited sun exposure in the winter months, and entire communities experience the malaise of Seasonal Affective Disorder. I suspect this is much more widespread than is generally appreciated. So 5 minutes of sun exposure daily will probably go a long way in improving your mood.

3. Bone health. One of the main ways the body produces Vitamin D is through sun exposure. This is especially important for females, who are more prone to diseases related to bone metabolism, specifically osteopenia and osteoporosis.

4. Decreasing musculoskeletal pain. One cause of generalized musculoskeletal pain is Vitamin D deficiency. It's something many physicians are not cognizant of, but if you actually check the Vitamin D levels of patients with diffuse pain throughout their muscles, Vitamin D deficiency is surprisingly common. And, as noted above, one of the best ways to increase Vitamin D levels is through sun exposure.

So, having listed some of the benefits of sun exposure above, what is an appropriate approach to staying sun smart and sun healthy. Here are some common sense guidelines:

1. Be active. I think this is by far the most important rule to follow. Try not to let climate deter you from staying active.

2. Don't burn. A significant part of the risk of sun exposure is from burning. So if you are in a situation that will require prolonged sun exposure (e.g., at the beach, a long bike ride, gardening, etc), where the appropriate sunscreens and sun-protective clothing to prevent sun burns.

3. Don't go without sun for prolonged periods. If it's been more than a week since you've seen daylight, that's probably an indication that you need some sun exposure. I am certainly guilty of this- the pressures of work and family sometimes keep us in buildings or cars for more than we may want. But if it's been more than a week, try to find some excuse to get outside for 5 minutes at lunch, just to make sure you get some sun exposure.

The Century of Behavior Change

There are two books that I frequently recommend for patients. The first is Stretching by Bob Anderson (ISBN-13: 978-0936070018), which many patients have found very helpful in helping them start and maintain a stretching routine.

The other book I recommend frequently is Mindless Eating, by Brian Wansink (ISBN-13: 978-0553384482). I don't have commercial interest in either book, by the way. Mindless eating is a terrific book about the many unconscious decisions we make about food every day, and how you can use those mindless decisions as means to eat healthier.

I definitely endorse the book, but the subject of this post is to comment on a tangential comment that Brian Wansink made in Mindless Eating. I hope I am not violating any copyright laws by quoting him here (I am new to the legal aspects of blogging) ...

On p. 205 of the paperback edition listed above, he writes:
"The 19th century has been called the Century of Hygiene. More lives were saved or extended due to improved understanding of hygiene and public health than by any other single cause. We learned that rats were not house pets and that it's a good idea for doctors to wash their hands before surgery.

The 20th century was the Century of Medicine. Vaccines, antibiotics, transfusions, and chemotherapy all helped contribute to longer, healthier lives. In 1900, the life expectancy of an American was 49 years. In 2000, it was 77 years.

I believe the 21st century will be the Century of Behavior Change. Medicine is still making fundamental discoveries that can fight disease, but changing everyday, long-term behavior is the key to adding years and quality to out lives. This will involve reducing risky behavior and making changes in exercise and nutrition. There isn't a simple prescription that can be written for such behavior change. Eating better and exercising more are decisions we need to be motivated to make."

I very much agree with the sentiments of Brian Wansink- I do think that the biggest health gains for the United States, and probably most other industrialized countries as well, will be in complying to healthier lifestyles.

Last year at the annual meeting for my field of medicine, the American Academy of Physical Medicine and Rehabilitation (AAPM&R), I was having lunch with a colleague, and he remarked that in his clinics, he had bimodal patient populations. Rather than seeing gradations in activity levels, he basically had two distinct and non-overlapping populations- the very active, and the sedentary. I don't have data to support that this is in fact true, but speaking to my colleagues and on my personal anecdotal experience, I believe it to be true.

Not surprisingly, the very active population appear to be living much healthier lives. First off, they are more active, and they enjoy being active. Second, as a group, they don't smoke, drink moderately, do not engage in many addictive behaviors (although many are workaholics, so I suppose that is an addiction). They are sociable, with strong community and family interactions. I don't know for fact that they are living longer, but since so many of them are golfing, playing tennis, and cycling into their 80s, I am willing to guess they are living longer and healthier lives than the sedentary population.

As for the sedentary population- well, they live a different life. They look older- it is not uncommon for a sedentary 30 year old patient to appear older than a very active 50 year old patient, despite otherwise similar demographic characteristic. Many more of the sedentary patients smoke (although not all do). I cannot comment specifically about drinking behaviors- anecdotally, both groups seem to drink similar amounts, but the sedentary group does seem to have a higher percentage history of substance abuse. The sedentary patients also, as a group, seem less happy.

I think the management for both groups is quite different. For the very active group, when they have a problem, it is much more likely to be an acute problem that can be acutely addressed, and they quickly go back to being very active.

For the sedentary group, the problems are more likely chronic in nature, and often require chronic treatment. And the key chronic treatment they need is lifestyle change. Thus, I think this ties in to Brian Wansink's idea- this needs to be Century of Behavior Change. I, and most other physicians I suspect, have more sedentary patients. It is a growing group, both in numbers and waistline.

I don't mean to downplay the very real and very significant changes in other aspects of medicine we will see. We will continue to see life changing breakthroughs in medications, radiation technology, imaging modalities, surgical techniques and instrumentation- all of these.

My sense, though, is that these breakthroughs, as a group, will have a higher impact on those patients who are already in the (smaller) very active grouping- it may help them improve their active lifespan by 10 years and their overall lifespan by 15 years- these are really big gains, and I don't want to dismiss them.

But .....

If we are able to basically convert a patient from a sedentary lifestyle to a very active lifestyle- well, I think that is a much more substantial gain. I think the improvement in years of quality life improvement might be, roughly estimating, 30-40 years, with perhaps another 10 years of additional total lifespan. That's an enormous change- certainly comparable to the gains produced by the Century of Hygiene of the Century of Medicine.

Let's take a hypothetical patient as an example:
43 year old man, father of two young daughters, visits a physician with a chief complaint of low back pain for 5 years. He works in sales, and spends much of his life on the road, which limits his diet to things he can eat in the car, and he certainly has little time for exercise, since most of his time at home is devoted to being a good father for his daughters and a devoted husband to his wife. Both he and his wife smoke 1-2 packs daily, which they typically do either while driving, or while drinking a few beers while watching TV after they've put the girls to bed.

A traditional medical model may focus on his chief complaint symptom of low back pain. And it may provide him transient relief for his low back pain. However, without addressing his sedentary lifestyle, he will likely have recurring problems, whether in his back or elsewhere. Furthermore, he made enter into a cycle of frustration with the health care system, feeling medicine is helpless to help him

Obviously, a better model is needed. I think the traditional "body part" focused approach to musculoskeletal care has failed to address his greatest need- lifestyle modification.

Let's call this patient Bob. Bob has entered a pattern many of us do, typically as we enter our late 20s- you know the right things to do, but the very priorities of life- work, spouse, family- the external obligations make one feel unempowered to take control of your life and do the things you need to do.

So, our first role as a physician is to be an advocate for the patient- let them know they aren't alone, and someone has their back.

Our second role as a physician is to let Bob know that he DOES have a choice, or in fact many choices. This is a simple concept, but in my opinion, an incredibly important concept that is often not stated explicitly to the patient, if not outright ignored. Bob needs to know that he empowered to make choices in his life. This insight alone is often enough to let him make positive changes in his life that will help promote a more active and less sedentary lifestyle.

Tangent: In psychology, they need to use an animal model for depression. It's usually difficult to pick out the depressed rat in a crowd, since they don't usually paint their toe-nails black and where goth t-shirts. So one animal model they use is called "learned helplessness." The animal (usually a mouse or rat) will be set in a series of conditions that no matter what they do, they never win. For example, they may be shown a series of levers that could produce different amounts of food, but no matter which lever they use, they can never win. They "learn" that they are helpless to determine there own fate. Psychologists can track the behavior, and interpret it as mirroring depression.

Most humans can relate to the experience of learned helplessness, and it's about as good a definition of depression as there is out there (as another tangent, I do actually believe that the learned helpless model is a more useful model than the technical DSM-IV criteria that most psychologists and psychiatrists use that, for reasons I hope to discuss in another post, I believe is seriously flawed). For example, think of the worst serious relationship you've ever been in- at the point just before the relationship ended, there is often a point where both partners feel that no matter what they do or say, it's not good enough- well, that sounds an awful lot like learned helplessness, and it's certainly not a pleasant feeling. It's depressing.

Let's get back to Bob- his chief complaint is that of low back pain, but his chief barrier is a sedentary lifestyle. And it is likely that the chief barrier to modifying his sedentary lifestyle to a more active lifestyle is a sense of learned helplessness- namely, that the behavioral modifications necessary for him to become more active seem outside the realm of his model of control.

Acknowledging this set of concerns is valuable in of itself. Getting back to Brian Wansink's proposition, though- I do think this is the Century of Behavior Change. I think the biggest gains we will see in the United States will be figuring out different approaches to help him modify his behavior so the Bob's of the world can become less sedentary and become more active.

And I think we are well on our way- the first step to answering a question is to actually know which question to ask.

I do not think this progress is easy. One reason that medicine has devolved into it's current simplified one-joint model for treating musculoskeletal conditions is it's for the most part easier. Developing models that consistently work for modifying behavior for a healthier lifestyle is genuinely difficult. It doesn't mean it shouldn't be emphasized.

Look, developing the germs theory and appropriate hygiene was hard, but we did it, and we are better off for it. Similarly, the development and utilization of some of the advanced medications of the past century was hard, but it made a huge impact. It was worth the effort.

Medicine is now ready to take on the next stage- Behavior Change. It won't be easy, but we can do it, and our patients deserve it.

In future posts, I would like to touch upon some of the best advice I've seen for encouraging behavior change.

Wear out, don't rust out

I am just coming back from a farewell dinner that some of my friends in Little Rock threw for me, since this is my last week at the University of Arkansas for Medical Sciences. I don't want to make changing jobs a habit, but one nice aspect of leaving is that it allows me to positively reflect on what you have learned at your time at the institution.

One of my good friends here who was at dinner with me tonight was Arny Ferrando, who is an outstanding researcher in the department of Geriatrics, and studies sarcopenia. Sarcopenia refers to muscle breakdown. Many people are familiar with the terms osteoporosis and osteopenia, which are the thinning of bone that occurs with aging. Sarcopenia is the equivalent process that occurs in muscle.

I've learned a tremendous amount from Arny this past year, probably more than he realized. Before I get to the main theme of this post, I will make a quick comment about sarcopenia. Probably the single biggest thing I learned from Arny is to be cognizant of muscle metabolism as part of the aging process and as a stress response. It is my belief that some of the largest improvements we will see in medicine in the coming decades will be in limiting the process of sarcopenia in aging populations and high stress environments.

Now, to the main theme of this post- "Wear out, don't rust out." That's an expression Arny likes to use, and I love it. The patients I most enjoy working with are adult patients who want to continue physical activity, but the process of aging has presented certain barriers- whether it is musculoskeletal pain, slower recovery rates, medical conditions, etc. While one certainly can avoid activity, eventually you will rust out. Given the choice, one is better off wearing out rather than rusting out.

I fortunately came of age in medicine where the benefits of exercise are more fully appreciated (although, in my opinion, not promoted enough). When I am giving lectures to medical students on exercise, one of my favorite examples I like to use is a comparison between my father and my paternal grandfather. My grandpa Peter had a heart condition, and the advice from physicans at that time was to avoid activity so as not to overly stress the heart. I have only very faint memories of Peter, as he died when I was 4. I remember him as a very kindly and gentle man, but also as a very frail man. He rusted out.

My father is very different. He started developed heart problems at a younger age. The advice he was given was very different, though- he was advised to continue actively exercising. As if often the case, some of the best schooling I have is from watching people I love acting admirably, and dad has biked 10 miles daily for the past 25 years. He is now several years older than my Peter was at the time of his death. I had a scare this winter when my father tore his quadriceps in his thigh, which is not a trivial injury. But he's already back to biking regularly. Bless him. My dad is 73, and I am pretty sure that he is going to wear out rather than rust out. This is my personal bias, but I think this is a better way to live.

I think there is one main reason to wear out instead of rusting out- it's a heck of a lot more fun. I think of my happiest moments here in Little Rock, for example, and most of them are along cycling along the Arkansas River or hiking up Pinnacle Peak. I have my own associated aches and pains, just like all people in their 30s or older do, but I'm awfully glad that I can still move and do the things I love doing.

Relatedly, I just saw one of my favorite patients this past week for the last time. She is a runner in her 60s who has developed some bone related problems that will hold her out of running for a short while. She thanked me, and her main advice for me as I embark on my career in Pittsburgh was "thanks for not telling me I'm never going to run again." On the off chance that she reads this, it is my hope that she keeps running for another 30-40 years. Eventually she may wear out, but in the meantime keep doing what you love. I'll be there cheering you on.