Sunday, June 22, 2008

Does mononucleosis decrease athletic performance?

In my prior post, I argued that the decreased performance of Roger Federer and Justine Henin (and myself) may be related to mononucleosis. Rather than purely speculate, I did a quick review to see what has been published on this topic in the medical literature:

Article 1:
Bailey DM, Davies B, Budgett R, Gandy G. Recovery from
infectious mononucleosis after altitude training in an
elite middle distance runner. Br J Sports Med.
1997 Jun;31(2):153-4.
Examined the impact on a long distance runner who contracted mono. He had worsening of several physiological parameters, which never fully recovered (measured ~5 months later), but did recover much of his actual athletic
performance, running a personal best in the 1500k run 10 months after he caught mono. Conclusion: suggests that athletes can regain a high level of function after mono, even if their physiologic parameters do not fully recover

Article 2:
Gleeson M, Pyne DB, Austin JP, Lynn Francis J, Clancy RL,
McDonald WA,
Fricker PA. Epstein-Barr virus reactivation
and upper-respiratory illness in elite swimmers.
Med Sci Sports
Exerc. 2002 Mar;34(3):411-7.

This study is more of what I was looking for. They looked at
14 elite male swimmers. Of them, 11 had prior infection with
Epstein Barr Virus. They tracked the swimmers during a period
of intensive training, and found that just before the swimmers
would get sick with an upper respiratory infection, they would
have recurrences of Epstein Barr Virus. It's not conclusive,
but it does suggest that for athletes a prior history of mono,
the virus never leaves your body, and that the virus will have
a tendency to resurface during periods of intensive training.

So, how does this impact my interpretation of
Federer, Henin,
and myself? I am sure there are other equally valid models
out there, but the model I am proposing is that when an
athlete (or borderline athlete in my case) gets mono, they may
be able to sustain short periods of intense exercise, but that
long term sustained intensity increases the probability of the
virus recurring, which makes long periods of sustained effort
substantially more difficult. Because of this, athletes would
require longer periods of sustained rest.

Like most people, I am assuming
Henin will come back at some
point, and just may need a year or two to let her body recover.
If I were advising
Federer, I would also advise him to take
more time off.
Because he is so good, he tends to stay longer
in tournaments than most other players (since he makes the semis
or finals of essentially every tournament he enters). I think
he would be better served by playing just the slams and a few
other ATP Masters Series events, but otherwise stay well rested.
He has nothing to prove at this point by playing a longer
schedule, and I think it will wear him out.

Wimbledon's Men's Preview, and the impact of Mononucleosis on elite tennis players

I am more excited about the women's tournament than the men's. I just think the women's game has more interesting figures. Jelena Jankovic may the best charismatic star since at least Andre Agassi, maybe even John McEnroe. The top star, Ana Ivanovic, has compelling rivalries with pretty much all of the other top players, including Sharapova, Jankovic, Safina, and the Williams Sisters.

The men's game has been relatively dull, and that is mostly because of the dominance of Roger Federer. Unlike the previous dominant player, Pete Sampras, Federer actually has a very exciting style of play, based largely on his tremendous range and ability to hit winners at every angle. Like Sampras, he is a classy individual, who represents everything you want in a nephew- he is courteous, respectful. Unfortunately, his personality is also pretty boring. I think the game is more interesting when you're top player is bit more mentally unstable, which is why I always rooted for Lleyton Hewitt or Marat Safin to beat Federer.

When it comes the Wimbledon preview, the underlying question is similar to that on the women's side- do you base performance on recent performance, or do you base it on a longer track record? On the women's side, Ivanovic is the best player if you look at recent performance, but to argue in her favor requires one to assume that her recent increase in performance is a real phenomenon. Similarly, Roger Federer has been the dominant grass player for 5 years, and his level of dominance is historic in stature. To argue that he has fallen back to the pack (in this case, the pack being Rafael Nadal, Novak Djokovic, and Andy Roddick), one would need to feel that Federer's drop in performance is real. I think it is.

My guess (and it is just a guess) is that Roger's recent bout with mononucleosis has had far more impact on his game than many have realized, and I don't think he will ever be the same player again. He started at such a high perch- probably the highest any male tennis player has ever attained, that he can drop off and still be one of the top 2-3 players in the world, but I think his reign as the Tiger Woods of tennis is over.

For me, the 2 lasting images of the 2008 tennis season are Federer getting overwhelmed against Djokovic at the Australian Open, and even more Federer not even trying to get at some winner's Nadal blew by him in the 3rd set of the French Open final. Many commentators have attributed his performance at the Australian Open to mono, but instead attributed Federer's performance at the French to a lack of heart. I think it's far more likely that Federer is just dealing with the consequences of decreased endurance and increasing fatigue, rather than suddenly he's lost his competitive spirit.

I will digress a moment for a personal anecdote. I had mono when I was 24 years old. I am obviously nowhere near the athlete that Federer is, but the one athletic attribute I did have was endurance. As a younger man, it was pretty much impossible to tire me out, and my recovery rate was very fast. As a marginal triathlete, for example, I could pretty easily work out at 75% of my max heart rate for over 5-6 hours (my training rides would sometimes be in the 8-10 hour range, and my heart rate was regularly in the 150-168 range).

Mono was probably the most unpleasant experience I ever had. I remember that I could barely walk for several weeks, and that I needed my then girlfriend to help me so that I could walk a mile to get lunch outside my house in Long Island. And I've never fully recovered. I've done a few century rides on my bike since then, but I have to keep my heart rate at a much lower level in my target range (typically 60%, rarely going over 70%). Part of that might be that I am no longer training as hard, but I've had periods where I've tried to up my training, and my body simply won't let me anymore. And it takes me much longer to recover from the workouts.

It's conceivable (heck, it's even likely) that I've just grown soft, but I think at least part of my decreasing endurance is a lingering effect from the mono, given that it has such a clear demarcation point.

As another aside, I think the same thing has happened to Justine Henin. Henin is one of my all time least favorite players, so I hate saying anything nice about her (I am an Amelie Mauresmo fan, and I thought the way she quit in the 2006 Australian Open was one of the most distasteful things I've ever witnessed as a fan). But if one reviews her career from the perspective of how she has coped with mono, it does give one cause for admiration.

Henin's first run as a dominant player began in 2003, and for a period of about a year, she had supplanted Serena Williams as the dominant player in the game. However, by mid-2004, she had contracted cytomegalovirus (CMV), which causes symptomology that is essentially the same as the mononucleosis that is more traditionally caused by the Epstein-Barr virus (which is what both Roger Federer and I have had). By the end of 2004, she had to take a leave of absence to try and recover.

Because Henin was still winning majors (namely the French), the depth of her drop in performance has not always been appreciated.

Looking at her win-loss records from 2003-2008:
2003: 75-11 (87%), year-end ranking #1, 2 Slam Wins
2004: 35-4 (90%), year-end ranking #8, 1 Slam Win
2005: 34-5 (87%), year-end ranking #6, 1 Slam Win
2006: 60-8 (88%), year-end ranking #1, 1 Slam Win
2007: 63-4 (94%), year-end ranking #1, 2 Slam Wins
2008: 16-4 (80%), withdrew as #1 player (with a huge lead)

As a frame of reference, the players who supplanted Henin in the period she was out of the #1 spot (when I am assuming she was most affected by mono) were Amelie Mauresmo, Lindsay Davenport, Kim Clijsters, and Maria Sharapova. There records for 2004 and 2005

Amelie Mauresmo:
2004: 59-11 (84%), no slams
2005: 53-16 (77%), no slams
2006: 50-13 (79%), 2 slams- I include this year, since it was Mauresmo's best year, and Henin still outplayed her

Lindsay Davenport:
2004: 63-9 (88%), no Slams
2005: 60-10 (86%), no Slams

Kim Clijsters:
2004: 20-2 (91%)
2005: 67-9 (88%), 1 slam win

Maria Sharapova:
2004: 55-15 (79%), 1 slam win
2005: 53-12 (82%)

So, what do I make of this? During the period after which she contracted mono, she was playing at least as well as any the women who supplanted her as #1, only she played less frequently. She had a higher winning % than any of her chief rivals except Clijsters, and won more Slams than any of them. By 2006, she restored her dominance, and was clearly the best player on the tour when retired.

What if games are dangerous territory, and unfortunate as it may be, things like contracting mono happens. This doesn't seem the same to me, for example, as what happened to Monica Seles. Monica Seles missed several years from the prime of her career because someone stabbed her for the express purpose of making sure she wouldn't be the #1 player. I think you have to factor that in when assessing her as an all-time great. Henin's a health issue, and should be evaluated similarly to an ankle injury. But because she kept winning slams and winning at a high rate, I think the impact of the mono on her greatness has been underestimated.

And since I am still in the realm of speculation, I think it is why she retired at such a young age. She is coming off her best year ever (and one of the great years in the history of women's tennis), but I don't think it is unreasonable to take her at her word when she says she is just exhausted. And I think mono has a lot to do with it.

As one more aside before I get back to Federer- where should Henin rank amongst the all-time greats? I think the game has changed enough since hte beginning of the WTA rankings in 1975 that I am only considering players from that period on (since, at this point, I am not sure what to do with players like Maureen Connolly, Eve Goolagong, Margaret Court, Billie Jean King, and Althea Gibson). After that period, I think there are clusters:

Tier I: Chris Evert, Martina Navrilotolova, and Steffi Graf. These are the 3 players who can make a legitimate claim to be the best ever.

Tier II: Monica Seles, Serena Williams, Justine Henin. These are the players who had periods of dominance that were as high the top 3, but didn't have the sustained dominance. Monica Seles is the hardest to evaluate, because we will never know what would have happened if she wasn't stabbed.

Tier III: Venus Williams is at the top of this group, but would also include people like Arantxa Sanchex Vicario, Lindsay Davenport, and Maria Sharapova.

I am pretty comfortable that Ana Ivanovic will make Tier III. My question is whether she will make it into Tier II (which I think she will), or even Tier I (possible, but not likely).

Ok, enough asides- back to Roger Federer

I think Roger Federer now is in a similar place to where Justine Henin was in 2004-5. He started at such a high level that when he falls, he's still as good as anybody at his best, but he is no longer heads-and-shoulders above everyone like he has been.

Furthermore, the players below him have ascended. Rafael Nadal is clearly better than he was a year ago, and he was already pretty close to Federer. Novak Djokovic is similarly just coming into his own as a player. And Andy Roddick is recovering from injuries and should be a solid threat in the tournament.

I think at this point, then, the perception that Nadal is a better player than Federer is probably real, even on grass. Both Nadal and Federer both won grass tournaments as Wimbledon tune-ups, but Nadal had to beat both Roddick and Djokovic to do it, whereas Federer played a much weaker field.

All in all, I think Nadal is the best player now. Given that Federer also has the tougher draw, with Djokovic on his half of the draw, I think Nadal has to be considered a solid favorite to win Wimbledon.

Saturday, June 21, 2008

Wimbledon 2008 Preview, Aging Patterns of Female Tennis Players

My interest in tennis is probably about as high as it's ever been. I had more fun watching the French Open than any other sporting event this year (particularly the semifinal match between Ana Ivanovic and Jelena Jankovic), and I think the game has more interesting figures than it has since the late 70s-early 80s, back when McEnroe-Borg-Connors and Evert-Navritolova were the stars.

The main reason I am making this post, though, is to comment on aging patterns in elite female tennis players.

Women's Preview:
My sense is that there are a distinct grouping of players who are well-suited to grass right now- players with powerful serves and groundstrokes. Venus Williams is the archetype of this player, and when she is at her best, I think she's probably the best grass player of all-time (with respectful nods to Martina Navritolova and Steffi Graf). The players in the current draw that I would put into this grouping, and thus the co-favorites, would include Venus and Serena Williams, Maria Sharapova, Ana Ivanovic, and Dinara Safina. There are a few others who also have this type of game, like Svetlana Kuzsetnova, Lindsay Davenport, and Amelie Mauresmo, but I would put them all step-down from the other 5 right now.

Of the non- "big babe" style players, I think that Jelena Jankovic is clearly the best player and biggest threat to win. I think, however, it would be hard for her to compensate sufficiently for her lack of a dominating serve or forehand, no matter how fit, fast, and flexible she is.

So, how would I rank the big 5?
1. Ana Ivanovic
2. Maria Sharapova
3. Serena Williams
4. Dinara Safina
5. Venus Williams

I would probably throw Jelena Jankovic in there somewhere, but I am not sure exactly where. At their best, I think Safina or Venus would kill Jankovic on grass, but Jankovic is in my mind far more likely to make it to the semifinals based on her consistency (i.e., I don't see JJ losing to a second-tier player, where Venus and Safina definitely might).

I think the distinction for overall favorite comes down to Ivanovic and Sharapova. They are having the best years so far, have split the 2 majors, are about the same age (Sharapova is 7 months older), and have similar games that are well-suited to Wimbledon. Sharapova has a better overall track record and has been elite for 2 more years, while Ivanovic is playing a bit better recently.

The main question in distinguishing the two of them is in determining whether Ivanovic's recent high level of play is transient, or whether she's truly raised her game. I tend to think that latter, which is why I have her above Sharapova. However, I may be completely off-base, and she may be a merely very good player having an unusually good year, like Amelie Mauresmo did in 2006.

I have several reasons for thinking that Ivanovic has raised her game, and that we are seeing the beginning of her ascent as an all-time great:
1. Age. While Sharapova and Ivanovic are almost the same age, they have matured differently. Sharapova looks about the same now as she did when she won Wimbledon in 2004 at age 17. Ivanovic, on the other hand, has done a lot of aging, in a good way. She is more muscular, has considerably less fat, is more mobile, and has greater endurance. 4 years ago, Sharapova was clearly a better overall athlete. That is no longer true. Ivanovic was probably always stronger, but she has now matured to the point, where she is also faster and has more endurance.

The main reason I wanted to include a Wimbledon preview in this blog is to speculate on whether there are variable maturation rates amongst female tennis players. It has been commonly noted that females often become elite tennis players at a younger age than their male counterparts, I don't know that this is universally true. I suspect that players with larger frames, like Ana Ivanovic and Lindsay Davenport, will mature later than their thinner framed counterparts. I also suspect they will have longer lifespans, and that thinner framed players will be more likely to retire at a young age.

One way of assessing this is to look at all of the women who have been ranked #1 by the WTA- that is a reasonable standard for an elite player. There are 17 players who have been ranked #1, starting with Chis Evert in 1975, and as of right now (June 2008) Ana Ivanovic is #17.

For each of the champions, I looked at the correlation of height or weight with 4 different performance measures- # of Grand Slams won, Age when they won their first grand slam, Age when they first reached #1, and Age at Retirement

Depending on the study listed below, I may or may not include all 17 players (it will be clear which players are included). Eve Goolagong is a bit of an odd case, since she is really a player from an earlier era, who for a short time passed Evert for #1. About half the list is currently playing, which limits their inclusion in some parts of the study, retirement dates are in some cases imprecise, and I suspect that many of the weights I have are inaccurate (e.g., I suspect Serena Williams weighs more than Kim Clijsters, and I think Tracy Austin was much lighter than her listed weight).

So here are the results:

Height- not statistically significantly correlated with anything, although taller players did tend to retire at an older age. The former and current #1 players who have not yet retired (Davenport, the Williams sisters, Mauresmo, Sharapova, and Ivanovic) are taller as a group than the players who have currently retired, so they are almost a different group than the players who have retired.

For those who care about the particulars:
#Slams: N=13, r=0.0959, p=0.7552
Age at first slam win: N=17, r=0.0504, p=0.7552
Age when first #1: N=17, r=-0.08918, p=0.7336
Age when retired: N=11, r=0.40262, p=0.2196

For weight, the trends are stronger. The one statistically significant relationship was that heavier players took longer to win their first Grand Slam event. They also won took longer to reach #1, but that wasn't quite statistically significant.

The actual data:
#Slams: N=13, r=-0.16443, p=0.5914
Age when winning first slam: N=17, r=0.527, p=0.0296
Age when first reaching #1: N=16 (excluded Eve Googalong, since dating #1 is unclear with her), r=0.403, p=0.1213
Age at retirement: N=11, r=0.125582, p=0.7129

If anyone is interested in examining the data, I would be happy to send them the excel spreadsheet.

So, this is an awfully long aside- let me get back to comparing Sharapova and Ivanovic. The underlying argument I was trying to make is that the two of them are similar in age, and Sharapova was clearly better for 2004-2006. Over the past 2 years, they've been relatively even, and Ivanovic has probably passed her from Indian Wells on this year. To argue that Ivanovic is actually the better player, I would need to make the case that she is a later maturing player, and that the recent uptick in her performance is a function of late maturation. I argued that players of her build (larger frame) tend to mature at a later age.

While the data above is not as overwhelming as I thought it would be, it does appear to be true that players with larger body frames tend to mature at a later age. I think that is what is happening with Ivanovic.

A few other factors in Ivanovic's favor:
- She just won the French Open, which was on a surface not particularly conducive to her game. Her first serve and especially her forehand were near unreturnable on clay. They will be even more dominant on grass.
- Her coaches and trainers stated that they were operating on a long term plan, with the goal of peaking in a few years. That is consistent with her play. Even between the Australian Open and French Open of this year, you could see big differences in her game, especially her footwork. That she could reach #1 while her game is still evolving is encouraging.
- She's had #1 talent for several years, and the main question with her has been her temperament. I think many were concerned she was another Amelie Mauresmo or Kim Clijsters, and too nice to consistently win at the highest level. Winning her first tournament, and doing so in dominant fashion, should help her going forward.
- I think she's very comparable to Lindsay Davenport, but perhaps a bit more athletic and mobile. Lindsay was also able to reach #1 before her game really matured, and continued to improve as a player, primarily because of improvements in her fitness.

I might be completely off-base, but I think Ivanovic is just now starting to emerge as the next superstar. I don't know that she'll reach the Evert-Navritolova-Graf level of superstardom, but I don't think it's unreasonable that she'll be a player of the stature of at least Davenport, if not Seles or even better. It will be fun to watch.

Back to the Ivanovic-Sharapova comparison. They are awfully close. I think Ivanovic has a better first serve, but that Sharapova is more consistent with her second serve. Ivanovic's forehand is better, but Sharapova has a better backhand. I think Ivanovic's biggest edge now is her mobility- I think clay made that more apparent. Sharapova's real edge was in her competitiveness and intensity, but I don't know if that is really there anymore- Ivanovic has made 3 of the last 5 finals. It's close, but I give the edge to Ivanovic.

The third person who might fit into this discussion is Dinara Safina. She is also a late bloomer. Part of this might be part of the same phenomenon- she's also an awfully big girl. I am guessing that Safina is the strongest woman on the tour, although Serena Williams and Lindsay Davenport are probably pretty close. But Safina has another reason that she might be a late bloomer- namely, that's she's a bit (how to put this delicately) .... emotional. At the French, she was able to harness that emotion for the most part. If that is real, then I think she's a contender for the near future. If not, then she'll be like her brother- always a threat to win or combust.

So, those are my thoughts for now. Can't wait for the tournament to start.

Tuesday, June 17, 2008

Fall prevention

One of the most important things I can do as a physician is prevent falls. I've been thinking about this quite a bit lately for a few reasons. One, someone very close to me has had a series of nasty falls. Second, as I say goodbye to some of the patients I've met in Arkansas, I've been able to see that we've made some successful interventions in preventing falls.

The first point I want to make is that falls are a big deal. For many patients, as they get older, the biggest barrier to them maintaining independence is making sure that they don't fall. When you are younger, the consequences of a fall are much less, since you can catch yourself if you stumble, and if you do actually hit the ground, you may only have a contusion. As you get older, you may deal with more catastrophic consequences, like a broken hip or a subdural hematoma (head bleed).

A useful analogy is automobile safety. The traditional American perspective on car safety is to buy the biggest, baddest car on the road (e.g., a Hummer), so that if you get into an accident, your chance of getting hurt is minimized. That is one way at looking at things, I suppose. But who says that accidents are inevitable? Another approach to safety is buy the most nimble and maneuverable car available, which can help you avoid an accident in the first place.

The same is true of falls. Much of the focus in preventing fractures has been working under the assumption that falls are inevitable, and working on damage control when the falls happen. So, for example, bisphosphonates (like Fosomax) are popular drugs that work to prevent bone breakdown, so if you fall your bones will be thicker and less likely to fracture. Additionally, many patients come in to see me because of the consequences of their falls (broken bones, dislocated shoulders, split lips, back pain, etc). While I can help them with some of these consequences, I wish I could have seen them earlier- before the fall ever happened.

Back to the car analogy- rather than focusing on airbags and crumple zones, you could focus on accident prevention. And the same is true of falls- we do not have to assume that falls are inevitable, but can make interventions ahead of time to make falls less likely.

In order to make these interventions, we have to think about what causes falls in the first place. While there are some extreme circumstances that can cause a fall- dodging a car, getting hit by a falling tree, etc- most falls are flukes. Most of the time, when people fall, they stumble over something minor (e.g., the edge of a carpet, a curb, uneven grass in a field, a crack in the sidewalk, a dog toy on the floor), and because they have a poor base of support, they stumble and eventually fall.

So, what can you do to prevent falls? Well, let's look back at the prior paragraph, becuase there are a few key elements there:

1. Minimize the little things- while there are always things that could potentially trip someone, there are many things that are easy to fix. For example, making sure that you don't have loose items on the floor that you could trip on (child's toys, dog or cat toys). Make sure that you don't have loose rugs, or if you do, that they are taped down at the edge.

2. Awareness of your surroundings- as we age, we tend to become less aware of our surroundings. Part of this is the wisdom of aging- you become so accustomed to your surroundings, that you fail to notice subtle changes (e.g., a new crack in the sidewalk). Additionally, as we age, we tend to have less feedback from our senses- our vision is not as acute, we have less feeling in our feet and less sense of where our joints move in space, we can't hear our grandchildren or dogs. For all of these reasons, we may become less aware of potential stumbling blocks. This is trainable, however- you can become more aware of your surroundings.

3. Improving our base of support- this is the key. Have you ever tried to balance a folding chair on just 2 legs? It's nearly impossible- 2 points of contact is an inherently unstable base. How about balancing a pen on one end? One point of contact is even less stable. Well, when you walk, you either have 1 or 2 points of contact. This is inherently unstable.
So, why don't we fall all the time then? Well, actually, we do. One way of viewing walking is that it is a series of controlled falls, where one leg is perpetually catching the other one from falling. As adults, we have sufficiently trained ourselves to coordinate this recovery process, but try watching a 7 month old walking. They haven't yet developed the recovery process, so instead of a series of controlled falls, they have uncontrolled falls (albeit, they are adorable controlled falls on to their cute little tushies).
As we age, our controlled falls become less controlled, and sometimes we stumble. Again, this is trainable- we can learn how to contol our base of support to minimize the risk of uncontrolled falls.

So, how should we go about this training? There are multiple approaches, but my 2 preferences are physical therapy and Tai Chi. I will speak about PT briefly, and Tai Chi at more length.

The key for physical therapy is to make sure the prescription is specifically for fall prevention, and that you work with a therapist who has specific skills in fall prevention. One essential factor as that at least a portion of the therapy has to be performed with the patient standing. While there are certainly benefits to seated strengthening exercises, the goal is to minimize falls while standing and walking, so the therapy must incorporate those positions. Similarly, modalties (things like heat, ultrasound, and electrical stimulation) can be helpful for providing transient relief of pain, they should not be the focus of a PT program designed to prevent falls. With those caveats, Physical Therapy is a wonderful tool that can help prevent falls.

Now, let's talk about Tai Chi. I am a big, big fan of Tai Chi, and have seen it make a huge difference in the lives of many of my patients. I will note that I have no financial interest in Tai Chi, so my enthusiasm (whether it is warranted or unwarranted) is purely based on my impression that it helps patients.

What is Tai Chi? Historically, it is a Chinese martial art, and like many martial arts, it not just (or even primarily) about fighting, but rather it is a philosophy and system about how to move the body.

Now, when I mention to some of my patients who have had recent falls that I would like them to take a martial art, there is some hesitency. This is understandable- they are mostly concerned with not tripping while they are bringing groceries, rather than how to take out a ninja with a nunchuck.

Tai Chi, however, is different than many other martial arts. One, it is slower. The movements are gentle, gliding movements, with significant focus on posture, breathing, and concentration. These are the very things that one needs to focus on to prevent falls. The movements are also geared toward always having a stable base of support. And I discussed above, that is the main key in preventing uncontrolled falls.

It is a real martial art, however- these very same gentle movements, if performed with a faster cadence, would actually be useful in combat. That is a bit of an aside, however, to our discussion- the main goal is fall prevention.

Does Tai Chi work? Probably. There are a decent number of studies that have showed reduction of falls in patients who participate in Tai Chi. None of these studies are perfect, but the confluence of the information in the studies make a decent argument that it probably helps.

My anecdotal experience is that it's one of the most useful interventions that I make with my patients. As I mentioned in my prior post, I am in the process of leaving my current job in Arkanas, so I've been saying my final goodbyes to some of my patients. One of the patients I said goodbye to today is an incredibly lovable 72 year old woman I've been seeing for the past 6 months. She's been raving about how much she has enjoyed her Tai Chi classes. Even more importantly, as I watched her walking out of the clinic, she had a very clear spring in her step.

That is one of the comments I hear most from patients who have started Tai Chi- they have a spring in their step. Another of my favorite patients- his wife has commented on how he looks younger now, and she thinks it's because of the way he looks when he walks. He has a more controlled gait- he always looks like he knows what he is doing. I can never be sure what made the dramatic change for these patients, but I attribute it to Tai Chi.

Fortunately, the availability of Tai Chi has grown tremendously. In the area where I currently practice, there is a wonderful senior center in North Little Rock called the Hayes Senior Center ( This is true of most urban and suburban areas- sometimes finding good Tai Chi classes is a bit more of a challenge in rural areas.

Anyway, to wrap up, here are my key points:
1. One of the most important steps one can take to maintain their independence is "Don't Fall"
2. Most falls are preventable
3. Normal walking is a series of controlled falls. The key is to make sure they are controlled, and the key to making sure your falls are controlled is to maintain a stable base of support
4. Tai Chi is a great way to train yourself to maintain a stable base of support

The long kiss goodnight

I've never actually seen the movie "The Long Kiss Goodnight," but for some reason I love the expression. This post is about goodbyes.

I am transitioning jobs. I am finishing up my time at the University of Arkansas for Medical Sciences in Little Rock, and in a few months will be starting a position at the University of Pittsburgh. A part of this process is saying goodbye to my patients in Little Rock.

Today, I had my last clinic visit with a few of my patients, several of whom I've grown quite close to. My job in Arkansas, as is the case for all jobs, has it's ups and downs, but one thing that was a clear positive for me was the patients.

One thing that physicians don't have an opportunity to do as often as we would like is let patients know how much they mean to us. That is one benefit of changing jobs- it gives me an excuse to explicitly thank them and let them know much they enriched my life.

There are many things about practicing medicine that are less than ideal, but still, there are very few professions that allow the privilege of having such a direct impact on another person's life. I suppose teaching, coaching, the clergy- those professions have some similar elements. And I guess that is part of what it means to be a physician- a little bit of education, a little bit of motivation, and a little bit of faith.

Anyway, in case any of my patients ever read this blog, and I didn't get a chance to say thank you personally- thanks!


I realize I have no actual content. However, I think it's useful to start any discourse with the parameters of discussion, so that the audience understands my perspectives.

One of the most important of these are going to be biases. Everyone has biases that color their perspectives. I have reasons for thinking what I think, but I am aware that not everyone agrees with my particular beliefs, and therefore often will reach different conclusions. I am almost certainly not cognizant of all my biases, but here are some that I am aware of:

1. I think exercise is a good thing.
2. Most limitations to exercise are relative, and not absolute. The key, then, is to identify those barriers that limit one's ability to exercise and find ways to adapt around those barriers.
3. Not everyone is the same. This, to me, seems like an obvious statement, but I know that many people disagree with this underlying premise, and this undermines some conversations. To be more explicit:
a. Men and Women are different from one another. That doesn't mean better or worse, but they are different. I think it's important to understand those differences in order to optimize one's potential. I'll go into more detail in some other posts, but it is my personal belief system that men and women differ from one another in some fundamentally different ways that is useful for us understand (e.g., throwing biomechanics, the biomechanics of jumping and landing, the processing of spatial information, perception of pain, communication, etc).
b. People change as they age. Again, I think this is important to understand, because the treatment plans for people change over time as they age.

I'm sure readers (if I have any) will let me know about some other biases as they come up (which I welcome).

What is Kinemedics?

Why am I calling this blog Kinemedics?

Mostly, because I think it's a catchy name. Kinemedics is derived from the Latin word Kine-, referring to movement, and thus I am defining Kinemedics as the use of movement and exercise as medicine.

In reality, Kinemedics will be self-defined over time as I continue to blog, so the true definition of Kinemedics will be "the kinds of things that are discussed on the blog Kinemedics."

Welcome to Kinemedics!

This is my inaugural post for Kinemedics. I suppose I should start by describing who I am, and why you should care about anything I might be saying.

As to who I am, my name is Gary P. Chimes. My primary role is an academic physician who specializes in Physical Medicine & Rehabilitation. That probably doesn't mean anything to most people- to be honest, I am not sure what it means either (since my interests are not particularly concordant with many other people who have the same titles).

The main things that interest me, and the things I am likely to blog about are:
1. Helping people exercise throughout their lifetimes
2. The use of exercise as the treatment for most medical conditions
3. Recognizing how different demographic factors affect the ability to exercise- in particular, examining how gender and age affect our ability to exercise
4. Improving the quality of communication between patients and their physicians
5. Improving the quality of medical education