Sunday, June 27, 2010

P90X, Muscle Confusion, Playing with Kids

Lots of people ask me about P90X

There's lot to like about it.  The main benefits, as I see it are:
1. It commits you to exercising frequently
2. It varies the workout so that you create "muscle confusion," so that your muscles do not know what to expect

There is another great way to get both of these health benefits- playing with kids.  I thought about this while playing catcher for one of my nephews.  From a workout perspective, it was great- it forced me to perform what was probably several hundred squats.  I would never have done this of my own volition, but it made my nephew happy, so it made me happy.

It was a great workout, but even more importantly, it helped connect me to a very important part of my community, namely my family.

I think this is very valuable to keep in mind if you are a parent and trying to figure out how to be a good parent and devote time to your kids while staying active yourself- be active together.  It's win, win for everybody.

It also helps create a better world.  It creates a world where your kids admire your activity, public use spaces are given priority, joyfulness is connected to activity.  That's the kind of world that has downstream benefits.

Which world would you rather live in?

This blog is starting to evolve into something.  I wasn't sure where it was going when I first started writing it, but there is an underlying theme, which is ....

Creating the world that you want to live in.

When it comes to health, fitness, and wellness, we are all confronted with challenges and barriers, and have to make decisions.  Sometimes very hard decisions.

When it  comes to making hard decisions with Choice A and Choice B, I think it is helpful to think "if I am successful with either choice, which world would I rather live in- the world created by Choice A, or the world created Choice B."

I think when we make decisions with this type of global perspective, it leads to making better choices.

Sometimes these choices are relatively simple.  An example- shopping at the supermarket.  You may have a choice between buying high quality fresh ingredients to make a dinner that you know will be healthy, or buy something pre-prepared that will be more convenient.  Which will you choose?

I think the choice to eat healthy will usually be a better choice.  You may be saving yourself for time with buying the pre-prepared option, but you are also buying into a lifestyle decision- that your life is too hectic to prioritize your own health, enjoy the creation of your own meal, and for what?  What is so important that you don't have time?  Even if it's as simple as buying some fresh fruit or vegetables to prepare, that is an investment in your own health.

That's a relatively easy decision.  Some decisions are much harder.  I have a patient who inspires me every time I see him.  He was, for many years, part of the system (privacy prevents me from discussing details particular to his case).  But on one of our visits, we discussed what type of role model he wanted to be for his children, and he took that message to heart, and turned his life around.  He's not perfect, but he made the conscious, and very difficult decision, to start living the kind of life that he wanted to live in, and wanted his children to live in.

That's what being a hero is all about.

Sunday, June 20, 2010

Under Recovery

My colleague Brian White, a PM&R physician based out of Cooperstown, NY, has an expression that I really like- "There is no such thing as over-training.  It's under-recovery."

Probably the most common sports injuries I see are what I call chronic overuse injuries.  Whether it is patellofemoral syndrome, tibial stress fractures, tennis elbow- all of these are examples of not allowing the body to sufficient time and creating an optimal environment for recovery.

The body needs a few things to recover properly:
1. Rest
2. Nutrients
3. An optimized endocrine environment

Taking these 1 at a time:
1. Rest
These refers to both sleep and muscle recovery.  It's important for athletes to get enough sleep to recover.   There are indicators that let you know you are not getting enough sleep.  One is that you should feel refreshed when you wake up.  The second is that if you wake up with an elevated heart rate, your body is telling you need more time to recover.

Another form of rest is cross-training.  For example, many age-group triathletes need more time to recover between workouts than they did when they are younger.  A good indicator that you are not allowing for optimal recovery is that you feel muscular fatigue at the beginning of your workout.

2. Nutrients
The body needs building blocks to recover.  For muscle in particular, the most important resources are amino acids, which are the building blocks for recovery.

Not all proteins are created equal.  Some are more bioavailable than others.  This will be a separate post in the future, but the general hierarchy is that essential amino acids are better than whey protein, and whey protein is better than soy protein.  The commercial products I generally recommend are Benevia Strength & Energy (, or the Whey Protein formulations available at Sam's Club and Costco (which are high quality and affordable).

3. Endocrine Environment
A growing body of research shows that in order for your body to recover appropriately, you needs hormonal signals to let it know that it is safe to recover.

When the body is breaking down, this is called catabolism.  During times of stress or overwork, the body will break itself down to make sure that building blocks are available in the bloodstream.  When the body is building itself back up, it's called anabolism.

There are 3 common endocrine syndromes I see that inhibit recovery- one in women, another in men, and a third in both sexes.

The endocrine issue that affects women is called the female athlete triad.  Technically, the female athlete triad refers to fractures, absent periods, and an eating disorder, but the way I view it clinically is that the female athlete is not taking in sufficient nutrient content for her caloric expenditure.  Women's bodies are very well calibrated, and the body will not allow itself to have a period unless there are sufficient nutrients to support both the female athlete and a potential baby.  So if you are a female athlete and do not have a regular period, you should have this evaluated by a health professional familiar with the female athlete triad.

The endocrine issue that affects men is hypogonadism.  This under-recognized disorder is when a man's body reduces it's natural production of testosterone because it is under stress.  If you find that you have decreased energy, loss of muscle bulk, difficulty with recovery, it's possible that your testosterone level has dropped in response to the repeated stresses of exercise.  This is especially true if you have a decreased libido, which is more common in hypogonadism than in similar appearing conditions like hypothyroidism and depression.

The final endocrine issue, which can affect both women and men, is Vitamin D deficiency.  The body can get Vitamin D through both diet and sun exposure.  Vitamin D deficiency may be especially common in areas that have lots of cloud cover, including my home town of Pittsburgh.  Therefore, in patients who are not recovering as well as anticipated, Vitamin D deficiency is one of the first things I check for. 

Friday, June 18, 2010

Practicing your new normal

Cal Ripken (at least I think it was Cal) "Practice doesn't make perfect. Perfect practice makes perfect."

Whoever it was, I think this statement is important. Any time you do a behavior, you reinforce that behavioral pattern, and with time, that becomes your "new normal."

We can use this to our advantage. In Brian Wansink's brilliant book "Mindless Eating," he shows how most people eat according to scripts, rather than because they are hungry. They eat because that's what they do when they come home from work, or that's what they do when they are stressed, or that's what they do when watching a football game, etc. Those scripts are what is normal for you. But you can create a "new normal." Instead of eating something when you come home from work, you can play catch with your son as soon as you come home. Instead of eating when you are stressed, you can make a point of calling your mom and letting her know she is important to you. You can replace a maladaptive habit with a healthier habit- you can create a new normal.

I once heard an interview with Tom Arnold where he made a similar point. He was a co-star in "True Lies" with Arnold Schwarzenegger, and Tom asked Arnold for advice on how to look buff for the movie. Arnold advised him to just practice walking with his stomach sucked in, and over time his posture and abdominal tone would improve. And it worked. It's a great pearl that can help prove abdominal tone, and is an example of "practicing your new normal."

This applies in other aspect of life. I've often heard the advice that you should not dress for the job you have, but the job you want to have. While I don't follow this pearl myself (I wear both polo shirts and sportcoat and tie at work, but I wear polos more often), but the idea makes sense- the best way to earn a job is start acting the part to confirm you are ready.

The main point I want to make, though, is in regards to posture. Whenever you sit or stand, whether you think of it not, you are "practicing" your posture. This is especially true with older individuals. Many older adults walk with a slumped posture, and are practicing bending at their waist, curving their shoulders, and sticking out their neck. This is reversible, however. There are some very good exercises that can, with practice, improve your posture, which can help your appearance, improve neck and back pain, and make you feel more vibrant and energetic.

It feels odd at first, but it's all about practicing your "new normal."

Why do certain exercises work?

There are many different philosophies for exercise, particularly for low back pain.  When assessing these programs, there are two separate questions- do they work, and why do they work?

As an example, there is an older form of exercise for the low back called Williams Flexion Exercises, that have been around since 1937.  They were developed with the idea that lumbar lordosis (the natural curve in the lower back) is unhealthy, and needs to be reversed, so he developed exercises that flex the spine to protect the back.

So do Williams Flexion exercises work?  They can.  I had a patient of mine who developed back pain, was taught Williams Flexion exercises, and did them for 36 years without having a recurrence of his low back pain.  He did eventually hurt his back again, which is why I saw him, but 36 years of prevention is pretty darn good.

So, summary action points:
1. Exercise
2. Exercises that help improve the range of motion in your hips are especially good- things like Williams flexion exercises, yoga, pilates, tai chi
3. Exercises that make you have explosive contractions of your muscles are good if you fit and healthy already (like P90X)
4. Caloric restriction is helpful for losing weight, particularly by controlling the size of your portions
5. It is often easier to restrict your portions by using a structured diet
6. If you are going to restrict your food options, try to eliminate dead calories first.  Soda and juice are good places to start, since they are essentially sugar water and empty calories.

Do Williams Flexion exercises work for the reason that was claimed?  Is it unhealthy to have a lumbar lordosis?   No, the reasoning is incorrect.   The reason Williams Flexion exercises work is because they improve hip flexibility, so that you are not asking the back to more than it was designed to do, but allowing the hips to improve their range of motion.

This is true for many diet and exercise programs.  Many diets, for example, are designed with food restrictions- just grapefruit, no carb, power fasting, etc.  These diets work, at least in part, because you are reducing your caloric intake.  An all-Twinkie diet would probably help you lose weight too, since it would restrict what else you were eating.

Similarly, there are some popular new exercise programs like P90X.  There are many benefits, but a large part of the benefit of P90X is that it structures diet and exercise.  Anything that makes someone diet and exercise is beneficial, and the specifics are probably less important.

Thursday, June 17, 2010

The Importance of Walking Speed

If you meet a person, and you want to know how much longer they will live, and what their remaining quality of life will be, what information would you want to know?

If you ask most physicians this question, they may answer something along the lines of whether they have cardiac or pulmonary disease.

Turns out, though, that a better way to answer the question is to assess their functional status.  The two most important factor that determine future quality of life are age and gender (women do better, which will be a topic for another day).  The third most important factor, perhaps surprisingly, is how fast does the person walk.

Walking speed is a great functional measure.  It's easy to measure, and captures a lot of information in a way that makes it a terrific summary measure.

For example, there are many older individuals who have multiple medical morbidities- diabetes, heart disease, high cholesterol, hypertension.  I probably know 100 people like that, and even if you are not a physician, you probably know many people who fit that profile.

Even with all those different disease states, they can be very different functionally.  If I meet two people who are aged 70, one can be a "young 70" and another can be an "old 70."  Walking speed is a great way of distinguishing which is which.

For those who want to learn more about the importance of gait speed in assessing health status, I encourage you to look up the research from Stephanie Studenski.

For the lay public, I would simply self-monitor the gait speed of yourself and the people you care about.  If you have an older loved one, and you are trying to figure out whether they are healthy and how long they will be able to stay independent and take care of themself, monitor how fast they walk.  That is more valuable than just about anything else in assessing how healthy they are.

Monday, June 14, 2010

Tips for Weekend Warriors

For many busy professionals, the weekend is the only real time we can get to workout.  Here are some tips to help maximize the weekend warrior experience.

1. Start light.  
Warm-ups in general are a bit overrated, but for the weekend warrior, they are important to help loosen the muscles up.  

I find some light jogging intermixed with a few deep squats helps loosen up the legs, and arm circles to warm up the shoulders can be helpful.

2. Pay special attention to the groin.
Like you weren't going to do that anyway ....

The groin is particularly susceptible to injury in weekend warriors.  The groin muscles (technically the adductor muscle group) are not commonly used in every day activity, but are used frequently in sports, and therefore are prone to overuse injuries if you only use them on the weekend.

The reason we don't use them much during the week is that when you walk at a normal pace, the way your bring your thigh forward is with a group of muscles called the hip flexors (muscles in the front of your thigh and pelvis, including the rectus femoris and iliopsoas).

When you run or move more quickly, you rotate your pelvis, which engages your groin muscles to bring the thigh forward.  One way to image this is to stride as far forward as you can with your left thigh, which will rotate your pelvis so that the left side is further forward than your right side.  From this position, if you want to bring your thigh forward, you would have to use your right groin muscles in addition to your hip flexors.

Some strategies to help protect your groin:
1. Some deep squats and light jogging, as noted above
2. The butterfly stretch ( after warming up
3. The upward facing dog stretch ( to help stretch the abdominal muscles.  This is important because the groin muscles and your rectus abdominus muscle (the six-pack muscles) share a common insertion point on your pubic bone.  I sometimes remind patients of this by referring to their adductor longus (one of the groin muscles) as the "seven pack" to remind them that it is part of the same group as the abdominal muscles, and therefore need to be stretched together.
4. If you are doing a kicking sports (e.g., soccer), be careful on your first few kicks that you don't slam your instep into the ground instead of the ball.  This is a common mechanism where soccer player often give themselves a particularly hard-to-heal type of groin injury called a sports hernia.

3. Try to fit in one high intensity workout during the week
Try to spend at least 30 minutes during the week in which you are exerting yourself to more than 50% of your maximum capacity.  This will help stave off de conditioning during the week.

As a practical matter, you may need to do this in short spurts.  Things like sprinting up the stairs every day when you get to work, or racing your son across the backyard when you get home, are great ways to build in short bursts of high intensity contractions.

In another upcoming essay, I will be talking more about strategies for "How to be more Awesome," which I consider an important part of the Kinemedics Philosophy.  One part of this, for parents in particular, is the importance of being excellent in the presence of your children.  I can't stress enough how important this is.  So, even little things like having your child see you do 10 push ups or  2 pull ups in front of them has some important ancillary benefits beyond their obvious health impact.

So, think of this nugget about short bursts of high intensity exercise as a variation of finding time to put more Awesome into your day.

4. Prime yourself for the weekend
One key way to make sure your weekend workouts go well is to make sure you don't go into the workouts tired.  The most important thing you can do to optimize your Saturday workout is to be healthy Friday night, and the same applies for Sunday morning and Saturday night.  Some strategies:
1. Don't drink too much- 2 drinks is a reasonable number for most people
2. Get enough sleep.  Don't stay out more than 2 hours past your normal bedtime, and try to stay close to your normal bedtime

I realize this is tough for some people, as they prize their social time, may be in a new relationship that requires more effort, etc.  What I say is that optimizing your health is about embracing a healthy lifestyle.  As we learned recently, not even Dennis Hopper can continue to live the Dennis Hopper lifestyle forever (it may even catch up to Jack Nicholson eventually).  So if you are a partier and carouser, you will have to change some time.  That time is now.

Now go out there and kick some butt!

Sunday, June 13, 2010

What makes a sport exciting?

I've been watching a large variety of sports recently- the French Open, the NBA Championships, UFC 114 and 115, the World Cup, live baseball games in Pittsburgh and Baltimore- and it's made me think about what makes a sport exciting to watch.

I think the #1 thing that makes a sport fun to watch is the sense that something could happen at any moment, and if you turn your attention away, you may miss something of consequence.

For example, I was watching a Red Sox-Orioles game in Baltimore, and the Red Sox were winning something like 11-2.  It became hard to pay attention- I think once you reach the point that two grand slams would not change the outcome of the game, it becomes less interesting.

Some blowouts can be fun, though.  I was watching the Germany-Australia soccer match this afternoon, and I was pretty riveted in seeing just how badly Germany could beat Australia.

In MMA, I think some fans confuse activity for excitement.  There are some fighters who are quite popular- Clay Guida and Michael Bisping come to mind- who I find pretty boring.  While they are constantly moving, they've shown they can't finish fights.  So even though Michael Bisping may throw 20 punches in a minute,  I feel like I can look away without missing anything.

Pat Barry,  on the other hand- he's exciting.  He may have thrown only 2 punches in his fight against Cro-Cop on Saturday, but they were absolute hammers.

For that reason, I generally favor fights in the heavier weight classes.  Lightweight fights have lots of action, but a battle between two behemoths like Shane Carwin and Brock Lesner- well, that could end at any moment.

That's exciting.

Preventing plantar fasciitis

A friend of mine asked me about some strategies for preventing plantar fasciitis.

The specifics will depend on the patient, but I think the optimal approach is to think of plantar fasciitis as a kinetic chain issue.

Remembering my 3 rules of the kinetic chain:
1. Forces have to come from somewhere
2. Range of motion has to come from somewhere
3. If you cannot address your forces and range of motion anatomically, then you will do so pathologically

When you use this perspective, you realize that usually plantar fasciitis is not a problem with the plantar fascia itself, but in asking the plantar fascia to more than it was designed to do.

The big issue, in this case, is range of motion.  Most people with plantar fasciitis have tight heel cords (their Achilles tendon), and therefore put too much stress on the plantar fascia.

The solution, then, is to stretch the heel cords.

My personal favorite stretch is the "Downward Facing Dog" position from yoga.

This is a great exercise in that it is a closed-kinetic chain exercise that uses your own body-weight to help load the Achilles tendon.   

I do make this caution, however- if you have back problems or are especially inflexible, this can place unhealthy loads across other joints, and you therefore should have someone (whether a PM&R physician or another clinician) evaluate your form, and perhaps make some modifications.

Health and Wellness Tip of the Day- Know the Goal for your Exercise

Failure to plan is planning to fail.

One simple tip that can improve the quality of your exercise program, whether it is a formal physical therapy program, or just a general workout, is to ask one simple question before you exercise- what is my goal with this exercise today?

This can make a huge difference in that quality of your experience, and doesn't require any more time.

1. Taking a walk.  Many of us take a walk at lunch.  Before you do, ask yourself- "what is my goal?"  It may be to get in some movement in the middle of the day, it may be to clear your thoughts, it may be to get some much-needed sun exposure.  By asking the question, it let's you judge whether you met your goal.

I find this helps me quite a bit.  I am often super-busy in clinic, but will try to find time for a 20 minute walk outside.  At the end of the walk, I can look back and say "I was able to make some for myself, got in some exercise, listened to a podcast, and saw some sunshine.  That was awesome."

2. Physical Therapy.  When you are in a Physical Therapy program, ask the therapist what the goal is for each exercise you are performing.  This will help you set a goal for those exercises, and determine whether you are meeting those goals.

One of the most common reasons patients are referred to me is because they "failed" physical therapy.  Often times, they are performing the proper exercise, but they don't know why they are doing an exercise, and therefore don't pay attention to whether they are doing it properly.

One common example is exercises for a tendinopathy, like Achilles tendinitis or Tennis Elbow.  There are many exercises one might do, but the most important exercises are typically repetitive eccentric loading.  I'll ask the patient to show me what they are doing, and they may be doing 6 different exercises, and not realizing that not all of the exercises are of equal importance.

For this very reason, when I give my patients an exercise prescription, I try to emphasize 1, or at most 2, exercises at a time.  I think it's far more important to do one targeted exercise well and with purpose then to go through the motions with 10 exercises.
Bottom line- you are all busy people, so if you are going to take the time to exercise every day (which you should), make those exercises count!

PM&R- Your Health and Wellness Physician!

I am a Sports & Spine PM&R physician.  One challenge for me is that most patients (or other physicians) have absolutely no idea what that means.

The way I like to think about what I do is that I figure out what a patient wants to do, look at the barriers that prevent them from doing it, and develop strategies so that they can overcome those barriers and continue without limits.

What makes this challenging is that it is a totally different way of approaching medicine.  Instead of asking what's wrong with you and getting rid of it, I like to look at what is already awesome about you, and facilitate it.

One way I like to think about this is to imagine the best possible version of yourself.  What do you like about that version of yourself?   You're happier, more energetic, better looking, active, interact well with your friends and loved ones, can do whatever you need to do?

Now- what prevents you from being that best possible version of yourself all the time?

For most people, the main barrier is that it never even occurred to them to ask that question.

So, let me ask you- what prevents you from being the best possible version of yourself all the time?  Wouldn't be great to have a clinician who can work with you on developing those strategies.

That is what being a PM&R physician is all about.

Saturday, June 12, 2010

Creating an Exercise Infrastructure

One of my parent organizations is the American College of Sports Medicine, and one of their primary initiatives is  the "Exercise is Medicine" campaign.

The idea behind promoting exercise as a form of medicine is that if Exercise was a pill, it would be most widely used medication in the world.  It is one approach that hits nearly every health goal for a patient, whether it be stress relief, weight reduction, lowering blood pressure, improving lipid profile, improving mood, reducing the rate of heart attacks, healing tendon injuries- you name it, exercise can help it.

In my opinion, the biggest barrier to more widely using exercise as a treatment is that we don't have an infrastructure to support it.  What I mean by this is that if I want to start a patient on a pain medication, the pathway is relatively easy- my electronic medical record has built in order sets that make them easy to prescribe, insurance readily pays for it, the prescriptions are automatically sent to the pharmacy, patients are used to having pain medications prescribed, etc.  Another issue is cost- even though pain medications are by far the largest real expense for treatment of low back pain (more than imaging, surgery, injections, or physical therapy), the copays tend to be low, so from the patient's perspective, medications are relatively cheap.

That is an easy infrastructure- the health care system makes it easy for me prescribe medications.

Prescribing exercise has less system wide support.  For example, even though physical therapy is cheaper than medication in terms of real world cost, the patient often has to pay more out of pocket, so they may perceive therapy as more expensive.

One of my missions as a Sports & Spine PM&R physician is to improve the exercise infrastructure.  The electronic medical record (EMR) has been a good tool for me in achieving this aim.  It's still not as easy as prescribing a drug, but the EMR does allow me to write macros for my most commonly prescribed exercises.  While I still customize these for every patient, this at least allows me to have a starting point as I review how to perform the exercise for every patient.

It takes more time and effort on my part, but from the patient's perspective, it's just the right thing to do.

Thursday, June 10, 2010

It's what you do AFTER exercising that can hurt your back

Exercise tip of the day- many people realize that when they feel back pain after playing sports, it's what they do immediately afterward that injures their back.

One of my favorite examples is from cycling.  Cycling, particularly long distances, places the spine in a flexed forward posture for a prolonged period, which places a lot of stress on the disk.

Oft times after a long ride, cyclists like to plop down- whether it is drink a beer sitting on the grass, sitting in their car to drive home, or sitting on a couch to grab something to eat and watch TV.

This plopping is where many athletes hurt their spine- their support muscles are already fatigued, so sitting in a slumped position exacerbates the loading on their disks.

My recommendation- immediately after cycling, do some exercises to reverse the flexed forward posture from cycling.  My favorite exercise is the prone press-up (essentially the same maneuver as the upward facing dog position in yoga, with a few refinements), but standing back extensions are a reasonable choice as well (standing and arching backward).  Standing back extensions are also a great choice after you've been sitting for a long time on an airplane or car ride as well.

New layout

For my 4 readers out there ....

I am new to blogging, so I am just learning how to layout the blog and make it more functional.  I think the larger fonts and serif font hopefully makes it more readable.

Wednesday, June 9, 2010

Barefoot running, Chi Running, and the 3 Laws of the Kinetic Chain

A good friend recently asked me what I thought about Chi Running.

I like it.

Chi Running is one of many approaches that teach runners to run softer and absorb more forces in their proximal muscles.  The idea is that by having a strong core, particularly in the buttocks, less forces will be absorbed in structures that are not designed to handle high loads, including the knees and back.

This is similar in many ways to barefoot running.  Not everyone can handle barefoot running, but for those that do like running barefoot, the reason it works is that it teaches you to run more softly.  When you run with a heavily cushioned shoe, you can hit the ground with a very forceful heel strike.  This is not possible when you run barefoot- it simply would hurt too much to slam your heel into the ground.

This is, in my opinion, the reason why all the new barefoot simulator shoes on the market (including MBTs and Skecher Shape-Ups) can be helpful- because they have a rocker bottom sole, if you try to have a forceful heel strike, you roll forward, which dissipates the force.

Back when I was a Sports & Spine fellow in Chicago, my colleague (the late, great Jim McLean) and I noticed that we could explain essentially every musculoskeletal condition through 3 very simple rules, which I now refer to as "3 Laws of the Kinetic Chain":
1. Forces have to go somewhere
2. Range of motion has to come from somewhere
3. If the body cannot absorb forces or obtain range in a way that is anatomically appropriate, it will do so in way that is pathological

A great example is running with bad form.  Every time your foot hits the ground when you are running, the ground pushes back against your body in what is called a ground reaction force.  This ground reaction force can be several times your body weight, and it doesn't just disappear into the ether- those forces have to go somewhere.

So where do you want those forces to go?  Ideally, you want those forces to go into the biggest, baddest muscle you got- that is the gluteus maximus (your butt).  Other good choices are the quadriceps (the front of the thigh) and gastrocnemius (the diamond shaped calf muscle).  The more you can train your body to absorb forces into these structures while you run, the less force will be transmitted into your spine, hips, or knees.

Barefoot running is a method where your body will naturally train itself to use these muscles, because if you try to run by slamming your heels into the ground, it hurts too much.  This works ok if you can adjust your stride appropriately, but many people find this too painful to tolerate.

Some commercial products, most notably the Vibram 5-Finger shoes, have been developed that help protect the feet while you are barefoot running.

Chi Running is an approach that helps teach you to engage your core while running, which is the same general concept.  As a general approach, I think it is fine.  If I was seeing a patient in my Sports & Spine clinic, I would try and see if I can be more specific as to exactly which muscles the patient should engage, but as a first iteration, Chi Running is a very reasonable approach.

The key to low back pain- stratification and the Katie Couric effect

What is the best way to treat low back pain?

I get asked this question all the time, whether I am seeing patients in my Sports & Spine clinic, lecturing at national meetings, or meeting with other experts.

There is one key to management of low back pain- stratification.

What I mean by this is that low back pain is not one diagnosis, and therefore trying to treat all low back pain with one approach is not effective. In a typical day, I may see patients who have many different causes of low back pain, all of which are best managed with different treatment approaches. The approach to managing an annular tear in a 23 year old Ironman triathlete is dramatically different than that of a 74 year old with zygapophysial joint arthropathy, which is dramatically different than the approach in a 34 year old woman with post-partum pelvic floor dysfunction.

Some of these patients I manage with an exercise program, others I may manage with an image-guided injection, and others I may manage by working in a team with the physical therapist or chiropractor. The key is that I recognize that every patient is different, and no one approach will work for everyone.

Unfortunately, many treatment recommendations are based on the assumption that low back pain should be treated as one entity, and therefore one basic approach should be used.

So, if you have low back pain, the biggest determinant in getting better is appropriate stratification into the appropriate treatment groups. Some of this is related to determining the appropriate diagnosis, but often times we can stratify patients into appropriate treatment groups even if we don't know the actual diagnosis.

For example, many patients are surprised to find out that if you want to get better, it is more valuable to know a patient's directional preference (i.e., which movements are most painful, such as putting on shoes and socks in the morning) than it is to look at an MRI. If I know that a patient hurts more with certain movements, I can design a physical therapy program that takes this into account. This is of great benefit to this physical therapist, and as Audrey Long demonstrated in her award winning research in 2004, if we design physical therapy programs with a directional preference in mind, the probability of improvement increases dramatically.

But I have many patients say to me "I hear you, but I've always been told that if you really want to know what is causing my low back pain, I need an MRI." MRIs are wonderful tools, but the reason they are not as helpful as you might imagine is because of what I call the "Katie Couric Effect."

We all know Katie Couric. Back in 2000, in the days before we had HD televisions, we didn't notice that she was actually a woman in her 40s. When she started working for CBS on the nightly news, two things happened- Katie Couric turned 50, and many of us started watching her in HD television.

Katie Couric is a very attractive woman, but when you look at her in HD television, many things are suddenly apparent that were not apparent on a regular television. She is the same woman that she was on a regular television, but because of the higher resolution of the TV, we are now more aware of some of the natural changes associated with aging that we would have been blissfully ignorant of otherwise.

Same thing with back MRIs. Just as the natural processes of aging can bring along gray hair and wrinkles, the normal healthy spine has some age-associated changes, including degeneration of the disks and joints. Much of this is incidental, and therefore when we look at a spine MRI, most of what we are looking at is incidental findings. And often times, the main cause of low back pain may not be seen on MRI.

Which brings me back to what is the best way to treat low back pain. The key is to find someone you trust who is able to figure out what is the best treatment approach for you. That person may be a Sports & Spine PM&R physician like myself, it may be a surgeon, it may be a chiropractor, it may be a physical therapist, it may be an accupuncturist, etc.

Ultimately, you need someone who can see you as an individual, and has the skill set necessary to tailor a program that is appropriate for you.

Tuesday, June 8, 2010

Great examples of maximizing function

This is from the professional website of my colleague, Brad Marcus.

I think it shows a great example of the kinds of things that patients are capable of if we don't set limits for them.

Practicing being joyful

It's been over a year since I last posted .... I will try to make shorter, but more frequent posts

About a month ago I went to a fantastic course on myofascial medicine that was put on by UPMC, and it's had some major impacts on the way I think about musculoskeletal conditions.

The single most impactful thought that someone shared with me at the course is that we need to practice being joyful. I thought that this was a remarkably brilliant insight.

The nervous system is designed to adapt to anything you do frequently as a "new normal." This can have negative consequences if you look at people are who routinely miserable. As a thought experiment. think about the last time you were at the DMV. It's a miserable environment, everyone hunches their shoulders, and there is a palpable tension in the room. Now imagine being like that all time- that would be a horrible "new normal."

Instead, imagine trying to practice a "new normal" by practicing being joyful. Here's a simple exercise- extend your hands overhead like you just crossed the finish line of a marathon. Didn't that make you feel better? I don't think it's possible to put your arms overhead in a victory position and be in a bad mood.

I don't think this is just psycho-babble- I think it reflects a real neurologic phenomenon. Paul Ekman did some ground breaking research that demonstrated that if you have a person put their face in a smiling position, their mood will improve. I think that this is true of the body as a whole as well- if you place your body into the position of happiness, you will feel happier.

I've noticed this when I work on some strengthening exercises in my patients. I often work on them to strengthen their posterior chain (muscles behind their back like the thoracic paraspinals) and stretch their anterior chain (muscles in the front of their body, like the pectoralis minor), and an interesting ancillary phenomenon is that most of them notice that they are noticably happier. It happens almost instantaneously. I don't think this is an accident- by training their muscles so that they can literally walk taller, they also figuratively walk taller- they become happier.

And so do I.