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.
Showing posts with label exercise. Show all posts
Showing posts with label exercise. Show all posts
Sunday, June 27, 2010
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 (www.gobenevia.com), 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."
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.
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 (http://www.ehow.com/how_2312300_do-butterfly-stretch.html) after warming up
3. The upward facing dog stretch (http://www.ehow.com/how_2277775_do-upward-facing-dog-pose.html) 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
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.
http://www.yogajournal.com/poses/491
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.
Examples:
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!
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.
Examples:
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!
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.
http://exerciseismedicine.org/
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.
Sunday, December 14, 2008
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!"
I think that is perfect. Just like the old Nike commercial says- "Just do it!"
Sunday, December 7, 2008
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.
Sunday, September 28, 2008
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 tha
t 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 stif
f 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.
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 tha
t 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 stif
f 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.
Sunday, September 14, 2008
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.
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.
Wednesday, September 3, 2008
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.
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.
Saturday, July 26, 2008
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.
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.
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.
Tuesday, June 17, 2008
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
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
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