Where's the sun?

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

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

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

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

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

Ramblings: Externalities

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Patient #1:

Internality: Initially comes in talking about her back pain

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

Patient #2:

Internality: Comes in bothered by hip pain

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

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

The Benefits of Sun

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

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

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

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

http://besunsensible.org/

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

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

So, here are some of the benefits of sun:

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

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

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

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

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

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

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

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