Ramblings: Externalities

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Patient #1:

Internality: Initially comes in talking about her back pain

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

Patient #2:

Internality: Comes in bothered by hip pain

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

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

The Stretching Trial

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

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

US Open Preview- Women's Draw

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

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

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

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

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

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

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

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

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

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

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

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

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

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

US Open Preview- Men's Draw

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

1. Novak Djokovic
2. Rafael Nadal

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

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

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

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

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

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

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

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

Michael Phelps

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

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

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

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

So what events would I like to see Phelps swim:

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

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

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

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

Go for it Mike.

Kinesiotape- part II, and some related thoughts on doping

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

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

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

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

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

2. Nutritional supplements

3. Sleeping chambers to simulate sleeping at altitude

4. Anabolic steroids

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

6. Prosthetics for lost limb segments.

7. Caffeine

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In my personal opinion, no.

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

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

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

Kinesiotape

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

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

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

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

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

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

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

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

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

What is the evidence?

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

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

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

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

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

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

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

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

So, back to the key questions:

1. Does kinesiotape work, in general?

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

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

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

3. Would I prescribe it?

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

Please share with me your thoughts.

Gary

The Benefits of Sun

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

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

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

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

http://besunsensible.org/

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

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

So, here are some of the benefits of sun:

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

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

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

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

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

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

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

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

The Century of Behavior Change

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But .....

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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