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.

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!

What makes a sport exciting?

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

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

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

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

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

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

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

That's exciting.

Preventing plantar fasciitis

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

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

Remembering my 3 rules of the kinetic chain:

1. Forces have to come from somewhere

2. Range of motion has to come from somewhere

3. If you cannot address your forces and range of motion anatomically, then you will do so pathologically

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

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

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

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

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.
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Bottom line- you are all busy people, so if you are going to take the time to exercise every day (which you should), make those exercises count!

PM&R- Your Health and Wellness Physician!

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

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

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

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

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

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

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

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

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.

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

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

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

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

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

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

New layout

For my 4 readers out there ....

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

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

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

I like it.

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

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

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

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

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

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

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

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

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