Posture

A lot of discomfort can be attributed to maintaining poor posture (check out this previous blog post). One easy way to maintain good posture is by starting off the day with good postures. Here is a simple way to get your day started off on the right foot.

Good Mornings:

1. When you wake up in the morning, stretch your arms overhead like you are having a good yawn

2. Keep your arms overhead

3. Concentrate on reaching upward toward the sky

4. Look upward

5. Try to reach your arms back, so that you feel like you have a good stretch in your chest

6. With your arms overhead, but looking forward, walk for 1 minute.  Make sure you watch where you are walking, but keep your arms overhead

- Now that you have started your day with a good posture, try to remind yourself throughout the day to stand tall, proud, and energized

It is especially difficult to maintain good posture throughout the day because as you tire, your body will naturally try to assume the fetal position and hunch over. Here is a very easy technique that you can use to “reset” your posture, helping to properly load your spine.

-Stand up with your back against a wall

-With your buttock and shoulder blades touching the wall, lift both arms above your head

-With your arms above your head, turn your head to the right, then to the left

-Bring your arms down, and step away from the wall, you should notice that you are standing straighter

-Try to maintain this posture throughout the day, and repeat as necessary

What's right with you?

One of the things that I think is off about modern medicine is that we are constantly asking "What's wrong with you?"

Part of the reason with this is that the main governing body that dictates most healthcare policy, the Centers for Medicare and Medicaid Services (CMS), won't pay for a patient visit unless we have a chief complaint.

If you think about that, it's an absurd way to approach life.  Imagine this any other domain of life. Imagine you went to a restaurant, and they asked "What's wrong with you?  What's your problem?"

There is an alternative approach, which is asking about your goals, your aspirations, and what barriers prevent you from achieving these goals.  I find this a much more positive way to talk to patients, and leads to a happier end point.

Along those same lines, in the Impression/Plan section of our notes, we often include a list of all the things wrong with a patient, which again strikes me as an overly negative way to approach medicine, and to approach life.  One of the things I try to include in notes with patients are predictors for success.

For example, I just met a lovely 63-year young retired educator with multiple musculoskeletal conditions.  I made sure my note included:

Predictors of good outcome:
- kindness
- intelligence
- nice skin (a marker for overall connective tissue health)
- non-smoker
- married
- educator
- minimal focal weakness
- has not hired an attorney
- primary motivation is to exercise

One of the joys of working in a physician-owned practice with my partner Garrett Hyman is that Garrett and I have the latitude to focus on the positive aspects of patient care.  CMS may not think these things are important (.... and you can see where CMS's true value system is, because they don't pay you for talking about the positive, only the negative), Garrett and I think it's important.  And we think that a focus on the positive is the "secret sauce" that leads to better patient outcomes.

Biggest Loser Group

Like many people, I struggle with my body weight.  I obviously treat health and wellness for a living, and I know what I need to do, but I need a support structure to help keep me accountable.

One tool that has helped me immensely is MyFitnessPal (www.myfitnesspal.com), which I will discuss in another post.

The most helpful intervention I've ever had, though, is a Biggest Loser Group started by one of my high school friends, Dan Stewart.

Our group, Dan's Friends are Losers, is a Facebook group started by Dan, and has been incredibly successful in creating a positive atmosphere that has kept us accountable.

This is a picture of Dan and I from April.  It's a bit cloudy- we took it right after Dan and I did two hours of mixed martial arts training at his gym in New Jersey.  Dan was training for his first MMA competition (which he won!  I think by a 1st round Kimura), and I visited his gym on my cross-country drive moving to the Pacific Northwest.

Dan has many great attributes a coach and motivator, and these are things I try to bring into my medical practice when I coach and motivate patients, the most important being positive energy and focusing on what I can do to help patients get better.

One thing that I've learned is that people can be in one of two modes, and you can't be in both simultaneously:
Mode 1: "What can I do to improve and get better" mode
Mode 2: "How do I make excuses for why I can't get better" mode

Dan is great at making sure we stay in Mode 1, keep our eyes on the prize, and focus on continuously improving.  Dan asks no less from me, and I owe it to my patients to try and be a positive motivator like Dan.

This is Kate.  She was my "summer buddy" - I life guarded at the pool in her home town of Roosevelt, NJ back in 1989, and she taught me everything I know about 1970s rock music, and kept me in good spirits while I hung out at the pool.  Kate is one of those great friends you lose track with over time, and we've reconnected through our Loser's group.

Kate's lost an enormous amount of weight - I think it's well over 100 bs, and is again a source of positive inspiration.  Whenever I think of Kate, she reminds how important weight loss really needs to be through a lifestyle change, and not just a periodic deprivation.

Scott and I went to high school together, but did not know each other then.  Scott's a great example of how you can make friends through the support group.  He won one of the rounds, and has managed to keep losing weight even after he "won."

More importantly, through our Loser group, I've developed a friendship with Scott.  I find him a thoughtful, philosophical colleague who constantly broadens the way I think about things.

This is Mike and I.  Mike and I first met as 9 year olds playing soccer, and what I've realized from getting to know Mike again while we are middle-aged guys in our early 40s is that you don't really know people when you are 9 years old.  Before Mike and I became friends again as adults, the most I could tell you about Mike was that he had a great cross pass for a 9 year old.  It's been enjoyable getting to know Mike the adult.

Ok, enough reminiscing.  What are some of the best tactics for weight loss I've learned a Loser?

Some tactical tips:
1. Go to bed early.  Sleep is necessary for proper healing.  Also, it's really hard to eat when you are asleep
2. Don't eat after dinner.  Most of my weight gain happens from night eating
3. Keep yourself accountable
4. Buy cheap jeans at Costco.  One of my favorite tricks is to buy a pair of jeans one size too small from Costco, and wear those when walking the dog in the morning.  Powerful incentive to stay on task
5. Keep tempting foods out of your sight-line.  Whenever people bring in "gifts" of chocolate or pastry, I immediately give it to my medical assistant to hide from me.  Even if I don't eat it, I think about it all day and then make bad food decisions.
6. Create opportunities for incidental exercise.  I have a Jungle Gym XT and Pull up bar set up both at the office and at home, which allows me to bang out a few quick reps .... BAM!- just did 5 pull ups before writing point #7
7. Focus on the positive.  I constantly repeat the mantra of "I want to be the best possible version of myself everyday" to remind myself of my goals
8. Focus on being better, not perfect. Better is obtainable, perfect isn't
9. Focus on what I can do, not on what I can't do
10. Express gratitude to the people in my life who have helped me get where I am today.  That starts with my girlfriend and my dog, extends to my partner Garrett and the rest of my practice, and most definitely includes my patients and my Loser group who inspire me every day

As Dan would say, "I'm a Loser, and that makes me a Winner!"

Hip Flexor Stretch

Hip Flexor Stretch

Limited hip mobility is often a major contributing factor to lower limb and back injuries. Your hip flexors — which allow you to lift your knees and bend at the waist — are located on your upper thighs, just below your hipbones. In fact, research by Casey Kerrigan has shown this one stretch in particular, performed 30 seconds daily, can dramatically improve many conditions. It can make a huge impact for many of our patients: 
1. Patients with spinal stenosis
2. Young athletic patients with tight hip flexors
3. Patients with lumbar facet arthropathy

To stretch your hip flexors:

Kneel on your right knee, cushioning your kneecap with a folded towel.

Place your left foot in front of you, bending your knee and placing your left hand on your left leg for stability.

Place your right hand on your right hip to avoid bending at the waist. Keep your back straight and abdominal muscles tight.

Lean forward, shifting more body weight onto your front leg. You'll feel a stretch in your right thigh.

Hold for about 30 seconds.

Switch legs and repeat.

The USMST and Professional Gratification

WALKING THE TALK

Physicians have an interesting background when it comes to defending the public health and engaging in health promotion activities.  Take smoking cigarettes, for example.  While this week marked the 50th anniversary of the landmark Surgeon General's report on smoking and health (published 1964), some of us can remember magazine ads of that time-period showing the wise-old white-coated doctor lighting up in his leather-bound office chair, promoting the supposed health benefits of smoking Newport Lights!  Now after decades of exposure to fervent anti-smoking messages, the tobacco industry's 'next generation of smokers' is smaller than ever.  

Next think about the obesity epidemic.  Many of us think we should lose a few pounds.  More and more physicians are discussing body mass index (BMI) and recommending weight loss and describing the health benefits.  Yet many physicians are themselves overweight or obese.  The same can be said about getting the recommended weekly amount of exercise?  Quite a significant percentage of exercise-prescribing physicians do not get the recommended amount themselves.   

What does it mean to our patients when we, as physicians, do not embrace our own teachings?  I think it means a lot.  We know that a person is 8x more likely to try and quit smoking cigarettes when counseled to do so by their physician as compared to a family member.  That's powerful.  However, I imagine the smell of smoke on my breath or clothes would dilute that message.

I recently stayed at a hotel that also hosted a regional dance competition, and there were hundreds of very athletic young women participants.  I was impressed, however, that these slender and strong dancers invariably were accompanied by a set of portly and stout family parental figures.  And I thought to myself, "what message do we send to our youth, as parents or teachers or physicians, when we fail to practice what we preach?"  The clear message is, it's great to be active when you're young, but adults are too busy to exercise and eat right.  Someday, when I am given the choice to live as I want, without anyone pressuring me to live and behave a certain way, I can be fat too.

TAKING ACTION

As an established mid-career physician two-years into a new privately held business, I recognize that I am very fortunate to have the flexibility to refine my practice direction.  Together with my wonderful partner, Gary Chimes, we are dreaming big as to how we as sports and musculoskeletal specialists can best serve the health needs of our community.  We truly hope to elevate the standards of health and well-being of the greater Eastside community.  And we understand that part of doing so involves demonstrating our own personal commitment to health and fitness.

SOCCER FOR HEALTH

And this brings me to the highlight of this post.  I just finished a fabulous weekend in Los Angeles at a 'tryout' for the US Medical Soccer Team (USMST).  The US Medical what, you ask?  That's right, you read correctly, the US Medical Soccer Team.  This fabulous not-for-profit organization was created approximately 5 years ago by two soccer-devotee physician friends.  A German physician told them about the World Medical Football Championships, and how about 8 other countries had been gathering each July for a combined conference (The Global Conference on Health and Medicine in Sport) and mini-World Cup event where national teams of physician footballers compete for glory and bragging rights.  These two visionary American physicians recruited other physician footballers (FYI around the world, soccer is referred to as 'football') from around the nation, and have been competing at the World Medical Football Championships ever since.

The physicians of the USMST are a special group in that the mission of the organization includes health promotion.  The team presently convenes for training and community service events 3 times per year, and these events are held on both coasts and somewhere in the central US.  

I learned about the team while attending the American College of Sports Medicine (ACSM) conference in June 2013.  The ACSM solicited the USMST to partner and collaborate on spreading the message that "Exercise is Medicine."  They signed a formal memorandum -- I attended this ceremony.  I then joined the team for their practice at the Indiana University stadium field, and I was immediately hooked!  I kept in touch with the team leaders, and was invited to their tryout in LA this past weekend.

In addition to a weekend of intensive soccer training, this gathering involved a health promotion event at the Boys and Girls Club of Long Beach.  In collaboration with the LA Galaxy (MLS team), we put on a dynamic and interactive program for children ages 6-16.  There were stations teaching about healthy eating and nutrition, why exercise is good for you, and we taught kids how to exercise.  The event built on past USMST events, and by all accounts was a great success.

Our weekend of training was expertly guided by a professional coach.  With most of the team at or older than the age of 40, we perservered through approximately 9 cumulative hours of intensive training.  By hour 3 it wasn't pretty.  Our moans and groans began to overshadow the roars of the airplanes landing at nearby LAX.  Though through all of the muscle cramping and arthritic joint aching, it became clear that this is a group of physician players with great devotion and heart.  

This year the World Medical Football Championships will be in Brazil, concurrent with the actual FIFA World Cup.  For this reason, getting a spot on the USMST roster is competitive.  Should I be called upon, I would feel lucky to be included.

It bears mentioning that this is not only a group of doctors who play soccer, these are physician leaders.  The USMST wants to make a difference in the health and well-being of Americans.   And they are partnering with the ACSM, and other organizations, to do just that.  Presently the USMST is self-funded.

Please see the organization's website for additional information -- www.usmst.org

I am so excited to find another outlet to practice what I preach...and it doesn't hurt that I may earn the opportunity to represent my country playing soccer in so doing....

Suspension Straps

Suspension straps are a great workout tool to help develop proper motor control. There are a variety of models on the market, but the one that we recommended is the Jungle Gym (check out the exercise aides section). They are incredibly convenient and can be set up pretty much anywhere. The ability to leverage gravity and your bodyweight makes it easier to balance, allowing you to focus more on using proper technique. Suspension straps can really help you properly engage the right muscle groups when performing exercises such as lunges and squats.

Initial Setup:

-Place strap anchors over the top of an open door away from the door frame about shoulder width apart

-Secure straps by closing door firmly, pull on straps to check

Squats:

-With legs slightly farther than shoulder width apart, knees pointing slightly outward and holding on to straps, lower buttock towards ground

-Make sure that you lean back, keeping your shins vertical over your feet

-Repeat for 10 repetitions

Notes:

-To ensure that your knees don’t collapse inward, make sure that they are externally rotated (away from your belly button)

-You should notice your buttocks engaging throughout the movement

-Make sure you take advantage of the straps allowing you to range past your weak point

-Once you feel comfortable enough with this exercise, you can make it more advanced by doing it on only one leg. There are a couple variations that you can do, one where you simply lift your leg straight in front of you while you do the squat (single leg squat), or you can cross your leg over your opposite knee (flamingo squat).

Lunges:

-Standing up holding straps in both hands, step directly back with right foot

-Lower your body so that your buttock moves downward and backwards, not forward

-Stand back up and return right foot to original position

-Repeat 10 repetitions

-Switch sides

Notes:

-pay attention to movement of front knee, make sure it moves straight up and down, not deviating side-to-side, the straps should help with this, but if you having trouble, move slower and don’t lunge down as far

-concentrate on sitting back, rather than leaning forward



Betting on patients- the one thing we can count on

Today I saw one of my favorite patients- a lovely 36 year young gal who herniated a disk in her back in a work injury

In reviewing my notes from an initial visit, I had commented that she had:

• positive factors predicting good outcome: very pleasant, still working, non smoker, nice skin (marker for overall connective tissue quality), smart, well motivated 

She had one major negative factor- she is morbidly obese, with a height of 6' 0", and a weight of 350 lbs

We discussed different treatment options, including physical therapy, injections, and surgery, but I emphasized that the main predictor of a patients outcome is the patient themselves, and not their anatomy.  It would be easy to focus on her weight, but she has so many wonderful positives, we made a point of focusing on those, while giving her specific tactics for weight loss.

I saw her again today, and she was just as wonderful as I had remembered her ..... except that she was 30 lbs lighter in a period of just 4 months!  

- she is working with a dietician

- she is exercising regularly

- she is focusing on portion control

Such a wonderful reminder that when we bet on our patients and give them an opportunity to optimize their health, they can do amazing things.

Thank you Ms Amazing (.... you know who you are) for being so wonderful!