Under Recovery

My colleague Brian White, a PM&R physician based out of Cooperstown, NY, has an expression that I really like- "There is no such thing as over-training.  It's under-recovery."

Probably the most common sports injuries I see are what I call chronic overuse injuries. Whether it is patellofemoral syndrome, tibial stress fractures, tennis elbow- all of these are examples of not allowing the body to sufficient time and creating an optimal environment for recovery.

The body needs a few things to recover properly:

1. Rest

2. Nutrients

3. An optimized endocrine environment

Taking these 1 at a time:

1. Rest

These refers to both sleep and muscle recovery.  It's important for athletes to get enough sleep to recover.   There are indicators that let you know you are not getting enough sleep.  One is that you should feel refreshed when you wake up.  The second is that if you wake up with an elevated heart rate, your body is telling you need more time to recover.

Another form of rest is cross-training.  For example, many age-group triathletes need more time to recover between workouts than they did when they are younger.  A good indicator that you are not allowing for optimal recovery is that you feel muscular fatigue at the beginning of your workout.

2. Nutrients

The body needs building blocks to recover.  For muscle in particular, the most important resources are amino acids, which are the building blocks for recovery.

Not all proteins are created equal.  Some are more bioavailable than others.  This will be a separate post in the future, but the general hierarchy is that essential amino acids are better than whey protein, and whey protein is better than soy protein.  The commercial products I generally recommend are Benevia Strength & Energy (www.gobenevia.com), or the Whey Protein formulations available at Sam's Club and Costco (which are high quality and affordable).

3. Endocrine Environment

A growing body of research shows that in order for your body to recover appropriately, you needs hormonal signals to let it know that it is safe to recover.

When the body is breaking down, this is called catabolism.  During times of stress or overwork, the body will break itself down to make sure that building blocks are available in the bloodstream.  When the body is building itself back up, it's called anabolism.

There are 3 common endocrine syndromes I see that inhibit recovery- one in women, another in men, and a third in both sexes.

The endocrine issue that affects women is called the female athlete triad.  Technically, the female athlete triad refers to fractures, absent periods, and an eating disorder, but the way I view it clinically is that the female athlete is not taking in sufficient nutrient content for her caloric expenditure.  Women's bodies are very well calibrated, and the body will not allow itself to have a period unless there are sufficient nutrients to support both the female athlete and a potential baby.  So if you are a female athlete and do not have a regular period, you should have this evaluated by a health professional familiar with the female athlete triad.

The endocrine issue that affects men is hypogonadism.  This under-recognized disorder is when a man's body reduces it's natural production of testosterone because it is under stress.  If you find that you have decreased energy, loss of muscle bulk, difficulty with recovery, it's possible that your testosterone level has dropped in response to the repeated stresses of exercise.  This is especially true if you have a decreased libido, which is more common in hypogonadism than in similar appearing conditions like hypothyroidism and depression.

The final endocrine issue, which can affect both women and men, is Vitamin D deficiency.  The body can get Vitamin D through both diet and sun exposure.  Vitamin D deficiency may be especially common in areas that have lots of cloud cover, including my home town of Pittsburgh.  Therefore, in patients who are not recovering as well as anticipated, Vitamin D deficiency is one of the first things I check for. 

The key to low back pain - stratification and the Katie Couric effect

What is the best way to treat low back pain?

I get asked this question all the time, whether I am seeing patients in my Sports & Spine clinic, lecturing at national meetings, or meeting with other experts.

There is one key to management of low back pain- stratification.

What I mean by this is that low back pain is not one diagnosis, and therefore trying to treat all low back pain with one approach is not effective. In a typical day, I may see patients who have many different causes of low back pain, all of which are best managed with different treatment approaches. The approach to managing an annular tear in a 23 year old Ironman triathlete is dramatically different than that of a 74 year old with zygapophysial joint arthropathy, which is dramatically different than the approach in a 34 year old woman with post-partum pelvic floor dysfunction.

Some of these patients I manage with an exercise program, others I may manage with an image-guided injection, and others I may manage by working in a team with the physical therapist or chiropractor. The key is that I recognize that every patient is different, and no one approach will work for everyone.

Unfortunately, many treatment recommendations are based on the assumption that low back pain should be treated as one entity, and therefore one basic approach should be used.

So, if you have low back pain, the biggest determinant in getting better is appropriate stratification into the appropriate treatment groups. Some of this is related to determining the appropriate diagnosis, but often times we can stratify patients into appropriate treatment groups even if we don't know the actual diagnosis.

For example, many patients are surprised to find out that if you want to get better, it is more valuable to know a patient's directional preference (i.e., which movements are most painful, such as putting on shoes and socks in the morning) than it is to look at an MRI. If I know that a patient hurts more with certain movements, I can design a physical therapy program that takes this into account. This is of great benefit to this physical therapist, and as Audrey Long demonstrated inher award winning research in 2004, if we design physical therapy programs with a directional preference in mind, the probability of improvement increases dramatically.

But I have many patients say to me "I hear you, but I've always been told that if you really want to know what is causing my low back pain, I need an MRI." MRIs are wonderful tools, but the reason they are not as helpful as you might imagine is because of what I call the "Katie Couric Effect."

We all know Katie Couric. Back in 2000, in the days before we had HD televisions, we didn't notice that she was actually a woman in her 40s. When she started working for CBS on the nightly news, two things happened- Katie Couric turned 50, and many of us started watching her in HD television.

Katie Couric is a very attractive woman, but when you look at her in HD television, many things are suddenly apparent that were not apparent on a regular television. She is the same woman that she was on a regular television, but because of the higher resolution of the TV, we are now more aware of some of the natural changes associated with aging that we would have been blissfully ignorant of otherwise.

Same thing with back MRIs. Just as the natural processes of aging can bring along gray hair and wrinkles, the normal healthy spine has some age-associated changes, including degeneration of the disks and joints. Much of this is incidental, and therefore when we look at a spine MRI, most of what we are looking at is incidental findings. And often times, the main cause of low back pain may not be seen on MRI.

Which brings me back to what is the best way to treat low back pain. The key is to find someone you trust who is able to figure out what is the best treatment approach for you. That person may be a Sports & Spine PM&R physician like myself or Dr. Hyman, it may be a surgeon, it may be a chiropractor, it may be a physical therapist, it may be an acupuncturist, etc.

Ultimately, you need someone who can see you as an individual, and has the skill set necessary to tailor a program that is appropriate for you.

Practicing your new normal

Cal Ripken (at least I think it was Cal) "Practice doesn't make perfect. Perfect practice makes perfect."

Whoever it was, I think this statement is important. Any time you do a behavior, you reinforce that behavioral pattern, and with time, that becomes your "new normal."

We can use this to our advantage. In Brian Wansink's brilliant book "Mindless Eating," he shows how most people eat according to scripts, rather than because they are hungry. They eat because that's what they do when they come home from work, or that's what they do when they are stressed, or that's what they do when watching a football game, etc. Those scripts are what is normal for you. But you can create a "new normal." Instead of eating something when you come home from work, you can play catch with your son as soon as you come home. Instead of eating when you are stressed, you can make a point of calling your mom and letting her know she is important to you. You can replace a maladaptive habit with a healthier habit- you can create a new normal.

I once heard an interview with Tom Arnold where he made a similar point. He was a co-star in "True Lies" with Arnold Schwarzenegger, and Tom asked Arnold for advice on how to look buff for the movie. Arnold advised him to just practice walking with his stomach sucked in, and over time his posture and abdominal tone would improve. And it worked. It's a great pearl that can help prove abdominal tone, and is an example of "practicing your new normal."

This applies in other aspect of life. I've often heard the advice that you should not dress for the job you have, but the job you want to have. While I don't follow this pearl myself (I wear both polo shirts and sportcoat and tie at work, but I wear polos more often), but the idea makes sense- the best way to earn a job is start acting the part to confirm you are ready.

The main point I want to make, though, is in regards to posture. Whenever you sit or stand, whether you think of it not, you are "practicing" your posture. This is especially true with older  individuals. Many older adults walk with a slumped posture, and are practicing bending at their waist, curving their shoulders, and sticking out their neck. This is reversible, however. There are some very good exercises that can, with practice, improve your posture, which can help your appearance, improve neck and back pain, and make you feel more vibrant and energetic.

It feels odd at first, but it's all about practicing your "new normal."

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.

Practicing being joyful

Several years ago, I went to a fantastic course on myofascial medicine, and it's had some major impacts on the way I think about musculoskeletal conditions.

During the course, my friend David Lesondak shared with me an amazing concept-  that we need to practice being joyful. I thought that this was a remarkably brilliant insight

The nervous system is designed to adapt to anything you do frequently as a "new normal." This can have negative consequences if you look at people are who routinely miserable. As a thought experiment, think about the last time you were at the Divison of Motor Vehicles. It's a miserable environment, everyone hunches their shoulders, and there is a palpable tension in the room. Now imagine being like that all time- that would be a horrible "new normal."

Instead, imagine trying to practice a "new normal" by practicing being joyful. Here's a simple exercise- extend your hands overhead like you just crossed the finish line of a marathon. Didn't that make you feel better? I don't think it's possible to put your arms overhead in a victory position and be in a bad mood.

I don't think this is just psycho-babble- I think it reflects a real neurologic phenomenon. Paul Ekman did some ground breaking research that demonstrated that if you have a person put their face in a smiling position, their mood will improve. I think that this is true of the body as a whole as well- if you place your body into the position of happiness, you will feel happier.

I've noticed this when I work on some strengthening exercises in my patients. I often work on them to strengthen their posterior chain (muscles behind their back like the thoracic paraspinals) and stretch their anterior chain (muscles in the front of their body, like the pectoralis minor), and an interesting ancillary phenomenon is that most of them notice that they are noticably happier. It happens almost instantaneously. I don't think this is an accident- by training their muscles so that they can literally walk taller, they also figuratively walk taller- they become happier.

And so do I.

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.

Great Forbes article on the downsides of "doctors pushing buttons"

The number 1 patient complaint I hear is "I wish my doctor spent less time listening to me, and more time pushing buttons." .....

Of course I never hear that.  Patients want their doctors to listen to them.  This recent article at Forbes goes into details discusses how pervasive the problem is- it's a really big deal.

Every physician I know wants to be a patient advocate.  From a patient perspective- we need YOU to be your physician's advocate, by voting and writing for your congressman.  If you want your physician to listen to you more, we need you to help us, by stop having government requirements force us to click buttons.  Enough is enough!