How to choose the right bed: what we can learn from the Pepsi Challenge

One question patient's frequently ask me is "what is the right bed for me?"

Like many things in musculoskeletal medicine, the answer is "it depends."  There is no one best bed for everyone, and the best choice will depend on a few different factors

One thing to pay attention is your preferred position for sleeping.  As a general rule of thumb, the most important thing to pay attention to is the position you wake up in, rather than the position you try to fall asleep in.  I had a patient the other day who thought she was a back sleeper, but she always wake up on her right side, which tells her that her body wants to sleep on the right side.

A second factor is paying attention to placement of your hands.  One of the hardest parts of finding a good night's sleep is figuring out where to place your hands relative to your upper body.  This is especially true for side sleepers.   The constant tossing and turning to find the right hand position reminds me of the scene from the movie Talladega Nights, where Will Ferrell's Ricky Bobby character can't figure out what do with his hands during his first interview.

The same thing happens with me when I sleep, especially if I am in a bed with pillows I am not used to, or sleeping in a bed that is too small for me.

One inexpensive item that can make a huge difference is using a full-length body pillow.  You can do what I do, and get a cheap one for $15 at Costco, or you can certainly get a much nicer one at a store like Relax the Back.

A third factor to consider with sleeping is the appropriate level of firmness when you sleep.  There is no best level of firmness for everyone, but I do find that patients often sleep with a bed that is a bit softer than would be optimal for them.  I think the reason for this is that the level of firmness that is most comfortable when you first lay down on a bed is generally a bit softer than the preferred level of firmness for a good, restful night of sleep.

By way of analogy, Malcolm Gladwell had a great anecdote about the Pepsi Challenge from the 1980s in his wonderful book Blink.   For generations, Coca-Cola was a the clear #1 brand in cola sales, with Pepsi a very strong #2.  Pepsi would set up booths in public areas and ask consumers to try a sip of the two products, and then reveal the brand of the cola they preferred.  Based on this "sip test", consumers strongly preferred Pepsi.

This challenge started in 1975, but took traction in the 1980s, enough so that Coca-Cola started to see drops in sales.  It eventually led to Coca-Cola reformulating their market-leading product, and producing a newer version of Coca-Cola called "New Coke" in 1985, designed to be sweeter like Pepsi.

New Coke is one of the all-time great marketing disasters, and soon Coca-Cola brought back their original, less-sweet Classic version.  So what happened?

It turns out that the attribute that makes a cola tasty for a small sip is not the same thing that makes a cola tasty for drinking several large glasses.  When asked to drink a thimble-sized sip of a cola, tasters generally prefer whatever is sweeter.  When drinking an entire glass, however, most people prefer something less sweet, as excessive sweetness can be cloying and unpleasant.

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Getting back to beds: The quality that makes a mattress comfortable when you first lie is generally how soft it is.  However, the quality that makes for a good nights sleep is how supportive it is, which is a different quality.   Softness and support are not oppositional- a mattress can be both.  It's just important to recognize they are different qualities.

Some things I would consider when buying a bed:
1. Give yourself ample time to mattress shop.  Plan on a few hours
2. Before you go, figure out what position you wake up in, and test beds in that position
3. Give yourself at least 15-20 minutes on each mattress to determine if it is a comfortable fit for you

Some specific stores I would consider when mattress shopping:
1. The Relax the Back store.  We've had very good experiences with specific owners of the Bellevue store.  They have excellent customer service and spend a lot of time with customers.  In the past, I've had concerns about Tempur-Pedic beds because of heat retention, but the newer generation of Tempur-Pedic beds no longer have that issue (although some competing brands of memory foam do, so I'd only recommend the Tempur-Pedic brand).
2. Bedrooms & More.  Located in Seattle near I5, they offer high quality natural latex mattresses, and also have excellent customer service.
3. Sleep Number.  The sleep systems, using individual air chambers, can be nice for couples who desire a different level of firmness.  This is what I have used for myself for about 7 years, and I'm happy with it.  I can't speak to the customer service of stores in the Bellevue/ Seattle area.

Single-Limb Exercises

What’s an extremely easy way to burn more calories, improve your stability, and increase overall strength? Start doing your exercises on a single limb!

We’ve talked about single-limb exercises frequently on this blog, and that’s because we think they’re the bee’s knees, the cat’s meow, the duck’s quack … and just to keep the dated references going – well, we think they’re just swell.

Single limb exercises obviously challenge your balance, but they do much more than that. They can help eliminate any strength imbalances since you can’t rely on your stronger side to make up for your deficiencies. Also, single-leg exercises are similar to movements you do in everyday life or while playing sports, such as walking, running, or leaping.  In addition, they can help you burn more calories since it takes twice as long to complete a single exercise.

But you might be thinking: “I’m not Gaston!” And that’s right. You’re not Gaston. No-one’s as burly or brawny, or as slick or as quick. Then again, no-one eats five dozen eggs every day (think of the cholesterol!) But that doesn’t mean you can’t perform single-arm pushups or single-leg squats like Gaston (probably does). You’re just going to have to build up to it. The act of performing a single-limb exercise is going to be very difficult for most people. Not only will balance be an issue, strength will be as well. Ease into it! You can modify exercises to fit within your strength level. Here are a few examples.

-          Upper body push: Single-arm Pushups against a Wall. Face a wall or doorway, spread your legs about shoulder-width apart, and raise your arm until it’s about chest height. Perform a one-armed pushup, making sure to keep your elbow close to your body. These might seem too easy at first, but I think you might be singing a different tune after 20 or 30. Remember to keep your core tight before you start your pushups. An easy way to make sure your core is tight is to clench every muscle in your body (your legs, butt, abs, and even your hands). To up the intensity, bring your hand to a lower plane, like a heavy table, a kitchen counter, a chair pushed against a wall, and eventually, the floor!

                      



-          Upper body pull: Single-arm Door Pulls. Open a door and stand facing the edge of the door so the doorknobs are perpendicular to you (round ones help here). Grab one doorknob with one hand, the other knob with your other hand, then bend your knees until you’re in a half-squat. Lean back until your arms are straight. Then pull your body towards the door. If you can, perform the pull with just one arm. Remember to keep your back straight and your shoulder blades in a stable position. To make things easier, use both arms, or move your feet further away from the door so you’re standing more vertical. To make things more difficult, place your feet behind the doorknobs so they’re further away from you/you have to squat more; or simply hold the contraction longer.

                    

-          Lower body push: Single-leg squats. Start by holding onto a doorframe or other sturdy object (like a couch) to make sure you don’t fall over. Don’t worry about cheating with your arms; you’ll still feel a burn after doing 10+ single-leg squats even if you help yourself up. Lift one leg off the ground and hold it either in front of or behind you. Then, squat as deeply as you can on your standing leg. Suspension straps can help TREMENDOUSLY with this exercise, as seen here:

Two things to remember:

1) Make sure you keep your bending knee from leaning inward – this is called a valgus fault, and can lead to injury. Activate your gluteal muscles to remedy this, as well as keeping your knee steady/leaning out. 

2) Don’t let your knee go over your toes. You want to be sitting back and activating those glutes. Letting your knee go over your knees can lead to injury.

-          Lower body pull: Single-leg Romanian Deadlift. Stand on one leg.  Keep your leg straight but without your knee locked out. Hinge at the hips, and bend over while keeping your back straight. Maintain a controlled pace and movement – think more Drinking Bird toy, less stapler snapping closed.

      

             

If there’s a running theme throughout these exercises, it is that FORM MATTERS. If any of these exercises are too difficult to do with proper form, then you may need to modify them further.  Also, these exercises are only a guide, not a complete work-out plan. There are many resources (books, personal trainers, online forums, etc) to find more information on complete work-out plans. 

The Parable of an Insurance Company's Perfect Physician: Dr. Donoharm

The Parable of an Insurance Company's Perfect Physician

Megalopolis Health Insurance (MHI) was searching long and wide for the physician who met their platonic ideal of what a doctor should be.  They found just such a physician, named Doctor Donoharm.  Dr. Donoharm was perfect on all measures that insurance companies crave on their quality metrics in the past year.

MHI started using Patient Satisfaction surveys as a measure of quality.   Dr. Donoharm was a model of perfection- zero patient complaints for the entire year!

MHI took to heart the Institute of Medicine's  To Err is Human report that attributed between 44- 98,000 patient deaths to physician error.  MHI recognized that the best way to save lives was minimizing physician error!  What a scourge!  And lo and behold, Dr. Donoharm had the lowest rate of physician error of any contracted physician.  In fact, Dr. Donoharm had no physician errors for an entire year!

MHI also realized that they could help stamp out the cost of physician over-utilization of resources.  At MHI Headquarters, they lived by the mantra "the most expensive tool is a physician's pen", and they were going to create a series of incentive systems to prevent physicians from over-ordering expensive tests.  They would follow the recommendations of the American Board of Internal Medicine's Choosing Wisely campaign to prevent unneeded tests like MRIs and expensive lab tests.  And when MHI executives looked to see who their #1 physician in terms of avoid over-utilization was for the past year, it was yet again Dr. Donoharm.

It was clear to MHI executives they had finally found the perfect physician.  No complaints!  No deaths attributable to physician error!   No unneeded tests!

MHI decided to pay a visit to Dr. Donoharm to see how they could teach other doctors act to model themselves.  The secret?

Dr. Donoharm died a year earlier, and stopped seeing patients.

The morals of this tale:
1. From the standpoint of an insurance company, the best physician is a physician who doesn't actually see patients.  They don't actually have to be dead (although, from the insurance companies standpoint, that's also one less patient to treat)
2. When an insurance company uses the word quality, what they really mean is cost containment
3. When an insurance company says they are saving costs, what they really mean is that they are increasing their profits
4. If you want to know if a doctor is a good, the quality metrics used by insurance companies and central health systems will confusing at best.

The US Medical Soccer Team Surprises at the World Medical Football Championships

While I've been involved with the US Medical Soccer Team since June 2013, this was my first time at the World Medical Football Championships.  The tournament was a great experience.  Over 500 physicians from 18 different countries gathered in Long Beach, CA.  Most of us stayed at one hotel, the Hyatt Long Beach, and we travelled daily together via bus to the fields at Cal State Long Beach.  We had 4 adjoining fields so that once done with a game, teams could stay and watch/scout other matches.  Staying and playing in the same locations made it easy to get to know people.  Evenings 4:30-7:30p were spent (by some of us) at our concurrent medical conference, and this was another opportunity to become acquainted with our colleagues.

The competition on the pitch was fierce.  These docs came to play.  Fortunately, 

the USMST had a decent draw, and our first round group matches were against Lithuania, South Korea, and Australia.  We fought a fit and young Lithuania team to a 0-0 tie (I believe they beat us something like 8-0 last year in Brazil) on Sunday, then beat a smaller but faster South Korea team on Monday 2-0, and on Tuesday we outworked a very tall and strong Australian squad to win 3-2 to win our Group and move on to the Winner’s Bracket.  

We presented our Healthy, Fit and Smart Program to ~200 children from the Long Beach Boys and Girls Club with the help of our international physician colleagues on the Wednesday.  

Wednesday afternoon our USMST team served as ambassadors on a Hollywood bus tour for our international guests.  Fun stops included: Santa Monica pier, Rodeo Drive, and Grauman’s Chinese Theater.  While no one signed any movie contracts, the bus returned full of happy faces and many souvenirs.

Then on Thursday the competition resumed and we were pitted first against Venezuela, a newcomer to the tournament.  By this time, injuries were stacking up for both teams and we had to dig deep into our reserves.  Our energy made the difference and we finished 2-0.

Friday we took on the tournament favorites, Czech Republic.  The Czech doctors were all young, skilled, big and strong.  They were very organized and strong in the air.  Without Alan, our best defender, downed by a torn Achilles in the Australia match, we couldn’t stop their air attack.  We lost in this Semi-Final match 4-1 (the last two of their goals came late on counter-attacks after we reduced our defense).

So that placed us in the 3rd place match on Saturday against Ukraine.  They struck first in the 1st half, and we tied it up early in the 2nd half.  Then we went up 2-1 with ~5 mins remaining, and they tied the match with ~30 seconds left pushing us into PKs.  Our squad rallied, and our fabulous keeper came up big, and we beat them 5-3 in PKs.

The USMST finished in 3rd place — a great accomplishment given our squad’s best past performance has been ~10th.  The Czech Republic won the tournament, beating Hungary in the Final.

Our Master’s team (45 and over) was quite strong, and went undefeated, but due to goal differential went into the Consolation Bracket, ending up in 5th place overall.

Dr. Bert Mandelbaum, the lead sports medicine physician for US Soccer, presented a lecture at our conference, and indicated his interest in assisting our organization in making further inroads with FIFA given our common interests of physical activity promotion and injury prevention.

All in all, I’d say this was an enormously successful week for the USMST and a fabulous experience for me.  A wonderful example of physicians from around the world 'walking the talk' of physical activity and adult play for better health.

Dr. Hyman Trains with the USMST in Seattle

I had the privilege of helping to host and train with the US Medical Soccer Team (USMST -- www.usmedicalsoccerteam.org) this weekend at Starfire in Tukwila (home of the Sounders).

We had four 2 1/2 hour very intense training sessions, and the hard work has paid off as our squad is looking nearly match ready for our up and coming international tournament at the end of the month.  Our team is the host of the World Medical Football Championships (WMFC) this year, to be held in Long Beach, CA, in conjunction with the Global Congress on Medicine and Health in Sport (GCMHS).

On Friday, we partnered with the Seattle Sounders organization (www.soundersfc.com) for an outreach event.  Former first team Sounder, Roger Levesque, now the Director of Community Outreach, joined us at the Rainier Vista Boys and Girls Club in Seattle where we put on our Healthy, Fit and Smart program for approximately 70 youngsters.  The kids were creative as usual as they were asked questions about physical activity, nutrition and the human body in an interactive format.  Amazing to observe a 9 year old recount their understanding of their uncle's heart attack as one of our cardiologists and physician-athlete discusses exercise effects on the heart muscle.  We are grateful for the opportunity to partner with another wonderful Major League Soccer organization.

On Saturday evening, we were grateful that Michael Morris, team physician for the Seattle Sounders, joined us at our team dinner at the Icon Grill in Seattle.  Our physician athletes appreciated the opportunity to get to know him and learn what it's like to help manage the physical injuries of elite soccer athletes.

Sonosite (locally based, international company) was kind enough to lend me a portable ultrasound unit (the Edge), affording me the opportunity to utilize my sports medicine skills to evaluate and treat several of my physician teammates.  A hearty thank you to Sonosite (http://www.sonosite.com/), who has also kindly agreed to help sponsor the GCMHS and provide equipment that will allow me to provide onsite diagnostic services to the physician-athletes participating in the WMFCs.

So now we're only 3 weeks away from our tournament.  We expect approximately 500 physicians from 18 different nations to participate in the conference and tournament.

The competition will be fierce, and the USMST up until now has not made it out of the group stages of the tournament.  We are confident, however, that as hosts, we can best our prior performances.

This will be my first year to participate in the tournament though I have had the opportunity to train with the USMST for the past 1 1/2 yrs on several occasions.  Fabulous group of physician athletes.  Though most of us are beginning to show our age on the pitch, every so often each of us enjoys a bright moment of greatness on the field.  

Please enjoy the following silly video clip, and please come support our squad in the WMFCs in Long Beach June 27-July 4!

Sleep: quality and quantity matter

You know that sleep is essential for health and well-being, but do you recognize the importance of consistent, sufficient, quality sleep?  We're sure you have experienced a poor night of sleep- whether it was due to internal factors (stress, pain, illness) or external ones (noise, temperature, an uncomfortable mattress), you suffered the consequences the next day.  

Sleep is the brain's time for physiological maintenance: the chance to clear out waste that has built up after a day of thinking,  consolidate memories and form neuronal connections.  5 benefits of getting a consistent 7-9 hours of sleep per night include: 

• Increased cognitive function: learning, memory, attention
• Better mood and emotional regulation
• Stronger immune system
• Decreased inflammation
• Better metabolic function and weight management

So, what can you do to increase your quality of sleep?  The short answer- have good sleep hygiene.  Here are 5 tips:

• Avoid caffeine in the afternoon
• The effects of caffeine typically last 5-6 hours. The National Sleep Foundation states that caffeine can take twice as long to process in women taking birth control pills or women between ovulation and the beginning of menstruation.  Take the safe route and limit your caffeine consumption to the morning hours.

• Eat dinner more than 3 hours prior to bedtime
• Give your body a chance to adequately digest food before hitting the sack.  Also, avoid any foods that could cause indegestion or acid reflux, exacerbated by laying flat. 
• Adhere to a regular sleep schedule 7 days a week
• While it's tempting to "burn the midnight oil" Friday night and sleep-in on Saturday morning, your body's internal clock prefers routine.  Having a schedule will help you fall asleep and stay asleep easier.
• Avoid alcohol at night
• That glass of wine might make you feel like it's easier to fall asleep, but your body will have a more difficult time falling-into and maintaining deep sleep.  Result?  You wake up feeling less rested and foggy.
• Exercise regularly
• Yet another benefit of staying active!  Regular exercise promotes restful sleep but, like dinner, make sure it's done more than 3 hours prior to bedtime.

As you continue on the path to becoming the best version of yourself, don't forget that (quality) sleep is an integral piece of the wellness puzzle! 

Ultrasound Case of the Day: Patella Injuries in Adolescent Athletes

I saw a fascinating case last month.  The patient was a high level 13 year old baseball player who developed pain in the region of his knee cap (technically called the patella).

He did not have any traumatic injury, so I had a low suspicion of an injury like a patellar fracture, nor did I suspect a traumatic injury his ACL ligament or meniscus.

He was just starting his growth spurt.  Youth athletes are vulnerable to a different class of injuries than adult athletes.  The patellar ligament is what I call a structural complex, connecting the lower portion of the knee cap (the inferior pole of the patella) to a small bump on the shin called the tibial tuberosity.

This patellar ligament complex can be injured in different locations, depending on age:
- Age 11-12- at the inferior pole of the patella, an injury called Sinding-Larsen-Johannson syndrome
- Age 13-14- at the tibial tuberosity (where the patellar ligament attaches to the tibia)- called Osgood Schlatter syndrome.

The age ranges for SLJ and OS are approximate, but as a general rule SLJ occurs earlier in adolescence, and the more common OS occurs a few years later.   Their timing is based on when the bony processes, called an apophysis, fuses to the rest of the bone.

By late adolescence, the apophyses have fully fused, so we don't see these injuries much by an athlete's late 20s.  We may still see irregularities in the bone, but these are remnants of a prior injury, and rarely the cause of injury itself.  Instead, in athletes who are past puberty, the most common site of injury is within the patellar ligament itself (usually closer to the patella than the tibial tuberosity), a a condition called patellar tendinopathy, or jumper's knee.

In our clinic at Lake Washington Sports & Spine, Dr. Hyman and I like to use high-resolution musculoskeletal ultrasound to image the patellar ligament complex.  Ultrasound is a particularly great imaging tool for assessing tendons, for the following reasons:
1. It has the highest spatial resolution- 5-10 times higher than MRI
2. Real time assessment- it is the only imaging test that adds in actually touching the patient, so we can confirm that the area being imaged is actually painful.  This is particularly valuable in rough-and-tumble athletes with a history of prior injuries, to help clarify whether the injury is new
3. Fantastic tissue differential- ultrasound is great at distinguishing between different tissue types


To give an example of an ultrasound image of a patellar-ligament complex injury, the image below is that of Sinding Larsen Johannson syndrome in an 11 year-old elite-level soccer player.  The yellow box shows irregularity in the apophysis of the inferior pole of the patella (to help with orientation, left is superior, right is inferior)

Getting back to the 13 year old baseball player, based on his age and pain near the patella, I was anticipating that he may have SLJ syndrome.  However, his pain was located higher (on the superolateral portion of his knee cap).

Indeed, as the image below shows, the patella looked pristine in the center, with a smooth cortex

However, when I moved the probe laterally, I could see two disruptions in his cortex

This is a case of what is called a bipartite patella.   The superolateral portion of the patella never fused to the remaining part of the patella.  The x-ray image below shows the non-union of the bipartite patella, along with the planes of the two images above

How did I use this information clinically:
1. Relative non-use
2. Physical therapy.  Particular focus include stretching of the rectus femoris at the hip, since we wanted to limit traction of the quad distally
3. Avoiding NSAIDs.  The specific mechanism can interfere with healthy collagen synthesis, essential in this growing athlete
4. Regular icing

This athlete did great, and was able to return to sport in 1 month