Emptying out the mailbag & clearing the history #1

Posted on July 30, 2014

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This is an idea I got from Bill Simmons. Particularly during the NFL season, Simmons will empty out his email inbox. There isn’t much of a theme to it, it goes off on tangents, can be random, but it’s a way to get a bunch of different thoughts and comments out there. I thought I’d try something similar.

Beyond emails, I keep the comment section of every post active, no matter how old. Because people aren’t going to consistently check old posts for new comments, good questions (and hopefully answers) get missed. I’ll add some of those here.

I’m going to mix things I come across in this as well. I’m routinely updating my recommended resources page, but realize people may miss when I add to that. Quotes, books, articles, I’ll toss some of it here.

Keep in mind a lot of this is email conversations and comment replies. By their nature they are not as thorough or complete as a post on one topic.

Here’s what’s covered in this installment (click to be taken to the section):

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A great point by an ACL patient

This person was talking to me about how much she’s been pushed during her PT sessions, how long the sessions have been (2-3 hours), and more:

“I went into the surgery after getting back lab results from my primary m.d. after being exhausted for months, that showed my Vitamin D levels were very low, under the lowest range considered healthy. It probably explained partially the ski accident; my immune system was low, and muscle density, strength super low, stress response.

Except for skiing during the winters, I hadn’t exercised recently except walking to work in SF [San Francisco]. Daily activity: I’m a photographer and photo retoucher, some custom design work—now at home, sitting in front of a computer.

Last week—week 6 is the first week that I started walking around larger controlled spaces: ski villages (flat) to try to build up more leg strength.

Point: I went into the surgery as a not ideal candidate because of my health going in. Because it’s not an urban area, and so many people here are pro or competitive level athletes, I think they have the time and the lifestyle for longer sessions. They are trying to get back to competing or freeskiing this season; I’m a bit of an anomaly it seems, because I’m not an athlete and I didn’t get hurt by skiing off a cliff.”

My response:

Your comments about the clientele your health team is used to are great thoughts. This has been something I’ve routinely encountered: Too many people think they are working with professional athletes and forget / don’t know how to handle everyday people.

In your case, another reason this is important is because you don’t have a crucial timeline to get back to something. Many athletes have a date they are trying to get to, such as opening day of the next season or whatever. So it’s common to push them. And as you mentioned, they are the group who best handles being pushed. Not to mention money is usually on the line. For you, you’re not worried about anything 8 or 9 months from now. You’re worried about how things are 10, 20, 30 years from now.

At the end of the day, the only things requiring aggressive treatment for ACL people are extension ROM and, to some degree, walking. If you have full extension ROM and are walking well, you can and should take your time from here on out.

Speaking of ACLs (graft healing timeline)

Note this person is at the six week mark:

“Re: hamstring graft. I just called the PT, and he said unless I fell at this point the graft wouldn’t tear. I pushed it, and got pushed the last time and walked a bit so the swelling resulted.”

If you’re swelling after things, that’s only going to make achieving certain ROMs harder. You can see a vicious cycle here: Force yourself to achieve ROM => Get swelling => Harder to get ROM now => Push harder to get ROM => Even more swelling => etc.

At 6 weeks, the graft is only just past the halfway point before it is set in place. So, your PT is wrong about the graft setting. The hamstring graft is a tendinous graft (the patellar is a bone). Tendon does not heal to bone in 6 weeks. Bone can potentially heal to bone in 6 weeks. (This is why the patellar graft has a quicker healing timeline.) For tendon to bone, 10 weeks is about the earliest. These numbers are pushing it though. Patellar at 8 weeks -similar to a broken bone healing- and hamstring at 12 weeks are safer timelines.

It’s no coincidence this -the 10th and 13th week respectively- is when most start jogging and doing more dynamic activity. And if the person really has their rehab dialed in, they will start with backward running at these junctures to further reduce the stress on the ACL. Eventually progressing to forward running.

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The lower back and side bending

(FYI the below text is more clear if you click the picture.)

Adam question screen shot lower back side bend

This is a very good exercise to work on proper side bending:

From an ADL perspective you basically get the person to stop twisting / bending, period. “Hips and shoulders always face the same direction” is a common cue I use. (Hard to twist if this is adhered to.)

Note that the exercise I embedded has to be done properly. The bending has to occur at the thoracic spine and not the lumbar. If that exercise is too hard for a person, I will have them place their hand under their arm pit and have them side bend over their hand to insure they cannot side bend from the lumbar spine.

In an assessment, this is what you do to figure out if moving the lower back too much is what’s causing pain. So, person side bends = pain. I place my hand at their ribs (roughly under the arm pit), have them side bend over my hand (thoracic spine has to be the segment which bends), and person will go “That feels better / there’s no pain.” (If you ever wanted a crystal clear indication of what causes back pain, that’s it right there. Lower back moves = pain; lower back doesn’t move = no pain.)

So, exercise wise, I work on how the person side bends, where ADL wise I typically get the person to stop any bending or twisting as much as possible, as I haven’t had much success trying to get people to change how they bend or twist during the day. Bit too much going on when one is at a desk or whatever to think of that. It’s easier for a person to grasp “Just don’t twist or bend.”

Hope that makes sense.

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More on movements versus muscles

A client asked me about glute medius activation, as well as my thoughts on this Evan Osar video:

I don’t see anything wrong with that Osar exercise using the bottom leg. I don’t do much bottom leg work. Whenever I’ve played with this I feel it’s really hard for people to know when their lower back is moving / compensating. But I haven’t played with it too much.

In general, I always prefer moving somebody compared to isometrics. Particularly isometrics where someone else’s hands are needed, which make it harder for the person to do the exercise on their own. The only times I really use any isometric stuff is working on balance / single leg standing, and abdominal exercises. In the abdominal exercises though, the stomach may not be moving, but often the limbs are.

There are other factors here as well. For example, the Clamshell is a highly specific functional activity as you see people who 1) Lay down / sleep in that position 2) Move in that position 3) Roll over to their other side from that position. When they roll many will rotate the lower back. Think when rolling over, the hips turning way before the shoulders, or vice versa. So, the Clamshell works directly on all the above. How you lay in that position, how you move in that position, how you move from that position.

You give people a good set up, cue them to open their knee but not their hips (lower back doesn’t rotate), and, when people roll over to work the other leg, you make sure the hips and shoulders roll over at the same time. This is particularly true for women, who are more prone to have side lying issues due to their wider hips.

With a Clamshell I’m not thinking of it as applying it to a standing exercise, I genuinely want the person to move in the side lying position. This is somewhat more of the movement versus muscles approach. Often just because you strengthen muscles in one position does not mean the body will take that to another position. Strengthen the PGM in a side lying position (through whatever way) does not mean the person will automatically open their knees while squatting. It can’t hurt to have a stronger PGM while squatting, but you still have to work on how the person squats. I’ve just gotten more and more away from “assess this muscle” and to “assess this movement.”

This may be my biggest deviation from those who follow Kendall or Sahrmann: I do basically zero muscle testing. I’m pretty sure the physical therapy department at Washington University in St. Louis is going away from this too. Last time I was there they were really using their muscle testing to assess how a person moved under resistance. It’s more of a “What do I see” approach compared to “What do I feel.” Which makes more sense to me. I trust my eyes more than my hands in this realm. It’s tough because Kendall’s work in this area was so tediously well thought out, and seemed in many ways a gift…but I think it’s pretty much useless.

One caveat to the above: Wash U. and Sahrmann have some good stuff on using the hands to assess joint movement. Particularly for joints that are hard to see. For example, watching the humeral head move is easy; watching the femoral head is much harder. Placing your hands on something like the femoral head and watching what it does as someone moves definitely has value. This is still more watching than feeling -you watch how your hand moves as an extension for how the joint is moving- but I don’t want to completely discount the value of putting your hands on someone.

One of the better paragraphs I’ve come across recently

From Histology for Pathologists, bolding mine:

“The insertions of ligaments and tendons are also calcified, and their insertions into the bone are effected by a similar keying. Because the insertions of ligament and tendons into the bone are generally studied in dry bone specimens, the bone markings we see are in fact the calcified portion of the ligament or tendon. Because the sites of such insertions are approximately the same from individual to individual, there is a tendency to think of them as static structures. However, since in the child growth is taking place continuously and in the adult bone turnover is continuously taking place (albeit slowly), it follows that the insertions of ligaments and tendons must participate in this dynamic process. (Our knowledge of anatomy is for the most part based upon the dissection of the dead; but, for morphology to be understood, time must be put into the equation. Life is characterized by continuous growth and change.)”

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Some good coaching resources

Insight into how to handle other people, such as athletes, clients, patients, is not easy to come by. Much of it is geared towards high level athletes, which often doesn’t apply to everyday people. Two good resources I came across recently though are:

Bowerman and the Men of Oregon: The Story of Oregon’s Legendary Coach and Nike’s Cofounder

Bill Bowerman was the track coach for the University of Oregon. He is perhaps the most famous track coach there is. Being a cofounder of Nike is of course part of this, but he was well known before that even began. He coached a ton of sub four minute milers.

This book was a bit slow for me at certain points, but there are some good insights into handling athletes (which can apply to everyday clients), the level of care required to have an impact on people, and the training that took part at Oregon. Namely how you shouldn’t train a person into the ground on a regular basis. Bowerman was a pioneer of the “Hard-Easy-Hard” frequency. For every hard day of training, you should have at least one day of easy training.

Steve Prefontaine gets a solid look at as well.

Eleven Rings: The Soul of Success

This is Phil Jackson’s memoir, primarily of his championship teams. Of which there are 13! Two as a player; eleven as a coach.

I really enjoyed this because of all the difficult personalities Jackson dealt with during his coaching career. People like Michael Jordan, Kobe Bryant, Shaq, Dennis Rodman and more. Phil has always been heralded for his ability to handle these personalities. There is some good information as to how he did this. But something else I really enjoyed was his delineation on when he screwed up. At least in sports, you really don’t get more successful than this guy. Yet he regularly made misjudgments.

1) Shows you how hard handling tough personalities can be 2) Shows you don’t need to be perfect in this realm to achieve great success.

-Personal Best: Top athletes and singers have coaches. Should you?

This isn’t something I came across recently but it’s a great article by surgeon Atul Gawande, one of my favorite writers, about the value of coaching even in the operating room.

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Did somebody say Gawande?

Dr. Gawande is not only a surgeon, but a public health researcher. This is probably the best, most comprehensive, even keeled discussion on the current state of healthcare in the United States. Gawande discusses where Obamacare is excelling (covering people), where it is faltering (controlling costs), how despite its faults healthcare costs in the last four years have grown at the slowest rates in 50 years, along with other factors.

His point about his son, an 18 year old who was born with a heart defect, no longer having to worry about being covered is a personal one for me as well. While I don’t have a genetic defect, I had a major operation where I couldn’t get health insurance for a year. With Obamacare, now I can. I really don’t think people understand how something this basic is so crucial for some. I genuinely had to decide between “Ok, do I continue to be self employed, or do I have to take a job just so I can get health insurance?”

I sincerely challenge someone to rebut any of the points he makes in this discussion:

I might as well close this section with two more healthcare articles:

Medicare isn’t going bankrupt

Is America better at treating cancer than Europe?

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Society really needs a rudimentary understanding of chemistry (chemophobia)

“And companies going along with chemophobia are really just contributing to the misinformation of the general public.  People assume that if you can’t pronounce the name of a chemical, then it doesn’t belong in your body.  But that’s just because we’ve given a lot of “chemicals” more palatable nicknames.  The chemical name for Vitamin C is ascorbic acid (aka 2-oxo-L-threo-hexono-1,4-lactone-2,3-endiol).  What about allyl isothiocyanate?  That’s gotta be bad right, it has cyanide in it!  Well, that’s actually the oil responsible for the pungent taste of mustard and horseradish.”

Quote from here.

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A researcher at the forefront of genetics gives his best health advice

Sharon Moalem screen shot

Another commenter followed that up with, “Ok, besides that.” I might have responded, “Open your window; get a standing desk.” (From here.)

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Jenny McCarthy must be so proud

I was talking with a client who’s in the medical world about this. “Those people are insane and idiotic. Not vaccinating your kid is lunacy.” To some degree, that person is of course correct. But at this point my response to these things, and what I said to this person was, “True. But think about it. Someone like Jenny McCarthy, a person whose only scientific achievement is confirmation of what men are attracted to, is WINNING scientific arguments. She is getting people to follow her advice amongst all rationale, all data, all common sense.”

I’m not exactly sure what it is, but the scientific community has to figure out what the hell these people are doing and use it themselves. The smartest people our society has to offer are losing debates about their own fields from playboy models and random, fear-mongering parents.

Robert Sapolsky has an essay geared towards this called “Anecdotalism” (here).

“But the scientific concept that I’ve chosen is one that is useful simply because it isn’t a scientific concept, can be the antithesis of — “anecdotalism.” Every good journalist knows its power — start an article with statistics about foreclosure rates or feature a family victimized by some bank? No brainer. Display maps showing the magnitudes of refugees flowing out of Darfur or the face of one starving orphan in a camp? Obvious choice. Galvanize the readership.

So maybe when I say argue for “anecdotalism” going into everyone’s cognitive toolkit, I am really arguing for two things to be incorporated — a) appreciation of how distortive it can be, and b) recognition, in a salute to the work of people like Tversky and Kahnemann, of its magnetic pull, its cognitive satisfaction. As a social primate complete with a region of the cortex specialized for face recognition, the individual face — whether literal or metaphorical — has a special power. But unappealing, unintuitive patterns of statistics and variation generally teach us much more.”

Maybe that’s part of the answer? Could be some answers in here too:

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Many Americans don’t realize they’re overweight

From here:

“These data highlight the importance of perception in the battle to fight obesity in the U.S.,” Gallup officials said. “This discrepancy may suggest that addressing the obesity crisis in America must first start by convincing overweight Americans that they are indeed overweight.”

I thought this was an illuminating quote as it’s important to realize normal is relative. Which is actually why I don’t agree with the latter part of this quote. There was a time, say ~30 years ago, where when a person was overweight, they knew it. You stood out in a much more significant way. That still didn’t stop people from gaining weight or help fight the obesity issue that has now befallen us.

Getting people to lose weight has a hell of lot more to it than convincing people they’re overweight. Plenty of people who know they’re overweight still have trouble losing it. Plenty of people have doctors tell them explicitly, “You need to lose weight,” only for nothing to happen. I’m not sure focusing effort here is worth it.

In Gawande’s discussion I embedded above, he has some comments about the difficulty in getting people to properly take their medication. Where much of the solution has been a social support system. Having a nurse regularly check in, house visits, phone calls, and more. He discusses how effective these measures have been, and how much they decrease costs in the long run.

I think this is more of where the solution lays. Adherence can’t only be a client / patient issue. These populations need a different level of help. Twenty minute office visits every 6-12 months aren’t the answer.

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