Sleep Apnea

This is a new idea for me.

My wife pointed out to me that I sometimes gasped for air during the night. so out of curiosity, I scheduled a sleep study at a local sleep diagnostic center. It was quite an ordeal. 26 electrodes attached to my head, chest, legs finger etc caused me to believe that I would not be able to sleep at all. But in spite of being wired like a guinea pig, I managed to fall asleep and what a surprise!

I learned that I suffer about 14 episodes per hour of sleep apnea where I literally stop breathing for up to 10 seconds! In addition, I learned that I get very little REM Sleep, and the REM sleep I get is very disturbed , and I learned that my blood oxygen saturation levels drop from 95% saturation to 85% saturation.

This probably explains the HUGE cup of coffee I tend to drink in the mornings and my tendency to be a "slow starter" only becoming fully awake by 10:00 am. I can honestly say that for about the last 10 years, I have felt like taking a nap every day.

The following week, I went back to the sleep diagnostic center and repeated the test, but this time with a CPAP (continuous positive air pressure) device, and to my complete amazement, the sleep apnea was cured, the snoring silent, the oxygen saturation level normalized, the breathing regulated and the REM sleep deep and prolonged, completely normal. The result, I am a completely different human being, rested, alert, and able to exercise with greater intensity duration and output. According to my calculations, I demonstrated a 6% increase in my output during exercise the first week.

I learned that 60% of adults suffer sleep apnea, that it can be dangerous (stroke or heart attack are possible) and that it is potentially is a marriage saver since my snoring has literally completely stopped. Wow!

If you wake up tired, feel like you need a nap every day, suffer from snoring, or if you are observed gasping for air at night, check it out...this could be really important for you.

Suggestions for Home Gym

Lets say you have under $1000 and you want a full home gym that will keep you totally fit, a big-bang-for-your-buck gym so to speak.

In framing my thoughts I am thinking of tools that allow you to exercise aerobically and anaerobically to build your aerobic conditioning, to perform power training, strength training and core training.

Tool number 1: The Kettle Bell Figure $75 max
For men the 35# kettle bell, for women, the 20# or 25# kettle bell.

The range of exercises you can do with this tool impact your overall strength of legs, shoulders and core profoundly.



Tool number 2: The TRX Allow $200 max

• This exercise is wonderful for core strength and offers several excellent upper body and lower body isolation activities.

Tool number 3: A 40# punching bag - Allow $150 to get the bag, the gloves and the tools to hang it.

You can do any number of punching drills - it is an excellent tool to help generate rotational power.

Tool number 4: The X-iser Stepper - Allow $400
This wonderful tool allow you to perform short bout high intensity exercise as well as core, hamstrings, gluts, shoulders, and calf muscles. This is an excellent tool that emphasizes short bout high intensity exercise for type two muscle development



Finally, tool number 5: The Concept 2 ERG - Allow $900
I include this because it is a great inexpensive total body tool that allows wonderful fitness development. Matching this with a kettle bell for instance, will give you an outstanding home gym.



Ultimately, the best exercise there is is the one you actually do. But these are the best tools I have found for overall body conditioning that are both effective and efficient as well as inexpensive.


Neil

Hip Pain Due To Trochanteric Bursitis

I am often treating distance runners with complaints of hip pain that leads to an active Trochanteric Bursitis.

First the anatomy: The bursae live under the Iliotibial band and over the Greater Trochanter. You can see in the illustration that the Gluteal muscles insert into the hip and iliotibial band. The role of the Bursae is to act as a lubricator for motion of the ITB (iliotibial band) over the boney prominence of the hip so that there is no deterioration of the ITB during motion.

The ITB is the cause of bursitis in my opinion. Typically, a shortened ITB increases the stress of the bursae and with repetitive tasks, like distance running, the bursae can become inflamed. This is what is referred to as Trochanteric Bursitis.

The Iliotibial Band Syndrome is a companion to Trochanteric Bursitis, and we often see them hand in glove. While ITB syndrome typicall causes pain in the ITB and at the knee, a tight ITB leads to increased pressure on the bursa and often causes it to become inflamed.

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It is easy to see the relationship between the hip and the ITB in this illustration which demonstrates the typical sight of pain at the knee in the case of ITB syndrome.

But even if you do not have a true ITB syndrome, you most probably have a tight ITB that causes excessive friction over the bursae leading to trochanteric bursitis.

We treat the bursitis as follows:

• Ultrasound over the bursae to increase circulation around the bursae
• Occasionally, with a prescription we might employ phonophoresis or iontophoresis - both cortisone delivery mechanisms - to help reduce inflammation.
  
• Ultrasound over the tightened spots of the ITB to soften the ITB
• Myofascial release therapy over the ITB using one of our tools like The Stick for instance. The Stick is also very useful at home. See my earlier blog on the use of The Stick to understand how best to use it
• Ice and Electrical Stim over the bursae to reduce edema and pain
• Orthotics to improve the biomechanics
• Kinesio Tape to lift the skin up over the bursae
• Stretching of the ITB
• Strengthening of the Gluteal muscles
• Introduction of cross training strategies for distance runners (running, cycling an swimming are all unidirectional activities - you need to introduce true cross training - ie lateral and rotational activities.
• We also encourage outpatients to take NSAID's as prescribed - but at least at a therapeutic dose - and to discuss this with their doc if the dose prescribed is less than a therapeutic anti inflammatory dose
  

One consideration for runners is that the knee does not really straighten while running, so flexibility of the hamstrings and of the ITB are important to pay attention to in order to avoid both ITB Syndrome and Trochanteric Bursitis.

You can read more about biomechanics on our website

Recurrent Lower Back Pain

I am often asked about why mechanical lower back pain is recurrent. I have four related explanations that I think have validity. These are:

• The first is the tension between mobility and stability
• The second is the fact that muscle guarding leads to atrophy
• The third is mechanical with respect to disc behavior
• The fourth is deconditioning

Mobility vs Stability
The premise is that we stand on a stable foot with an ankle that moves, we have a stable knee and a hip that moves, our lumbo/pelvic region should be stable, our thoracic spine mobile, our shoulder girdle stable, our cervical spine mobile.

If you accept that premise, then the logical conclusion is that restriction somewhere leads to mobility somewhere else. A restricted hip, for example, can lead to lumbar break down as greater stresses are transferred to the structures of the lower back, especially the discs, during such activities as forward bending. Segmental hypermobility (excessive mobility in one motion segment) is very destructive to the soft tissues, especially the disc.

To treat the mobility/stability dysfunction, a good assessment needs to be followed up with a personalized exercise program to lengthen shortened tissues and strengthen weakened tissues. A good hamstring lengthening program will go a long way to decrease excessive forces across the lumbar spine.

Muscle Guarding
The deep para-spinal muscles such as Multifidus for example, are muscles that guard when the back causes one pain. The guarding, a localized tightness can extend as many as 5 levels up and 5 levels down in the lumbar spine. This is not a problem on its own, but the fact that guarding leads to atrophy of those same muscles, and the atrophy is a precursor to mechanical lower back pain especially in a segment that is hypermobile. The weakenss of the atrophied para-spinal muscles allows the component motion of sheer to occur which in turn causes local nerves to complain and pain to be experienced. Strengthening the para-spinal mucles is key to resolving segmental dysfunction. Muscle guarding and segmental dysfunction go hand in hand.

Mechanical Factors
The lumbar disc has an axis of rotation that is close to the front of the disc. This means that the posterior lateral corners of the disc are actually subjected to the greatest stress during rotation. This gradually leads to failure of the posterior lateral fibers of the disc and eventual disc herniation. Paying attnetion to one mechanical functions - ike facing what you are doing, avoiding combining bending with twisting and lfiting, avoiding prolonged static postures and so on is the best medicine.

Deconditioning
The simplest way to say this is that very few fit people have recurring mechanical lower back pain.

There it is. Much of this is then in your control. You can get in better shape , with special attention being paind to restrition and weakened areas (like the hamstrings on one hand and the core on the other), and the spinal rotators as well. And you can avoid lifting things that are awkward to lift, or use really goo dmechanics when you do sit around or have to do serious lifting.

Finally, don't forget to use ice....30 minutes of ice (ice and water in a plastic bag right on the skin) is a great way to manage pain long term. You will get up to two hours of relief, and possibly even eliminate pain altogether.

Congratulations President Obama!

The BIG Picture

Friends, I write this post to share with you something I am really excited about. I believe that we need to help each other as much as we can. I believe we need to do this on a global scale, and we need to do it now. Especially with the economy in such crisis. I watched the Obama Inauguration Kick Off today, and was again moved by our amazing capacity to reboot as a nation. Coming from South Africa as I do, I can share with you that around the world, people are watching and longing for a successful Obama Presidency, and an American economic recovery. Our fiscal health impacts everybody.

Well I am a huge fan of Micro Banking, first described by Professor Muhammad Yunus in his book Banker to the Poor, and I set as a goal to participate in micro banking as a contributor, fund raiser, lender as best as I could in my lifetime. I had hoped that once I retired from PT I would be able to help people, especially in the third world, self actualize. But with the world wide economy so dire, I felt that I needed to act now.

Well I recently discovered KIVA.org - an amazing organization that allows a person to donate $25.00 and once it is re-payed, loan it again and again and again indefinitely. KIVA has a process of bringing together viable entrepreneurs with potential lenders and in a few short years, KIVA has grown from 7 loans on their website to over $50,000,000 successfully loaned out, to now, with one loan a second being made, and over 16,752 lenders made a loan this week alone.

I am inviting you to join KIVA.org, and to make a small contribution to see how it works. If you are like some of my friends, you will find it an amazing way to contribute directly to someone in need with no overhead to speak of, all your contribution reaches the intended person. You can set up teams, like my team here. Or you can join a team (you are welcome to join my team if you like), or you can donate as an individual.

Please consider joining KIVA.org, make loans to people you select in the part of the world you select, at the rate of lending you select, and help a person achieve a happier life. In my humble opinion, doing so will help you feel good as well.

Thanks,

Neil

Why 6 Weeks to Return to Sport?

In a word, scar tissue formation.

Interestingly, the way the body deals with an injury is by forming scar tissue. We repair, and we do so with remarkable alacrity. The process of the scar both becoming stable and tolerant of tensile stress is pre-determined. Assuming everything goes well, there are very specific time lines.

• Between 0 and 4 days, there is no prepair per se', just bleeding
• Between 4 days and 15 days the construction of the "scaffolding of repair" takes place. This scaffolding is not tolerant of tension, but it gradually picks up strength
• By day 21, the scar achieves 15 percent of its final tensile strength. This is good because at three weeks loading is important to help organize the scar and make it as strong as possible - more of this later.
  
• By day 42, six weeks, the scar achieves about 40% of its final integrity, and there is much that one can do on a scar like that has achieved this level of tolerance without irritating the injury.
• And by day 90, the scar achieves 90# of its final integrity.
  

The process that the scar undergoes, building of a scar from the initial injury, is significantly impacted by the introduction of tension. The reason for this is that the cells that build scar, fibroblasts, have a pole like the earth has a pole, and with intermittent tension, the cells align themselves parallel to the lines of stress, and the scar tissue fibers they lay down are also placed parrallell to the lines of stress. This leads to a stronger and healthier scar that is tolerant of stress as those fibers bond with adjacent fibers.

Why Use a Stick

The Stick is a wonderful tool that we use here in the clinic almost every day and on almost every patient. we actually sell them here, but you can also buy them at their website too.

We use The Stick two ways:
- To smooth out dense connective tissue thickenings and
- to treat "trigger points" in the muscle.

Trigger points were first identified by Janet Travell, MD, President Kennedy's physician. These are microscopic areas of inflammation in the muscle tissue that lead to local muscle fiber contraction. Trigger points are palpable, painful and they interfere with normal muscle function. The Stick is used to treat these trigger points in a "seek and destroy" fashion. Yes its painful! The key is to find the trigger point, press hard and maintain the pressure as long as you can to let the trigger point resolve. You should find an immediate increase in flexibility of the muscle. Allow a day or two to pass before you do it again.

The other way we use The Stick is to "brush" the dense connective tissue. we do this by rolling gently, but deep enough to affect change in the way the tissue feels. It is not so much a trigger point level of pressure, but rather the rolling can be a before or an after exercise activity. My athletic patients who use the stick find this to be a very worthwhile process.

My theory is that the benefit of The Stick accrues because local dense connective tissue trauma produces local dense connective tissue scarring. That local scarring produces a local thickening of the tissue, that in turn interferes with normal function, ie elasticity, of the tissue. Using The Stick over time leads to a softening of those local scars, and allows the normalization of the elastic properties of the dense connective tissues. In turn, muscles can cantract and develop tension normally, and the overall function of the part improves perceptibly.

There you have it.

Again, if you would like a Stick, we carry a couple of them for sale.

Whats your "Real Age"?

Each year about this time, I wonder what my real age is - as opposed to my chronological age. I saw a banner ad on the internet today that said "Barack Obama's real age is 42, Whats yours?" and it reminded me of the website Real Age.

I am 49, and after checking my data, the website concluded that my real age is 44.8 - Not bad, but I am on a mission to improve my health status and get my real age down even lower. The website reminded me to take my vitamins, and hang our with friends. I also noted that pets reduce your real age (could it be the unconditional love?) as does exercise and diet.

My exercise program at the moment is basically heavy weights plus interval training five days a week and one day a week of a long walk (2 hours) with my wife and dog, one day off.

Why interval training? Because the data is crystal clear on this point. Short bout high intensity training is significantly more effective at lipolysis (breaking down stored fat), it improves plasma glutamine, increases Human Growth Hormone levels, and increases Type II muscle mass- the power fibers.

In two short weeks I have noticed that I sleep better, I am leaner, I eat with more consciousness, and my stress levels are reduced. On the whole, I feel better so far.

If you have questions about your exercise program, feel free to drop me a line. In the meantime, check out Real Age and find out how you can improve your health status.

How Aggressive Should Physical Therapy Be?

Muscles need to be pushed to grow and become healthy. One overlying principle that there is in my world view is that Type II muscle selectively atrophies. Another way to say that is "use it or lose it". The reason a 40 year old man looks so different than an 18 year old is that the 18 year old engages in activities that stimulate the production of Type II muscle (fast twitch fibers) whereas the 40 year old typically engages in activities that are more endurance oriented, and which only stimulate Type I muscles, the endurance fibers. Another aspect to this consideration is that Type I fibers adapt to exercise levels, implying that at a steady state, the Type I fibers no longer mature and grow.

In a nutshell, what this means to me is that first of all, for rehabilitation to be complete, both Type I and Type II muscles need to be stimulated. So exercise needs to include short bout high intensity activities for that specific purpose.

Now that said, given that I believe that PT is a three tier process, Phase 1. Get you out of trouble, Phase 2. Make you strong and durable, and Phase 3. Make you bulletproof, the short bout high intensity component of the rehabilitation process is best timed to coincide with late Phase 2 and all of Phase 3 activities. In fact we use the ability of a patient to execute short bout high intensity activities to signify the end of their rehabilitation and the start of their return to training. In the case of athletes, they can return to practice at this point, and still yet increase their match fitness to be able to return to competition safely.

We keep statistics in our office, and our data shows us that our average number of visits in our center is 9 per patient. We see people 2x per week, and so we usually see people for about 6 weeks, more or less. Now this is just an average and of course we see people longer and more often if the situation calls for it. For example, our Work Conditioning Program participants are in our facility daily for 6-8 weeks, and we often see athletes who need just one or two visits. But if you figure that we see people over about an 8 week period, it is in that time frame that we move from Phase 1 to Phase 3, and if that is to be the case, then PT needs to be aggressive.

This means that as a patient you would need to work pretty hard to resolve your issues in that short time frame.

That means we have to have you working on restoring your foundational movement patterns, building your functional (especially core) strength, and rebuilding your lost Type II muscle mass in that brief period of time.

The only way that happens in that time frame is with sweat and post exercise muscle soreness. Post exercise muscle soreness in this case is NOT pain (ie, irritated joints, tendons, discs etc).

In the event that you are interested in reading more, you can visit our website where I go into more detail about PT at Sports Reaction Center.