Sunday, January 18, 2015

Hormones like a teenager

In my prime-I was a muscle head.  Lived in Wildwood New Jersey.  Had 3 roommates (1 bartender and 2 bouncers).  Worked out at Atilis Gym in 1982, that summer the gym owners asked me to compete in a Mr East Coast and Mr Natural New Jersey.  I was 18 and didn't give a sh*t so I joined and won both (teenage divisions).  I lifted weights with some Venice beach-like-male-airheads and refined my "Muscle and Fitness magazine" body building movements.  (Joe Weider's publication was a bible back then)


I seemed to develop a lot of muscle mass with what I was taught so I took it with me to college and later.  I believe when we adapt a "routine" that: works, doesn't cause injury and gives size gains.....that becomes religion for the remainder of our exercise lives (at least for guys).  The lucky ones can still continue with the "usual" exercises no matter what age (maybe tailoring the routine to help with weight gain).  The not so lucky end up in physical therapy for some age related ache and are given a 3-6 week sentence with a physical therapist.  From that point on, free time limitations and achey reminders keep the "new routine" fresh.    

I stumbled upon alternative and complementary therapies when I tried to avoid rotator cuff surgery from a rock climbing injury in my 40's.  I did my own rehab and kept it to bare essential movements to maximize time in the gym and still get a "pump".  (can't let go of the feeling to muscle fiber with targeted movements with weights!!)  I beat the knife but it took a few years; I also dived into marathon running, yoga and more recently hiking.  Still can't stay away from trying to chisel a little muscle definition-so I have been doing this truncated weight/cardio work out (called peripheral heart action or circuit weight training before there was cross fit) guys do and getting by to work the heart and keep fit.

I started a new chapter in my life by signing a contract to go back to running a primary care office like I did in the 90's.  (worked in family medicine and carved a niche with my sports medicine clinic in Wheaton).  This week I decided to go back to using cables to work my shoulders.   [In a gym there are free weights, Nautilus-type machines to isolate body parts, universal cable machines for some restricted movement then Smith Machines for universal bars and big plates (wagon wheels).  So there I was.....pushing the envelope with repetitions, grunting from pain (had my bluetooth headsets on) and since it was empty-running between 3 stations back to back like a college crew teams would do.  As I finish my last of 3 giant sets, I feel a great pump to delts and traps....no ache...good heart rate....well targeted and I'm done!!  It just hit me, I was so used to the bare basics of quick power lifting movements that I forgot my old techniques of fine muscle tuning.  The feeling brought me right back to days at the gym in Wildwood NJ!!  Then I look up and see:





LOL!!!!

Saturday, March 29, 2014

Lose weight; change your life; don't get hurt.



Spring is here and most people are scrambling to start dieting.  If you are like everyone else playing catch up, don't expect to do things the same way this year.  The 2014 snow season kept most runners in, most drivers delayed, most exercisers bundled up.  The usual dietary reflex in the deepest cold is to seek nutrient dense comfort foods.  In other words, the bears are coming out of the den with an extra padding of fat this year.  It just so happens  there are also 2 drugs that are building up steam as part of the "cheat-code" for initiating weight loss.  Qsymia and Belviq were released in mid to late 2013 (and so far no deaths!!).  Of course the most important impact anyone can have to lasting weight control is total lifestyle change.
I maintain my patients seek to address 3 components of life:

Thinking
Eating
Activity

The eating part everyone says "I know what to do, I just have to do it".  I disagree 100%!!!  If adopting a nutritional change was as easy as shopping the periphery of the grocery and choosing labels of low fat, our nation would be lean and healthy.  The World Health Organization published a controversial ranking of health throughout the world in 2000 and the US was 37th out of 190 countries (but we spent the most money per person in the world).  Seems out of proportion but just look at the check out line and notice how many people look overweight (1 in 3).  I just came back from an indoor water park and it was disappointing to see out of shape kids (waiting a few minutes I would see the inspirational out of shape parent float by) but then I thought this was job security for me.  However I refuse to just prescribe medicines and watch people become behaviorally addicted to weight loss drugs.  Anyone that goes to see me out of network knows if you want meds like phentermine, I must hear from your team of coaches to make sure I agree you are a "responsible adult".  When I hear the catch phrase above, it usually leads my brain to image how this person will look in 10 years.  (It's always the same-10 pounds heavier with 3 new medicines and 1 new surgical disease diagnostic procedure).  It takes more than just reading a few chapters from an author and experiencing 10 pounds of fat burning in 2 weeks back in college days to say you know what works for you.  In my short 20+ years of medicine, I have learned that community can overcome disease but disease can overcome the individual.  We have all the answers on how humans work (down the the DNA sequence) but a patient requires the knowledge to be applied in an individual designed lifestyle plan.  There is alot of great reproducible evidence out there (pubmed, google scholar) but I find myself "piece mealing" snippets of plans together to initiate, modify and maintain the routines people come in to see me for.  And it usually has to be reformulated in stages.  The "giving spirit" in me tries to keep people from spending their hard earned money on me and rather on nutrition, exercise and meditation coaches.  Infallibly, the plan works for a while but has to be reformulated as the goal was achieved and the next pinnacle has to be planned. I guess this is where most people throw the towel in, they hit a plateau, don't see further gains and just regress back to previous life/weight with disappointment.  So they tasted victory but lost the focus to maintain it, and the picture of summiting Mt Everest sticks in the memory more so than the pain of losing all your fingers and toes.

"I know what to do".   I believe most people with guidance can daisy chain small bursts of change to ultimately get to a goal that is healthy and rewarding.  It takes the right tweek from the right specialist to hit the next pinnacle.  I dont mean a medical specialist, this is more of a makeover specialist-the specific trained coach that can overcome the specific obstacle we run into.  (...could be flexibility, nutrition, self esteem, spouse issues, injury, food allergy....we are multifaceted and complex and problem solving requires a community of healers).  Currently, my best vaccine for the disease of weight gain is listening.  I don't mean you sit on a couch and regurgitate all frustrations to me-that would be a waste of my time and your money. Quid pro quo interviewing is the best way to get me started in creating a template for change.  Unfortunately this takes an average of 60-90 minutes for me while medical insurance has been chipping away at the proverbial office visit (13 minutes total to break even).  Those basic areas of change do require some trust.  When people say they know what to do - I translate that to mean they are not willing to change.  Experimentation is hard because it requires a step into the unknown but if I can summon the help of Jim Fixx, Linus Pauling, Atkins, Benson, Ornish, Weil, Chopra......there will be a wealth of knowledge to help catch you when you fall; (everyone falls!!)

When I hear "I know I need help", the creativity of my right brain takes the logic from my left brain a beautiful painting is created.  

To experience the Saguil Approach to lifestyle change, sign up for the April lecture at Advocate Sherman Hospital in Elgin (Randall Rd and 90)  Link to Event Tickets

Saturday, January 11, 2014

Back pain from Shoveling



The last 10 days has been a massive winter "dump".  The snow fall seems un-ending and I have been getting alot of great outdoor time.  I love the clean look of a driveway after shoveling but hate that one crack in the sidewalk that catches my shovel tip just as I am going full speed with a big avalanche.  Well I also noted when my fingertips were painful, throbbing, I didn't realize my back was telling me "take a break!!!".  My mind was saying oh, just finish the last part of your driveway and it will stay dry magically forever.  Pain is usually delayed like whiplash....the next morning as the eyes open and the first step of the day is met with "whoa....did I sleep wrong?....oh....I shoveled yesterday!"  Then the realization is that it's still snowing so you have to do it again.
Muscle spasm if the activity is aggressive and blunt, will be felt accordingly at the time.  If activity is long and repetitive, the pain and inflammation is delayed up to 2-3 days.  It doesn't have to be an ache in one spot, pain can be a flare up of an old pinched nerve/bulging disc type pain.
The way the back is made is skin to outer layer, muscle covering (epimysium), muscle, fascia and bone.  The muscle is built to contract repetitively for life (think of the heart that beats every second for your entire life)  The problem our back muscles come into is the brain gets "superman strength" when reasoning about taking a break vs getting the job done now and going onto another chore.  With fatigue the muscle can still be stimulated to contract and do the job but lactic acid will accumulate, energy (ATP) will be used up, and some tendon fibers will tear (microscopically) and imbibe blood/edema slowly (versus a skin cut where blood comes out fast).  With a slow leak throughout broad low back muscle, swelling and stiffness will occur after about 12-24 hours.  Usually felt next morning.....same concept as whip lash.  With my previous post on whip last, there can always be pinched nerves, broken back bones, herniated discs....but those are usually sudden onset.  (only way to tell is to see a professional)
My best advise is to
1-do no further harm, lay off further shoveling, no exercise for 3 days, take brakes if you have a sitting job.
2-start with antiinflammatories immediately, that could be supplements like turmeric/magnesium, topicals like helicrysium/capsaisin/wintergreen, or prescription medicines/muscle relaxers/NSAIDS/narcotic pain relief.
3-get hands on healing, your choice of chiropractor, massage therapist, physical therapist, a relative with strong hands
4-raise the flag and see an MD/DO if urine or bowel incontinence occurs, pain doesn't allow sleep, numbness or tingling start, cant get out of bed, symptoms longer than 3 days

Tuesday, December 10, 2013

Shoulder Pain

I turned 40 in 2002 and as I approached that age, I was involved with a lot of x-games sports.  I remember rock climbing and attempting a "dyno".  (this is when you grab onto the ledges, pump up and down building up momentum and launch up to grab a hand hold somewhere above you .....Tom Cruise in MI 1) and missed.  It resulted in a year of not being able to bench press, lift overhead, and catching of my shoulder with any movement.  Some of my old patients may remember when I was working with a huge ice pack on my shoulder for 3 weeks.  I had seen my physical therapist who specialized in throwers, I took some of the best prescription medicines available, even got ready for arthroscopic surgery after the 6th month of not being able to exercise.

At that point, I had stumbled on alternative healing.  While an employee of CDH, one of the stipulations in my contract was to have my CMEpaid for, I chose a seminar in California with some guy that was teaching acupuncture to pain medicine doctors.  I planned on signing my name on the roster, blowing off the lecture and hanging out at the beach.  The keynote was made by Dr Joesph Helms and I remember sitting in the front row in a room of 800 doctors and with my long hair (midlife crisis) challenging him with questions on acupuncture in sports medicine, acupuncture in pediatrics, acupuncture for medical diseases.  But this guy nailed all my questions with very intelligent answers!  Then when he asked for a volunteer, I gave him my body (very skeptical and anxious to get to the beach).  Remember my shoulder was still painful and limited with range of motion from the rock climbing injury earlier in the year.  He place 3 needles into my shoulder and within 10 minutes, I had pain free, range of motion just like my pre-injury state!   I was sold on this weird 2500 year old concept of healing.  Thus began my journey into alternative and complementary medicine.
Note that I still had to do my rotator cuff exercises, my scapular stability exercises, take glucosamine sulfate, and have acupuncture 2-3 times a week for a few months.....but I avoided surgery and now have regained full range, better strength than before and can do hand stands in yoga at 51 years of age.  (the acupuncture isnt just a passive treatment, it helps the body heal so anyone with injury or disease still has to put in the sweat equity and maintain the building blocks to health and healing (see my Anti-inflammatory Lifestyle video here).

Sunday, May 26, 2013

Tight Hips

Had a new guy start in my Meditative Yoga class at Northwest Community Hospital Wellness Center.  Spotted the usual difficulty with keeping still during opening breath work in Sukasana (sitting crosslegged).  Figured either anxiety sufferer or leg problems.  He came up after and turned out to have a hip problem.  Guys usually have big muscles and poor flexibility.  The short-cut in figuring which machines to use or barbell movements to rely on is do what is most popular in the mags or just go down the machine line and hit one body part at a time.  Problem with applying general body region movements or machines is you have to be in posession of an "average" body.  In my sports medicine clinic, even between twins I find differences in knee alignment, foot arches, posture, muscular thickness, pain tolerance.  So applying general guidlines to and individual person is a formula for failure due to non-sustainability. 

What also is a "curve ball" in developing a personal exercise/movement routine=what are the end goals.  Cross training for running, shoulder development for looks, bounding height for dunking, flexibility for mixed martial arts, power for contact sports.....this is where it is so important to get a "second opinion" on applying an exerciser routine to your life.  I don't mean with a sportsmedicine doc, I highly value to ingenuity of exercise physiologists in figuring risks, strengths to embrace, weaknesses to address and lifestyles that would limit a long term sustainable life change.  So this is where my tight hip/50+ year old yoga student has entered into the "melee" of personal fitness programs.  For the short 8 weeks of having him come for guidance, I can at least help him in planning a continued exercise/overload program.  If we can use 3 easy poses of yoga as a staple or preexercise warm up, over time he should be able to gain progressive lengthening to a very contracted hip capsule.  Keep up with the basics no matter how deep he gets into other sports/activities and one day he'll have the flexibility of a highschool gymnast. 

Problem with hips is most americans view the groin and hips as very private.  The figurative concept of hiding from sight always translates to physiologic function.  Although a painful image, think of a sexually abused kid dreading the gyne office PAP smear when she gets into her 30's.  The psychology of injury always limits the form and function.  One of the reasons I save hip poses for the end of class is for the first 45 minutes, I not only get students to warm up body temperature but they also have worked on breath and relaxation so any psychological worries are not as distracting compared to before class.  If all distractions (I mean psychological ones like "my hip is about to break" or "feels like the muscle is going to tear" or "shoulder is about to come out!") are calmly removed from the forefront of one's attention, it will usually be able to apply exercise/overload.  Getting to the point where the hip is tight in the movement but not terribly painful....then holding at that point, concentrating on breath, and when guided-slowing coming out of the pose with control.  When I was captain for my school Track and Field team, I would lead warm up and remember bouncing the joint in the 1980's to provide warm up, flexibility, and stretching-usually on cold ground!.  (How wrong I was!!!)  The slow entrance into range of motion, gradual addition of torque and length, and relaxed breath will usually convince the muscle group to release it's contracted state after minutes.  Some will note after a long hold the sudden realization that the knee is now touching the floor in pigeon pose or the forehead is on the knees in forward fold.  (Others it takes a few months)

Here is a video link to a few poses that I showed my student and helped him to adapt (via use of yoga blocks and blankets) for daily repetition/ritual. 



Of note is it took me 2 years to attain pigeon pose equal on both right and left.  I suffered a hamstring tear going around the back stretch 110yards in a 440yard medley for state championship and coach said he heard a pop from across the field.  Cost the team 1st place and always held that in the back of my mind (and the back of my hip)...and that was 1979!

Saturday, May 4, 2013

Mommy Wrist



Something about the having a baby is just beautiful, ask any mom.  Then there's the fragmented sleep, weight gain, transition back to running a house and working......and wrist problems.  Carpal Tunnel has been so published/talked about in the last 20 years that anyone will be able to figure out if their symptoms are similar and find conservative treatment to start online. 

I had a patient come in referred by ob/gyn.  Second time around mom with wrist pain that was "different".  Started about 6th week after leaving the birthing center and has been persistent since.  Mom is now 3 months out and suffering.   Tried to use the brace from walgreens for carpal tunnel with no help.  Pain grabs her with certain movements and now is interfering with sleep.  No history of this before and no trauma.  Still breast feeding but planning to wean off and return to work in about a month.  (Incentive to get the wrist pain resolved since she uses a computer 8 hours a day)

There are a few things I watch out for in anyone complaining about joint pain.  First is always broken bone or tumor.  Luckily with the wrist, small joint, easy to evaluate.  Then I think in mechanical terms and locate the area of pain/dysfunction.  Finally look above, below and referred.  In rare cases the pain will come from soft tissue like infection, other tissue, blood vessel or metabolic problems.  If I can't find a good solution or patient has tried everything, time to add traditional chinese medicine  and break out the needles to "move stuck energy" until conventional modalities start to work. 

If the pain is evaluated early, usually history gives the diagnosis (physical exam and testing backs up the dx).  If the pain has been "lived with" for a long time, the presentation can be different as the average person will compensate and may not remember the new symptoms vs the old symptoms.  Detective work ensues (experience and listening) and chipping away at confusing red herrings starts until the true problem reveals itself.

In this case, I ruled out scaphoid fracture (very important bone in the wrist that if ignored, leads to chronic disability) and went straight for the gusto-finkelsteins test.  BINGO! reproduced pain exactly.  This is notorius for moms as they reach to pick up 3-4month old (baby has good head stability by then) and lift up play face to face.  Gave a specific splint for thumb immobilization, advil (only antiinflammatory ok with breast feeding moms).  Also suggested facilitating healing with diet control (no dairy or wheat), turmeric and magnesium (ok with baby) topical treatment (helicrysium, tea tree, traumeel, ice massage) and acupuncture as back up if not better in 3 weeks.   If all else fails, steroid injection into the sheath of the tendon will help, and shouldnt effect breast mild production.  By then occupational/physical therapy will problably be necessary. 

Tuesday, January 15, 2013

ACL's




So RG3 is scheduled to get into sprint and cut mode by fall 2013.  When I did my sports medicine fellowship with DePaul in '95 I remember Preston Wolin showing some of his slides (no PowerPoint back then) on acl basketball players jamming from the foul line within 4 months post surgery!  I also remember the gasps coming from the other docs at the conference.  It seems like we push the envelope on getting people back into the damaging activity they were initially injured in.  Why is this?  To get more viewers? To be seen in your 4th year of athletic scholarship during March Madness?  To win for the team?  Nothing else to do?

Problem is we treat the ligament and do nothing for the person.  Just cause you have a full boat scholarship doesnt mean you eat all organic, get quiet time to maximize healing, get good rest to recharge the brain, or dive into community love.  Wouldn't you say the best chances for healing in cancer (the Emperor of all Maladies) is with medicine/surgery and all the above?  So what is the difference with surgery for an acl and healing.  In the last 20 years the materials used for acl repair have gone from mesh to cadaver to same side patellar tendon/opposite side patellar tendon to triple twisted hamstring.   Regardless of which one, the longevity is overall about the same and results are more dependant on the health of the surgical candidate.  (Put a million dollar graft in an obese, diabetic smoker and results will be poor/put a cheap piece of fiber in a fine tuned 20 year old and s/he will be performing 80% on a single leg hop within 3 months.) 

So for the sake of this blog; things to improve outcome. 

-You must know the ins and outs of your surgical issue and all the newest controversy.  And don't just rely on Joe Mercola's website for information.....research acsm, google scholar, pubmed, nih to name a few places. 
-Never stay with a rude surgeon no matter how good his reputation is.  Some surgeons have "peculiar personalities" like to debate/name things after themselves/be captain of the ship....just kidding-many good friends are surgeons. (I also know of some big assholes that shouldn't be practicing medicine) First and foremost-a patient has to be his/her own advocate so know your rights and trust your gut. 
-Most of the major sports teams have medical groups that pay to be the team docs.  Yes they contribute indirectly to the sports franchise to be the guy.  Not in kickbacks or financial incentive.....more like locker time, trainer training, "free coverage".  So it depends on how good your results are, who you know on the board, and how much you can "give" of your time/staff.   So if in a strange city (ie Colorado with an acl skiing injury) ask for the "pod" that works for a major sports team) Pod = orthopod for short but its like calling a police officer a cop.
-Always go to primary care to make sure you are maximized to heal.  This doesn't mean get a family practice guy to sign off that you are ok for anesthesia.  (I have always though this presurgery physical is a waste of time.....only thing I use it for it when I remind my surgical candidates that they have to lose weight, see a therapist, lower cholesterol or work to get off their medicines.)  This means having a professional nit pick your sleep, nutrition, look for vitamin deficiency, get you into "prehabilitation" so you don't go into surgery with poor exercise tolerance, endurance, stamina, strength.  Post surgery outcome can be improved if you fix the thyroid, improve the IBS, work on the food allergies or beef up the depression.  You do want to start healing asap right?-why not prior to surgery.  There are prolotherapy techniques that are only done by a few docs (I've been using Ross Hauser in Oak Park since the 90's) and now PRP, to mention one type, is catching on with orthopedic surgeons to facilitate healing.  (essentially using natural healing products to speed the body to rebuild-that Hippocrates guy knew what he was talking about!!!)  For the low grade acl tears/strains that the surgeon wont cut on, definitely worth prolotherapy but little expensive and not covered by insurance.  Better than just watching it and using the ol' Donjoy  "derotation" brace.  I had a football coach for Holy____ High School every game lay down on the field and say he needs a second to get his knee back into place.  He had an acl tear that was unstable, was told to just watch it by his orthopod, but wasnt told every time it gave out, there was an 80% chance of tearing a meniscus/cartilage.  At this point he probalby has already gone through total knee replacement....nice advice from his doc.  (I told you there are some docs that shouldn't be practicing medicine.  A license to practice medicine and no concept of healing is like allowing the mentally unstable gun permits.)
-Get a good Chinese medicine trained acupuncturist to help with the healing process.  As long as you don't use the chinese oral herbs, no need to ask the surgeon.  If needles aren't placed within 6inches of the surgical site....cannot blame the acupuncturist for anything.   And the surgeon wont know anything about acupuncture and will just say don't do it.  I was at a ACSM conference with the biggest pods in the country and a question came up, if NASCAR drivers with back pain would benefit from acupuncture (heat usually comes right up the seat in the car) and a pod immediately said there was one study that said acupuncture doesnt work.  (Kiss my sit bones dude, not reading the right papers!!!)  Of course all the young up and coming resident/docs were writing in their notepads..."acupuncture doesnt work".  Of course if needling speeds up recovery, it is the surgeons skills that did it!
-Pain control is to be coordinated with the primary care guy (if s/he is good with botanicals) or the naturopath.  There are great botanicals that help with pain, decrease the dose of prescription narcotics, and don't interfere with healing.  In fact there are great homeopathic meds that speed up healing not too mention aromatherapy (I love the essential oil-helicrysium....helped me get through 2 marathons with no pre marathon training!)
-Nutrition and food technology is growing by the minute so the old concepts of eating what ever tastes good can slow down and hurt your chances for fast healing.   Enlist the help of a registered dietitian.  What you are eating, when you are eating it, what supplements you take could be archaic.  Why not give what every cell in your body needs to work DNA.....and no, Hooters Organic Chicken is not healing (maybe to the eye). 
-I am a yoga instructor as well as a sports medicine doc so I always embrace the mind body medicine power of facilitating healing.  Even if you dont meditate 30 minutes twice a day, visualization helps prior to and after surgery.  I have a tutorial on how to improve outcome when "stuck" in a hospital ICU or orthopedic floor.....click the link I have great confidence in hypnotherapy especially in athletes! Steven Gurgevich from The Arizona Center for Integrative Medicine at University of Arizona is fantastic!
-God forbid....I know some athletes who stack roids....if you are on anything.  Let someone know, don't just detox cold, get primary to check your liver/kidney/adrenals and "T".  Need to maximize every organ in your body if you plan on asking the entire body to heal fast.   Unless you are a steroid free proathlete (Lance has done some great things for cancer survivors but I wonder if roid use prompted testicular cancer?)  Pro athletes are gifted humans....there was an EKG strip circulating around the primary care sports medicine community before Jordan was Jordan.  His preparticipation stress tests showed a resting heart rate of 40!!!  (as a reference, check your pulse rate now....probaly 80 right....imagine Michael Jordan's body was working off season at half the effort your body goes through in an average day).  Pros would probably heal up quick even with a bad diet!!!

See you next season!