Check your pulse

While warming up for my boxing class at Contender Boxing and Fitness, I watched Mike take some "non-fighters" through a cardio class. He was working them very hard and there was some sweat flowing in the gym! Obviously these guys were in good condition but I asked Mike if they monitor pulses. I said it would be a good idea for people to know how to do this. It's a standard that is easy, cheap and a good "barometer" to let the patient, client and the trainer know exactly how much this person is working his or her heart. Some people have a good will and don't want to give up even if the heart is working a little too much. For an untrained or nonconditioned new athlete, this could be a problem especially with the older than 40 crowd.

The American Heart Association suggests:

Age/ Recommended HR/ Max HR

20 years/ 100–170beats per minute/ 200 beats per minute
25 years/ 98–166 beats per minute/ 195 beats per minute
30 years/ 95–162 beats per minute/ 190 beats per minute
35 years/ 93–157 beats per minute/ 185 beats per minute
40 years/ 90–153 beats per minute/ 180 beats per minute
45 years/ 88–149 beats per minute/ 175 beats per minute
50 years/ 85–145 beats per minute/ 170 beats per minute
55 years/ 83–140 beats per minute/ 165 beats per minute
60 years/ 80–136 beats per minute/ 160 beats per minute
65 years/ 78–132 beats per minute/ 155 beats per minute
70 years/ 75–128 beats per minute/ 150 beats per minute

Your maximum heart rate is about 220 minus your age. The figures above are averages, so use them as general guidelines.

I tell my patients to try and hit the lower number of the pulse range for 20 minutes of exercise checking every 5 minutes for about 12 trips to the gym. After that work up to add 20 beats per minute every 2 months (conservative) until you have reached the highest number of the recommended HR. If you can maintain this for 20 minutes 3 times a week, your heart will be fit. (assuming no other risks exist like breathing problems, seizures, diabetes, stroke...which should be evaluated and cleared first before starting an exercise program.)

I like the watches that check pulse but they are at a price. Personally, I use the Suunto T6. Others that are popular are the Polar, Citizen, Timex, Nike....it all depends on what other goodies you want with the pulse monitor, (distance, direction, gps, barometric pressure, software fitness analyzer). My goal is just conditioning, I'm 45 shooting for 160-170 for 20-30 minutes. This is over an above the recommended levels but I have also been cleared of any medical illness with stress testing, heart scans and cholesterol fractionation.

Good old fashioned finger pulse checks are cheapest, one work of caution is checking the neck pulses. There is a sensitive area in the neck called the carotid bulb. In some people, this could be very sensitive and cause a "vasovagal" reaction like that of a jiu jitsu lock. It may be a bigger artery to find but probably good to avoid in anyone over 40y/o.

Exercise Safe! Push it to the limit! Stay Healthy!

capsicum

There's a great topical drug that helps facilitate back pain control. We used to use it for Shingles (a form of viral herpes skin infections) which is very painful and sometimes leads to morphine sulfate use for control of pain. It's uses have been extended to standard pain issues. Many people will see it in the pharmacy next to the Icy Hot or Tiger Balm. Most folks pass right by it since packaging isn't eye catching. I've seen several great forms of capsaisin in the form of Zostrix cream (my personal favorite in the emergency room for people with back pain or neck pain) and salonpas adhesive patches (my personal favorite -most of my older relatives in the Philippines used to walk around with these pads stuck to them and before medical school I used to think of it a some form of voodoo). Any topical pain reliever is made to cause a sensation to the skin that will overpower normal sensation. Example, when a baby is given a cap/hat for the first time, kid usually pulls it off since it doesn't feel right. Soon after trying over and over again, the baby gets used to it. When applying zostrix to skin, it burns. It's a dull sensation but the feeling is like applying hot pepper to skin. Actually, the active ingredient is from hot peppers. The feeling is distracting to the person in pain and one of the methods of relief is to make them think about something else....well, hot pepper will make you do that!

The other relief in pain is more scientific and separates this component from the Icy Hots and Tiger Balms. RCT (randomized clinical trials) performed with capsicum the active ingredient in capsaisin cream, revealed it reduced the amount of Substance P to the area it's applied to. Substance P is a neurotransmitter found in pain fibers and when depleated, pain fibers don't fire to send messages of pain to the brain. Overall, pain sensation if reduced. Practical problem for the cream has always been accidentally applying too much or getting it in the eyes. One of the reasons I like the patches of Salonpas (walgreens) is you could cut as much of a size as you like and not get the hands greasy. Caution: there are salonpas patches at walgreens that don't have capsicum so read ingredients before you buy.

The place it comes from is the seed and little ribs found in red peppers. Different peppers have different ratings usually measured in Scoville heat units (SHU). This rating is usually talked about during the pepper eating contests of Texas. (some people have too much free time although I find myself attracted to watching this and hotdog eating contests while riding my stationary bike at Planet Fitness)

So far, I have not read any info on chronic use and becoming accomodated to it. There have been no other problems aside from people with allergies to peppers using it without reading ingredients. The Saguil Approach to proper use is to apply it 4 times a day and after achieving pain relief, work to stretch the triggered/spasmed muscle. Usually it will be painful at first like any stretch done properly. If continued on a regular basis, the stretch will lengthen muscle fiber and help overall to reduce pain and inoperability of the muscle causing the pain. More stretching leads to more blood flow to injured muscle and faster healing. Alone it may work for small spasms, for larger and more chronic areas, it would be an excellent adjunct to other therapies. Should always inform the massage therapist or physical therapist of it's use. I remember when doing my sports medicine fellowship, we used to comment on russian coaches spraying every injury they had with topical anesthetic and i would always laugh at the technique. Now that I am wiser-(herbally), they actually had a great technique overall in attempting to distract the athlete while ultimately stretching injured muscle. Now using it for a fracture .....not!

*Capsicum also comes in oral form....obviously since it is derived from pepper. But I think its best application it topically, as you will read from other posts, I prefer the use of turmeric, white willow bark boswelia for inflammation. In the future I will talk about arnica and tea tree oil.





(Altman RD et al, Semin Arthritis Rhean 1994, 23:25-33).

(Watson CPN et al Clin Ther 1993, 15:510-526)

(Diabetes Study Group, Diabetes Care 1992, 15: 159-165).

glucosamine sulfate

When I finished my sports medicine fellowship at DePaul University, I was doing the usual family practice thing in the office but then applying physical medicine to all patients. I was seeing a large number of knee pains especially during spring and summer. Many consults were from my partners and at that time they had a large number of older patients. With the multitude of medicines they were on already, I dedided to try something I read about in a journal. At the time glucosamine sulfate was just gaining momentum in the US. All the studies available were from Europe comparing glucosamine sulfate to naprosyn and ibuprofen in joint range of motion. Of course the results were equal if not better than the two medicines. With the lack of gastrointestinal side effects. I began asking patients to try 1500 mg daily of the supplement but there was no place to buy it aside from walgreens. Nothing against that chain (thats when they didnt have drive through) but I found only a small group had nice results. Usually it was the patient that went a step further and found a distributor that marketed their own brand. So quality was proving a better impact with knee pain patients that the quanitity driven chain stores.

Glucosamine sulfate studies were usually with chondroitin sulfate. The action was thought to be stimulation of that little cell called a chondroblast. These are the ones that build up the cartilage matrix when damage has occurred to the smooth moving surface of a joint. There were later studies in the US, a big one was teh GAIT study which said it didnt help compared to celebrex. Problem is that the study doesnt specify if the glucosamine was pharaceutical grade or off the "walgreens shelf" brand. They also only used glucosamine not g-sulfate or g-HCL. Well, my patients respond and no side effects to stomach ulcers, renal failure or heart disease like they do with celebrex.

The "Saguil Approach"= remember, glucosamine is a means to get to an end. I always combine it's use with a proper diet, an antiinflammatory diet and visits with a good physical therapist (that knows McConnell Taping-I believe she is an Austrailian therapist). One the patient and therapist develop better flexibility and Quad control and fix the "Q-angle" of the knee, should be able to decrease the supplement. Omega 3 fish oil is good as well as turmeric, ginger, boswelia, white willow bark (see previous posts) and cryotherapy.

Turmeric for sore muscles and joints

The active ingredient from the plant is curcumin. Many studies have been started on the healing properties of curcumin. It is thought to work as a cox2 inhibitor. Sooner or late, we will hopefully see the documented positive results on paper. A few good supplement companies produce combination supplements for inflammation which include the herb. If suffering from inflammation and muscle soreness, consider a few of brands mentioned below. The positive result is that turmeric is also used in certain cultures for healing stomach ulcer. The typical prescription for swelling and inflammation is an NSAID (nonsteroidal antiinflammatory drug). Motrin, ibuprofen, advil are one form of the family of nsaids. Motrin at high dose works well for pain, swelling and even fever. A common side effect is an upset stomach due to its side effect of decreasing the protective layer of mucous that lines the stomach. The family also flares up ulcerative colitis when used. Thus the beauty of turmeric in being able to help with pain from a muscle strain, broken bones, joint swelling without causing ulcers. The national institute of health states that some studies indicate liver problems so until studies are completed, people with gallbladder disease should be careful in using this supplements. Turmeric is used in many Indian foods and give the yellow coloring to many dishes. Ayurvedic medicine practitioners rely heavily on the powder form for many ailments including cancer treatment.

An easy to attain form of tumeric is from New Chapter....Zyflamend. Only problem I found is it has a good smell of oregano. Pill can melt if held in the hand for long time. Works great for acute muscle damage or inflammation. On going studies also show great results withmen who have prostate inflammation. 6 months of use actually reversed several cases of in situ precancers for greater than 50 percent of the med who were being followed. See their website. http://newchapter.com/

I use IF relief from Natures Sunshine. It may be harder to find but I order it from an herbal store I used to go to in Clermont Florida and they usually give my patients a discount.

http://www.herbpantry.com

chiropractors

Are Chiropractors safe? Most people wit back pain will come to the office or Express Care with an acute event. Many will either have used a Chiro in the past or were considering one before seeing me. On the whole, I like chiropractors. I think the theory of subluxation is valid and many patients of mine have had good results with visiting a chiropractic practitioner. To argue a fact, I have had some horror stories from Neurosurgery friends stating bad results from manipulation. (Remember, this is also true of seeing a doctor for a diagnosis, occasionally there are some docs who just don't practice good medicine). To be safe, get a recommendation from a friend or doctor who has used the chiropractor before. See a primary care doctor or an orthopedic surgeon also to make sure you have two opinions. Remember, if it continues to hurt when you have had the manipulation, medicine, therapy or needles.....something is wrong. It never hurts to do and xray for trauma or and mri for anatomy but the history and physical exam is always the strongest thing in a doctors arsenal to defeat pain and disablility. A doc that goes straight to mri in treating back pain is missing something. (3 in 10 people with no pain will show a bulging disc on mri).
One thing I have to say is I have seen the growing trend for chiros to have physical therapists in the same building or do the therapy on their own. I am very particular about what a therapist does to my patients. I often ask someone with an acute flare up if they had attempted physical therapy in hopes that we can get them to see someone but I immediately get the answer,"I tried therapy and it doesn't work". When patients see me for back pain, if there is no nerve death yet and work is tolerable, maximize on every possible modality, treatment and herb/pill to get the pain away. It only goes away with changing muscle tone, letting the disc go back in, continuing with proper nutrition and sleep. For the person that can't afford therapy, time off from work or medicine, time to save money and change jobs.
Miracles don't happen when you come to the er, chiro or MD. If back pain is from chronic weight, manual labor or poor nutrition and poor healing, most docs can only help to keep the pain to a minimum while the patient changes the lifestyle. Had a guy come to the ER yesterday who had back pain and a few bulging discs since last year but can't afford PT and can't take time off work. He wanted narcotics cause they help with pain. He has been suffering since last spring and hasn't done anything but visit the Er every once and a while. I was going to give him pills but I would only be postponing his need to make a lifestyle change. Wife already stated he had an addiction problem to vicodin so obviously he wants a shortcut and will not address the big issue of finding another job or getting a loan to see a good physical therapist. Said he tried chiro and PT and it "didn't help"...(obviously he only tried one center).
Do the research on the chiro, see a physician also and make a timetable to change your life. The back is telling you something isn't working with life now so you must make a change.

patellar pain/knee pain

A dislocated knee cap with the tip of the cap out of the groove:



So my daughter was in class and heard a sudden....eyyyyyooowwww!! Teacher then exclaims, does anyone know a sportsmedicine doctor.....index fingers proceeded to head to the general direction of my offspring. Apparently the teacher, Mrs. M was getting out of her car and as she placed her foot down, one of her knees (probably the knee cap or patella in particular) caused a sudden excruciating pain but then backed off and just ached from that point on. Improvement is probably already happening but with certain positions, the intensity returns just like the car, immobilizing her suddenly then leaving as fast as it came. I didn't get much more information from my daughter but don't need it. As I always preach, 80% of a diagnosis can be attained from history taking alone. Physical exam backs up the history/diagnosis and tests like blood or xray support the physical exam. In 14 years I have come accustomed to the usual issues that befall the knee. With no preexisting issues like arthritis or surgery, the standard history like this is most likely a patellar injury. To review the anatomy of the knee, we have a hinge joint like a door that opens and closes. Very simple movement, but this joint in particular is complicated in that it must be able to jump and sprint like a rabbit but at the same time be ready to hold in place up to 200 to 400 pounds (all this for an average of 70-80 years). The two big bones that make the knee are the thigh bone (or femur) and the shin bone (the tibia). These two bones rest on each other with little wafer-cusions (cartilage)between them. To be able to move these bones in a hurry and hold a great quantity of weight, we need long but thick muscles (the front thigh or quads). The Quad muscles originate from around the hip and insert to a small point on the shin. When the leg is straight, quads are straight, when the knee is bent like a squat, the muscle has to rub against something to get from the hip down to the shin. Like a spagetti noodle rubbing over the edge of a fork, it will eventually break so our creator made this thing called the patella that helps guide the muscle over the rough edge of a bent knee. This knee cap (patella) has a smooth surface that comes to a point like the bow of a ship. This bow sits in a groove in the thigh bone. As long as the "bow" is in the "groove" muscle works well, we sprint and lift weight without a problem for 80 years. Great architecture right? Yes except for when the knee is bent and then is pivoted slightly. When the "bow" of the knee cap has enough force in the wrong direction, it will slip out of the "groove" and crack, scrape, chip the edge of the bow (knee cap). This smooth surface that coats the undersurface of the patella is very delicate and when a large ridge of bone pushes up against it, the soft surface dents, cracks, rubs off, chips. Next time you eat a thight bone from KFC, looks at the white soft cartilage that lines the joint you just broke open. its softer than bone but harder than muscle, easily chewed (or dented,scraped,rubbed,chipped). I think with her mechanism of injury, our teacher, Mrs M. has suffered a patellar chondral contusion. (Bruise to the cartilage of the knee cap). As with all bruises or scrapes to skin, it takes about 10-14 days to have that scab fall off and skin to heal up right? Well in the case of a knee cap scrape, the knee is constantly being exposed to friction while we are asking it the heal up, this postpones the healing process. Keeping the knee straight (like "Fester from Gunsmoke" or "Madmax" from the Mel Gibson movies) will allow the patella to heal faster but without a big knee immobilizer and crutches from the ER, it's hard to remember to keep the knee straight. What usually happens is we have great intentions in the morning but as the day goes on, occasionally we get into a bad position and eyyyyyoooowww! That little scab to the backside of the knee cap tears open again and then its another 10-14 days of healing. The Saguil Approach is to use ice during the first three days for 10 minutes at the top of every hour. After that its 10 minutes three times a day. An antiinflammatory is helpful and the good ones can be prescribed by me or the over the counters are sometimes used, (but I think they cause too much stomach upset.) I like using supplements like IF relief from Natures Sunshine or Zyflamend from New Chapter. Anything with turmeric, boswelia, white willow bark, shark cartilage, oregano...all good for speeding up the healing process. Acupuncture works great! (but it is a temporary relief while waiting for the "scab" to heal. Arnica and tea tree oil help. It always is useful for the physical therapist to show you some exercises to strengthen the quads and keep them holding down the patella in the right position. The gifted therapist who knows Maconnel taping can assist the knee cap in staying in the right "groove" for as long as the tape stays on the skin. When this fails and pain continues to the 3-4 week mark, time for xrays and a possible mri. The problem is; the only true way to diagnose a patellar surface injury is to visualize it directly with a surgical scope. Most of the surgeons (and me included) will try a steroid shot as a last ditch effort to reduce inflammation before considering surgical evaluation.

Muscle stiffness

Many times we exercise to the point of muscle failure in efforts to stimulate the joint/muscles to tolerate more of the movement or weight next time. Sore muscles are expectedand usually the pain will last for a few days. Athletes have evolved so much to society that we feel working out everyday is a good thing for overall self esteem and wellbeing. Most of the weight training we do is done to the point where our glucose and glycogen stores are used up in a training session. At that point, exercise is painful, coordination is slow and endorphin response isn't as rewarding so we stop and head to the locker room. I have seen some hit the energy "wall", in 30-45 minutes and I have seen some go till 60-90 minutes. (Then there is the Iron Man athlete who goes for several hours). What separates these varying times is conditioning. Many of the soccer players I cared for at UCF in Orlando would play both halves with only a few minutes of a breather. There have been studies performed on world class soccer players measuring the amount of glycogen in muscle before and a intervals during training. ( I still don't understand how they got volunteers to play, get a peice of calf muscle cut out, play and repeat this procedure....hope they got alot of money!) Glycogen runs out in a matter of minutes but these players can obviously continue to play well and this was found to be possible with glucose repleation during the match. Thus the importance of frequent hydration with water and glucose. And the post match glucose consumption was crucial in the 2 hours after ending exercise in order to build up glycogen stores for the next game. This was the basis to the old carbohydrate loading from a decade or two; after going through exhausting exercise and total glycogen depleation, "reboot" the system with a combination of carb to protein calories equalling 4:1. Just check the bottle or bar or meal you are putting in your mouth and make sure the total of carbs and proteins listed equals the mentioned ratio.

Rest and sleep is always important and most of us time the next work out to 1-2 days away. The old way to think was hit the same body part in about 48 hours....which comes out to lift weights for targeting one area 3 times a week. Monday-wednesday-friday for back biceps, abs then tuesday-thursday-saturday for chest, triceps and legs. This is more of a beginners way to exercise. The same muscle group is given 48 hours to heal yet we can still get to the gym and weight train and bond (and hunt in some clubs) every day of the week. There are some more advanced athletes who can train muscle to a higher level of fitness and those folks usually need 2-3 days of rest and time off to fully rebuild and damaged muscle fibers, tendon/bone junctions or ligament insertions. Those athletes are the ones you will see, very stiff and sometimes requiring trainer stretching or massage therapy. These people won't necessarily stay at home for 2-3 days after training a specific muscle group, usually its working on cardio or accuracy or cross training during the down time. Not all can afford a trainer or massage therapist so we all learn to stop pushing the exercise at a certain level while training so as not to tear those ligs, tendons or muscles in efforts to be able to return in 48hours. In the case where a paycheck is involved in the performance, one would get tempted to push the training to the highest level and with the resultant damage, a performance enhancement drug would be used to speed up the healing process. Growth hormone, (anabolic steroids in general) are used to fix the muscle. tendon/bone, ligament. Body builders, football players, profesional wrestlers, baseball players....or more recently, sprinters and even mixed martial arts (MMA) athletes.

Bottom line is that muscle stiffness is usually the result of doing exercise differently than usual. It could be a beginner starting, a good athlete trying a new routine, or an unsafe athlete doing the wrong or unintended movement. Most usually grow to enjoy a little stiffness, (imagine ..... loving pain) knowing a good work out just occurred. When the stiffness makes us walk like frankenstein then that experience of the level of exercise is usually placed in the part of the brain that houses nightmares and spankings from childhood. If the resultant stiffness/soreness effects our job performance for a day or two and we can't work, that to is put to the memory banks as being a "bad work out". Humans usually tailor the exercise for very little pain and maximum recovery time. I believe this is where poor psychological drive or just no motivation to push harder keeps the average joe athlete at a low level of exercise and very slow muscle size gain and poor performance improvement. A trainer is great for motivation, a training partner should be good (but I have seen some that end up talking too much) a training group is great for the encouragement. I have always been a proponent of little rest between sets of exercise. I am always asked, "how many minutes should I rest between lifting a weight". My answer is why wait. With no history of medical problems like heart or lung disease.....I would say go from one station to the next. The way exercise was done about 20 to 30 years ago was station to station with little rest. I used to call it circuit weight training as I remember, Robert Gajda (Mr Universe 1966) termed it PHA or peripheral heart action. Most of the new trainers now know it as HIT or high intensity training (see the "300 work out" on you tube) . If it is worked up to and not done as a beginner, an average person can get a standard workout done in 20-30 minutes and not have soreness the next day yet still get size gains in muscle. An advanced athlete can compress a large workout into a small time. Gajda used to be able to do an easy 200 repetitions in one work out. The "300" was the routine used to get the actors in the movie "The 300" in shape for filming and it involved 300 reps.

Personally, I love the feeling of getting "pumped up" and more importantly the satisfaction of having just finished a workout and being drenched in sweat. I'm 45 and I have to work my heart out with cardio. But I also hold the title of Mr Natural New Jersey 1982 so I have a little body dysmorphic syndrome that makes me want to look like "Arnold". See my post in herbal411review.blogspot for antiinflammatory supplements if you want to speed up healing naturally without steroids.

Link: Delayed Onset Muscle Soreness