Monday, June 11, 2018

What is Your Threshold?

What is Your Threshold?

I heard a talk the other day about what level are you walking around at.  The talk was about anger and anxiety and how an event we have come to blame can trigger an outburst.  For example,  you may be driving around and not paying attention and accidentally cut someone off.  That person may give you a polite beep, or they may get sent into a road rage and lay on the horn, cursing you as they do it.  

It wasn't the event that set them off, the event was just an opportunity for them to express anger.  It gave them a "valid" reason to express the anger building in them.  They were at a 9/10 already.  Perhaps you have experienced it with your kids or a coworker, they do one wrong thing and you lose it.  The question becomes do they deserve better?  Don't your kids deserve more then 1 or 2  buffer on the anger scale?

The reason that resonated with me, is A, I think I can walk around with to high on the annoyance scale at times and B it relates to therapy quite a bit.  Self reflection can be tough.  

How often as therapist have we heard, I do this (insert anything) and my pain goes away.  That insert is an adjustment, yoga, a stretch, exercise, drink this, eat that, rub this, anything really.  But, it comes back.  So they do it again.

How often as therapist do we do (insert anything), it gets better and we think (insert anything) is the answer to everything?  But, it comes back.  So we do it again.

Lets say you are looking at 4 blocks.  They are stacked on top of one another.  At the height of the 3rd block there is a line and we get pain when we go over that line.  That is the threshold.  So 4 blocks is pain, 3 block is no pain.  2 block we couldn't tell a difference from a 3rd block.  1 block is the same, we couldn't tell any difference between 1, 2 or 3, but oh man, add the 4th and we are hurting.  

Those blocks can be anything.  Bad sleep, bad nutrition, bad emotional baggage, over used muscle, weak hip, dehydration....anything that might have a negative impact on how our body feels and moves.  We target one thing and we get better.  

We will use Joe as an example.  Joe got a new mattress, he wakes up every morning now and his lower back doesn't hurt.  Joe now believes a mattress is key along with a good night sleep.  His friend tells him he should drink more water now too.  He tries and doesn't feel any different.  His other friend say, you should walk more.  He does for a few days, but doesn't feel any different, so he stops. He goes to his in-laws and sleeps on what he now looks at as a bad mattress and wakes up with lower back pain.  He has without a doubt, in his eyes,  proven that his mattress is what keeps his back healthy.  

But, the mattress was only one block.  He didn't stick with the water to rehydrate tissue long enough, to see if sleeping on any mattress was the only key.  He didn't keep walking to build up a stronger aerobic base to see if that would help a few months in.  

We all have several blocks regardless of pain or movement.  We can all get better at dropping our levels down a notch to be more resilient, to be less fragile, mentally, emotionally and physically.  It requires self reflection and consistency.  It's great to have a (insert magic) thing to do to bring us to a good place, but lets not rely on one thing.  Let's figure out what else can be done to increase our threshold.   Let's build a bigger buffer zone.  

Friday, June 8, 2018

Time Does Tell; But Why Wait

A few posts ago, I wrote about the truth teller of time.  Often, we can only wait to find out if the choices we made today, have truth or importance years down the road.  Looking back at your life, whether it was 20 years or 20 days, how did the decisions you made that you thought were important pan out.  Were there things you didn't address that turned into a big deal?

The crux of the situation becomes how can you speed up choices?  How can you become a fortune teller?  Like Keirkegaard stated, "Life can only be understood backwards, but must be lived forwards."

There is one way...

Find those that have lived in your situation before.  Most likely someone, somewhere has sat and thought and chose one way or another years ago.  How did it go, break down their situation from similarities and differences and evaluate the outcome.  Study the greats.  Study history.  Find mentors.

If I was a coach of athletes, I'd study Dan Pfaff at Altis, Mike Boyle at Certified Strength Coaches.  If I was trying to combine big power lifts, with big endurance events, some one like Alex Viada that has done it.

Perhaps your wondering how going on a certain diet or way of eating would influence your strength.  Nothing beats actually doing it, but find someone that has done it or doing it and learn from their experiences.  Things that helped them, things that hurt them.

Someone has paved the way, most likely.  When I ruptured my achillies, I had several people I was able to reach out to that gave me a "plan."  I had a set of loose guideline that I could bounce my day and week around.  I didn't have to wait weeks to find out if I should do this now.  I didn't have to wait months to find out what I did was right or wrong.

Don't reinvent the wheel.

Look for people that studied what you are thinking about studying.  Did they find value in it?  Why did they leave a job or take a job?  Pros and Cons of living in a neighborhood, or owning a home?

Hindsight is 20/20, but lets cheat the odds and learn from someone elses experience.

Saturday, June 2, 2018

5 Needed Principles for High Performance

I have been watching a few interviews and videos that Red Bull High Performance Director Andy Walsh has been involved in over the last few days.  Andy Walsh has created one of the most unique high performance centers in the world.  He is always trying to find new and effective ways to train athletes, make them better.  Last year, you may have heard of the Stratos program, where Felix Bumgartner jumped from Space!  Regardless of going after space jumps, motor bike acrobatics, 100 mile bike rides, or soccer goals, he believes in figuring out 5 principles.

1.  Motivation:  Find out what motivates the athlete.  It doesn't matter if it is intrinsic or extrinsic.  Intrinsic would be something on the inside of the athlete.  Pride, ego, desire for improvement.  Extrinsic is things like money, fame or recognition.

2.  Repetition:  This is important for improvement.   You have to be able to practice the task you are trying to get better at.  Hard to improve a task if attempts are not made at the task.

3.  Feedback:  There must be a way for the athlete to know they are improving.  Is the repetition method working?  Without feedback it is very hard to be able to gauge if you are getting better.

4.  Progression:  Learn a skill then learn a harder version of that skill.  If progression isn't built in, boredom will most likely occur.  The athlete isn't challenged.  There won't be engagement in the long term.  With out progression, skill acquisition will stall and improvement will also become negligible.

5.  Failure:  The environment will need to be set up so that athlete does not fear failure.  Failure shouldn't be looked at as punishment, but as a learning tool.  We just learned what doesn't work.  It shows where your limits are, most important it shows where you need to put the work in.  Andy believes this is where many programs fail.

As a therapist I've been trying to figure out how to include these 5 principles into each patient/athlete encounter.  Most of the time, pain will drive someone in to see us, but the majority of the time the pain has been present for awhile.

Why Now?  Why did they decide to do something now?  This is an important element to discern.  What was their motivation.  Recently, a lady told me her feet had bothered her for years, but now she couldn't walk to church.  That was her MOTIVATION.

I thought her lack of big toe mobility was the issue.  I did some work on her big toes and we started going over some routines she needed to do several times a day (REPETITION)

She was able to walk about 5 minutes before the discomfort would set in.  Anything over this was going in the right direction.  (FEEDBACK)

Every 3rd day we upped her distance she was to walk.  (PROGRESSION)

Every Sunday she walked to church.  We were then able to gauge where she was "failing" at.  (FAILURE)

In my own rehab jumping rope has become all 5 of those principles.  It's nice to see where I can get better, where I can progress, what moves continue to hit my shins (failure).  Andy talks about skateboarders as the leading candidates for progression, feedback and failure.  They can practice tricks over and over and over again and falling is never seen as punishment or failure, just learning.  

See how you can incorporate these 5 Principles into your training and treatment plans.

Friday, June 1, 2018

Doors Closed and a Life Opened

You don't get a chance to see the big picture until a significant chunk of time has passed.  How certain forks in time, certain decisions play out over a course of decades.  Time is and always will be the greatest filter for what choices we make, for opportunities won or loss, for ideas acted upon and for ideas left by the wayside.

My first memory of football was Billy Sims jumping over a defender, juking and high stepping into the end zone.  I was probably 6 or 7.  It was the first time I had goose bumps from excitement.  I didn't watch football either.  It was something that just struck me as amazing.  It woke up something built into me.

I wanted that.

I didn't play football until 7 years later.  8th grade.  I was going to be a running back.  I was small and just started lifting weights.  I prayed every night to get bigger so that I could play football.  Every single day I had only one thought in my head, get better so I could play football.  Every time I studied for a test, it wasn't to do well on a test, it was a to get a better grade for getting recruited.  Every day I worked and prayed to make the NFL.  I went to college and even lived down South for year under the guise of an NFL developmental camp.  I had an agent and the stuff that comes from that.  Combines, workouts with teams, more lifting, more running.  Never made it.  I came to the hard but honest answer that I wasn't good enough.  I was ok with that in the end.  I had left no stone unturned.  I can look back at that time from 8th grade till one year post college and say I had done everything to make it and it didn't happen.  There is a great relief knowing I never have to whisper the dreaded two words, "if only."

Two things have brought even more peace in my lifetime.  The first was this poem shared by a friend years ago.  Push The Rock

The second was an article I read the other day.  It was one of the most honest articles about what we are discovering about post NFL life some players are dealing with.  This article about Ex NFL running back Jamal Lewis life after football, struck a chord.  I think for the first time I realized how much I may have gained by not getting the opportunity to keep playing football.  Joint pain is one thing.  Losing your brain, how you think, how you process, seems so much more....scarier.  If it changes your personality, it changes you.

It really gets into some deep philosophical questions about if your brain deteriorates and your personality changes is this flesh suite still you?  If you can't think, reason, enjoy the environment you live in, create new memories or remember the old one, are you still alive or just existing.  It's why diseases like Alzhemiers and those associated with dementia are so scary.

I've been concussed but not on that level.  I've had several minor ones, but again not on the frequency that is seen in the NFL these days.  I'm under no delusion that I would have lasted long enough in the NFL to have these severe issues, but who knows what ailments lingers with you even from a brief window of physical beatings.  We don't know.

Jamal Lewis shows where he grew up, why he viewed sports as his only avenue out of his circumstances.  He states it was the best option for him.  I grew up with way more options.  As more and more of these athletes step forward and share their stories, I think we will see more and more young athletes assess their choices.  It's very brave for these ex athletes to share their own fears about the future, even if the only thing that happens is that it gives one person a sense that perhaps that road taken wasn't the best option after all.

Wednesday, May 30, 2018

Breaking Loops and Some Book Reviews

The blog life has been seriously lacking in the last few months.  Lots of excuses about time, interest level and content.  I've always enjoyed writing though, so my goal is to get consistent with this electronic journal again.

I've realized a few road blocks.  First and foremost, it started to feel like I didn't have much left to communicate that was "new."  Why rehash old ideas?  This was a subtle nod to perfectionism.  This is bad.  Nothing gets done.   Not every post will get shared 10,000 times, but if it helps one person, then it was worth it.  Even if that one person is me.

Remember your principles for writing.  When I write, I know what I'm thinking.  Writing makes me a a better communicator.  How do I explain this concept I think is important.  Another valid reason for writing again.  You may here something hundreds of times, someone says it with a little twist and it suddenly makes sense.

It feels good to create.  Even writing this little bit, makes me feel productive.

What I have been up to since it wasn't this blog?  Reading, lots of reading.  Here's a quick run down.
Endure by Alex Hutchinson.  Really enjoyable read.  Did I learn anything new.  Not really.  But, it rehashed some old thoughts and that is a big win.  It got me really diving deep into aerobic physiology.  Any book that spurs further reading/learning/thinking is a winner.  Fatigue debate runs on, is it body and physiology or brain.  Most likely a combo.  Rate of Perceived Exertion is a big deal.

Skin in The Game by Nassim Taleb.  To be honest, I don't know If I'm smart enough to read his stuff one time and take away all his ideas.  Big idea, be careful of taking advice about anything where being wrong, the downside, no negative is felt.  Be invested with others that are invested.

12 Rules for Life by Jordan Peterson.  This may be my favorite book Ive read in a few years.  In fact, I loaned it to a friend.  I plan on reading this again in the fall.  I really believe the concepts in the book are timeless.  It is somewhat like a modern Ben Franklins 13 Virtues.

End of Average by Tom Rose.  This was recommended by a friend.  Surprisingly good, and not what you think.  It's not a self help book, more of a history of how "average"  came to be almost bad.  For example, if I described you as average looks and average intelligence, you may be offended.  Learning to quantify numbers into data, seems boring, but the examples are funny and their is some big take home points if your a parent or coach.  I will always remember, their are no below or above average learners.  We all learn at different paces.  Your child or you may need extra time to learn math, but need less time to learn grammar.  The problem is in schools you have 45 min.  It's set.  The history of the public schools are very interesting as well.  Basically, just designed to put out non thinking, obedient worker bees.  Great for factory floor workers, not so great for modern day job and life.

Salt Fix by James Nicolantonio.  Seems to make a solid case for getting more salt into your diet.  I came by this by wondering why when I was sick I always craved high sugary/carb type foods.  Why if my body is smart would it crave something that was obviously not great for your immune system.  Sugar does impede your immune system a bit.  It didn't make sense.  Enter the need for salt.  How the salt craving can be mistaken for the other white craving, sugar.  Lot of wisdom in your grandmas advice to have some chicken noodle soup and you will feel better!

Why We Sleep by Matthew Walker.  I'm only half way through this, but it is pretty mind blowing what we know about sleep now.  Get your sleep.  It literally helps every single human trait.  Every sickness, disease is less.  You live longer, get stronger, stay healthier when you have consistent 7 plus hours of sleep.  After reading this, it will really challenge you if you work so much that you can only get 6 or fewer hours of sleep.  Trading life and the life you will have, health for work/money.  Because it comes down to the simple fact that yes, you are.  Pretty easy to shut the TV off and get an extra  30 min or hour.  Joe Rogan did a top notch podcast with him.  Most of the information in the book can be found in the podcast (So far at least, but I'm only half way).

Tuesday, February 6, 2018

Achillies Tendon Rupture: Post Surgery Weeks 3-8

The cast came off and the CAM boot went on in week three.  The CAM is just a fancy boot that locks in certain degrees.  I had the CAM set at 20 degrees of plantar flexion for weeks 3 and 4.  10 degrees for weeks 5 and 6.  Weeks 7 and 8 I was supposed to be at zero degrees, but decided I would just go to my zero degree weight bearing boot.  The zero degree weight bearing boot was supposed to be for weeks 8-10.  


Since I skipped the last two weeks of the CAM boot and went to the weight bearing boot, my heel was getting incredibly sore.  I purchased some soft gel heel cups and put them in my shoe or boot and this helped.  My feeling after being in the weight bearing boot for a full day of work, is that my heel would actually be better off in just a plain tennis shoe.  Instead of being in a boot for another month I just made the call that I was better off without a boot and went for the tennis shoe and a heel cup.  (It is now very evident we walk around in a type of high heeled shoe, as this was less aggressive then my weight bearing boot)  

It felt great to be free from the boot.  Since I no longer used the boot, I decided it was time to take the dreaded measurement to see how much calf atrophy had taken place.  Pre achillies, my left calf was 40.5 cm, right calf was 42.5 cm.  Post boot, my left calf was 38.5 cm and my right had grown to 43 cm.  There is definitely some work ahead in the hypertrophy department.  (post in the future on the science of hypertrophy)

Weeks 3 and 4 I had been training in a high heeled Timberland boot doing everything that I could think of that didn't cause discomfort, but put a load into my legs/hamstrings/calf.  About week 5 I switched to an Olympic Weight Lifting shoe.  Things like heavy KB swings felt great in them.  Squats and all the variations of squatting you can think of.  Trap bar deadlifts with a more neutral shin angle.  The big breakthrough in week 6 is I specifically started doing heavily assisted calf raises. At first these seemed uncomfortable (not painful) with me relying on strongly assisting my bodyweight.  Straight leg raises with the gastrocnemius doing most of the work is much, much harder then the seated work, where the soleus does most of the work.  This goes along with the atrophy, my lateral gastroc is gone.  My medial soleus was much stronger and bigger in comparison.  

Week 6 also brought the breakthrough that I can put on my bike shoe and pedal my bike on an indoor trainer.  While higher resistance at the time didn't feel great, it was doable.  It was nice to be back on the bike!  Week 6 and 7 I basically started to do as many seated and standing assisted calf raises as I could.  I rode the bike almost every day for 20-60 min.  The end of week 7 saw a 2x10 min interval at 200 watts.  (don't laugh bikers, this is good for me)  I deadlifted in a flat shoe 3x2 at 295 pounds.  My brain put the kibosh on 335, I just couldn't budge it.  The next day, I was nailing unassisted standing calf raises though.  Interesting that it happened after that.  Neurally speaking, I think my brain took some of the breaks off and my calf responded.

I'm still dealing with some swelling around the heel and the lateral heel in particular.  I am using floss bands and ankle pumping to try to address this issue.   By end of week 7, I was getting almost 5-10 degrees of dorsiflexion without ever stretching, just walking (limping), biking and strength work.  I assume this will improve with more motion.  I work the tissue of the lateral calf area into the lateral ankle with my MOBI every day for a bit and this really cleans up my gait.

My follow up appointment with my surgeon was exactly 8 week from the surgery.  Happily the stuff I had been doing is paying off.  It's hard to really know when it's your first achillies rehab and you only are going by what you can find.  He was blown away by the lack of atrophy, the ability to raise up on my toes, the thickness of the tendon (this was good)  the mechanics of the ankle and the strength of the muscle.  He stated it was the worse achillies he had done, but it was easily the best he had every seen someone respond.  He even called in another surgeon to see me do a calf raise.  She was shocked.  They both now will have a new set point on what they can tell their patients on what to do minus just wear a boot.  (that was the guidance I was given)

The journey so far has been about doing what we know to do and applying it.  Getting creative to figure out ways to exercise and also keep it from being monotonous.  Rehab can be discouraging if you do the exact same things every day.  Find new methods, but keep your principles.  I'm still a long way off from heading to the track for a sprint workout.  But, I'm closer then I was 7 weeks ago, and way ahead of where I would be if I was still scooting around in a boot.

I post a lot of the variations of rehab videos in a timeline on my Instagram drjasonross   You will have to wade through a few (ok lots) of pictures of coffee and an occasional picture of my kids.  But, I'll be posting more training videos in the future as well.

Wednesday, January 24, 2018

The Science of Muscle Atrophy from Immobilization

An achillies tendon rupture I experienced last month had me in a cast for two weeks and a non weight bearing boot for another 4.  With any injury, you have to define your plan of recovery and the goals for the process of healing and the big concept of return to play.  The biggest goal for me right off the bat was to limit atrophy as much as I could.  Better to preserve muscle then spend months trying to reacquire it.  The last few months of rehab in an achillies rupture is getting the size back to essentially have enough cross sectional area to give the strength back to plantar flexion.  The goal became to fight off atrophy.  Learn your enemy, his tactics and weakness.

What is atrophy?

Atrophy can occur from a few mechanisms.  They are immobilization, spinal cord injury, loss of gravity( space) and aging.  For most of this post will be dealing just with immobilization.

The opposite of atrophy is hypertrophy, or get that muscle bigger.  There is quite a lot of science that shows the model for this, on the contrary and a bit surprising, there isn't a clean model for atrophy.  This is because a chronic decreased use is hard to come by to study.  Most of the research is with rats and dogs.

Immobilization

Limb immobilization has been used for a very long time to protect a broken bone or injured tissue from further injury.  Essentially, one is creating a barrier from movement.  The most common negative consequence of this is muscle atrophy from decreased use.

Muscles respond to the tension they are placed under.  Electrical activity, tension and slight motion can still occur while immobilized, just not gross movement.  Muscle tension hasn't been measured in an immobilized state.  Think of immobilization as reduced, not disused.

(most of these notes will be from the excellent textbook "Skeletal Muscle Structure, Function, and Plasticity" by Richard L. Lieber

There have been some studies that have studied the EMG of muscles in an immobilized state.  One example (that I found especially relevant for my achillies rupture) was implanting  electrodes in a fast twitch medial gastrocnemius and slow twitch soleus muscle of rats.  There was decrease in EMG after just 1 week, greater decrease in the slow twitch medial soleus then the fast twitch gastroc.  The take home for this study was that EMG had nothing to do with atrophy changes.  Just because there was a decrease in EMG didn't mean less atrophy.

There was some interesting relationships between being immobilized in a lengthened, shortened or neutral position.  The soleus immobilized in a neutral position showed 50% atrophy, in the lengthened position it showed no decrease at all, those in a shortened position atrophied the most.

Most of the disuse models have shown that slow twitch muscles atrophy to a greater extent then fast twitch muscles.  Soleus will atrophy more then the gastrocnemius and anti gravity muscles atrophy faster then their corresponding antagonists.  (gastroc will shrink more then tibialis anterior)

A few interesting points regarding immobilization of the quadriceps.  Comparing rectus femoris ( a two joint muscle) the vastus lateralis and Vastus medius.  RF underwent the least, this was theorized because it was more "active" as it had access to two joints.  Vastus medius had the greatest atrophy as it had the greatest percentage of slow twitch so it had the greatest response to the decreased use.  For ACL or knee immobilization the vastus medialis traditionally shows the greatest atrophic response.

The takeaway from this is that muscles that are used quite a lot will have more slow twitch muscle fibers and if they are immobilized, expect it to have a greater atrophic response then a fast twitch muscle, or a muscle that was used less on average.  There is also seen a change in fiber type from slow to fast after immobilization.  (This really surprised me)

Muscle power seems to be a direct relationship to the cross sectional area.  Atrophy definitely brings strength loss with it.  Remobilization after the immobilization then brings the therapy goal of  hypertrophy.  There are not a ton of studies done on how long it takes to bring back the tissue to pre immobilized size.  The data just says it takes longer.  (Big help!)  One dog study showed that 10 weeks of immobilization and 4 weeks of active recovery brought with it a 30% reduction from the original size/characteristics.  The fiber type changes are expected to change back.  Extracellular connective tissue also returns to baseline.

At the cellular level muscle protein turnover is occurring.  Degradation is happening faster then synthesis.  After only one day of immobilization the soleus muscle can decrease their protein synthetic rate by 50%.  This decrease is seen continuously for around 30 days, then the muscle mass stayed around constant.  In other words it took about a month for the muscle to reach homeostasis.

Two genes have been credited with universal regulation of atrophy, MuRF1 and MAFbx.  These enzymes are used to mark proteins for degradation.  ( In the future, maybe they will be used to prevent atrophy!)  The number one player for the regulation of these enzymes is the transcription factor Foxo.

Foxo, interestingly, can be used for atrophy and hypertrophy.  Things that cause atrophy, like immobilization, activate Foxo to upregulate MuRF1 and MAFbx and stimulate protein degradation and thus atrophy.  Things that stimulate hypertrophy, exercise, electrical stimulation, overload, cause an activation of another factor called akt, which inhibits Foxo and stimulates protein synthesis and thus hypertrophy.

The take aways are if you have the ability to cast or immobilize in a lengthen state do it.  If you can get moveing before the 30 day window do it.  Create muscular movement even if the joint can't be moved.  ISOMETRICS.  If there is a way to use electrical stimulation do it.  Work the contralateral limb.  Upping some protein intake probably won't hurt.  The balancing game of introducing movement and load to protecting the original injury is not a cut and dry situation and is an under studied field.