House Call, MD

by G. John Mullen, DPT 2011

With the Superbowl only days away, Colts fans across the nation are keeping their fingers crossed for Dwight Freeney’s return.  The Colts’ All-Pro defensive end said he’s been walking around barefoot and along the sandy beach outside the team’s hotel to strengthen his sprained right ankle.  The question is whether this game-changer, who recently suffered a severe ankle sprain, will be ready for the sharp cuts and quick footwork he will need on Sunday.  As simple as this sounds, hard cuts followed by the unfortunate rolling of an ankle cause ankle injuries to numerous players (pro and recreational alike) each year, injuries that may have been prevented with proper footwear, ankle strength and coordination.  Before we discuss those topics, let’s go over what an ankle sprain is as well as the main causes of ankle injury.

Stat Fact: Ankle sprains in men and women whose average age was 23 had an injury rate of 10 per 1,000 hours of sports participation.

What is an ankle sprain?

An ankle sprain, more commonly called “rolling your ankle,” is a stretch or tear in one or more ankle ligaments.  These injuries are caused by running, jumping, landing on an uneven surface or awkwardly planting your foot (or tackling a quarterback in the NLF in Freeney’s case).  The most common type of ankle sprain is of the anterior talofibular ligament (which connects the talus to the fibula) and the calcaneal fibular ligament (connecting the calcaneus to the fibula) on the lateral side (aka the outside) of your foot.  You can see this ligaments on the image to the right and imagine the type of ankle movement that would strain them.  This type of sprain is caused by rolling your ankle downward and inward (exactly what you had imagined).  There are many other ligaments in the ankle that can be stretched or torn in the sprain but the overwhelming majority of ankle sprains involve these two ligaments.  In addition, there are three different grades of an ankle sprains: Grade I is a stretch of the ligament, Grade II is a partial tear and Grade III is a full tear of the ligament.

The signs and symptoms of a sprained ankle are similar to most musculoskeletal injuries:

• Pain and swelling

• Bruising

• Difficulty walking

• Stiffness

Stat Fact: Sprains of the lateral ankle make up 85% of all ankle sprains.

Acute Ankle Sprain:

Now that you know some basic facts about the ankle, we will discuss what to do if you have just sprained your ankle playing a pick-up game of basketball or Louisville Chugger.  Most ankle sprains are Grade I (i.e. relatively benign) and will begin to feel better within a few days.  To help speed up the healing process, most physicians, physical therapist and medicine men will tell you to R.I.C.E. your ankle.

• Rest: For 24-48 hours after an injury, rest your ankle and allow it proper time to heal.  During this time sit back, relax, watch The Office and discontinue any physical activity.

• Ice: Icing can be used to decrease swelling of the injured ankle.  Ice should be used for approximately 20 minutes (about the same length as an office episode…) at a time and should be used intermittently throughout the day (about 6 times).  Make sure the injury site does not go numb when icing the injury.  When the injury becomes numb, tissue can be damaged and more harm can be done!  The type of cooling method is irrelevant, but make sure the ice pack, pack of frozen corn or cold pack covers the inflamed area. Additionally, make sure not to leave the ice on for longer than 20 minutes.  The ice is used to reduce the swelling in the area.  When ice is left on for longer than 20 minutes, the body begins to think that it is freezing and increases the amount of blood to the area to warm it up (thus increasing the swelling!).   The take home: 20 minute on, 20 minutes off!

• Compression: An ACE bandage works best, but any type of garment can be used to compress the injury site.  Wrap your ankle from your toes upward to your calf, but do not wrap too tightly or more harm than good can be done.  Make sure you can still feel a pulse in your foot (blue toes are a bad sign!).

• Elevate: This is simple, keep your ankle higher than your heart…lying down is key here (for those of you trying to maintain the kung fu position with one leg in the air) and remember to keep your ankle elevated with a pillow while you sleep.

If the ankle swelling does not subside after a few days (~7 days) or if the ankle is preventing you from everyday activites, it may be necessary to see the physician or physical therapist and it is likely you have suffered a Grade II or III sprain…our hearts go out to you.

Chronic Ankle Instability/Functional Ankle Instability

Now that you’ve sprained your ankle and the pain and inflammation has gone by the wayside, you may be interested in preventing future ankle sprains. If you are a bit of a couch potato (not recommended by physicians) it is likely the sprain was a freak accident and is unlikely to occur again.  On the other hand, if you are an active individual, the ankle is likely to be reaggrevated by future activities.   The good news is that future ankle injury can be prevented by non-surgical options including ankle braces (orthosis), strengthening and improving balance.

1. Ankle Braces: External ankle braces such as an Aircast or any semi-rigid external device is recommended during physical activity.  This device should be fitted by a trained exercise specialist to make sure the device is working and fits properly.  If properly worn the device will provide the support an individual needs to safely perform all of their sports needs (sounds like a good pitch if you ask me).

2. Balance: Balance exercises include: single leg standing, single leg squats, single leg calf raises, etc. Any of these single leg activities helps improve your balance while strengthening your ankle simultaneously. As you progress, you can perform these exercises with your eyes closed or on top of a pillow to make them more challenging.  A Dyna Disc or Bosu Ball (see pictures) can also be used to improve strength and balance of your ankles.  Squat, lunges and various other exercises can be used on these devices to increase the difficulty of the exercise.

3. Strengthening: Balance and strengthening go hand in hand as it is a critical aspect of rehabilitation for an active individual.  Strengthening is usually performed with elastic bands and on a Dyna Disc or Bosu Ball.   One exercise that can be used is called the elastic band clock and involves holding the band at 12 o’clock, 3 o’clock, 6 o’clock and 9 o’clock.  I know this sounds like nonsense but if you loop the elastic band around your foot and hold the band directly above your foot, you are in 12 o’clock, and if you hold the band in your hand on the outside of your foot you are in 9 o’clock similar to the picture on your left.   Push your foot against the resistance of the elastic band and stretch the band as far as you can without moving your shin or any other aspect of your leg (you are moving your foot at the ankle).   Movements in all these planes of direction will greatly strengthen your ankle and improve your balance.  These exercises can be done for 3 sets of 15 repetitions and should not be terribly difficult.  A little TV time makes them infinitely more enjoyable.

Stat Fact: Basketball players with a history of ankle sprains were nearly five times as likely to sustain another ankle injury.

If these non-invasive interventions do not help the ankle instability, surgery may be considered.  Ankle surgery is done only in the most severe cases of ankle instability and would have to be recommended to you by an experienced orthopedic surgeon.

Ankle instability and sprains can hamper one’s recreational football and basketball career, but implementing these three main sources of rehabilitation (bracing, balance, and strengthening) can get you back in action sooner and keep you there longer.  Rehabilitation programs vary greatly from injury to injury and if you have chronic ankle instability it is recommended to see your physician or physical therapist to implement an individualized plan to help strengthen your ankle and get you back to 100%.  Let’s hope Dwight Freeney is doing his ankle exercises (enter his long walks on the beach) and keeping that ankle elevated (for the Colts’ sake that is!).

References:

Handoll HH, Rowe BH, Quinn KM, de Bie R. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev. 2001;(3):CD000018. Review.

Loudon JK, Santos MJ, Franks L, Liu W. The effectiveness of active exercise as an intervention for functional ankle instability: a systematic review.  Sports Med. 2008;38(7):553-63.

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by G. John Mullen, DPT 2011

With the New Year comes the annual New Year resolution.  At the top of every New Year’s resolution list is a promise to be “healthier”.  Everyone has a different opinion regarding what it takes to be “healthier” and it can range from smoking a pack instead of a carton of cigarettes, eat two foot long subs instead of a party sub or increase your running routine from 10 to 100 miles a week.  Ok, that may be a bit of a hyperbole but when asked time and time again, the top of the New Year resolution list is related to exercise.  The most popular and simplest form of exercise is running.  Running is great cardiovascular exercise, however many injuries stem from running and often arise from doing too much too early.  One of the most common injuries is iliotibial band friction syndrome (ITBFS).  This injury can linger for long periods of time without quick and proper treatment but if assessed and treated soon, the effects can be mitigated.

Stat Fact: Health club memberships typically increase 12% in the month of January (4).

What is ITBFS?

The iliotibial band is a fibrous band that runs on the outside of your leg from your hip to your knee.  It is generally firm, but as it is irritated it may become extremely tough and sensitive.  Irritation of the iliotibial band can be due to poor biomechanics, anatomical flaws or muscle weakness.  Many of the biomechanical flaws stem from muscle weakness, but the anatomical flaws are a bit trickier.  The main anatomical flaw is flat feet, which causes your knee to internally rotate with each step, subsequently stretching your IT band.  While stretching is typically good, when done repeatedly it can break down the tissue and inflammation and tightness can occur.  The most common biomechanical flaw is too much hip adduction (bringing your thigh bones close to one another) and internal rotation (rotation of the knee inward) of the thigh bone (femur).  This motion is controlled by the gluteus maximus (the upper fibers to be exact…also the sexiest muscle in the body) and if this muscle is weak it can cause repeated stretching of the muscle leading to problems similar to those seen with anatomical flaws.  These are the main causes of ITBFS, but many other anatomical issues may cause ITBFS (leg length discrepancy, bowed legs, previous injury, improper footwear, etc.).  However, simple muscle strengthening is not the solution, especially if you already have ITBFS.

What should I do if I have ITBFS?

First, go see your physician to get a referral to a physical therapist.  Make sure your physical therapist watches you walking, running, and explains what is going on biomechanically because it is essential to understand the problem before it can be resolved.  Some modalities (ice, electrical stimulation, etc.) may be used to decrease pain and inflammation, but these things will only solve the problem temporarily. A proper running analysis, combined with a stretching and strengthening program will be most beneficial in the long run (yes, this is a purposefully placed pun).  Every physical therapist will have their own unique treatment style but, as an overview, it should include:
•    Diagnoses and evaluation of the injury
•    If ITBFS is determined, a temporary termination from running will be suggested to allow proper healing
•    The need for shoe lifts, inserts, orthotics, etc. will be assessed
•    Modalities will be used to treat inflammation and pain
•    Soft tissue mobilization to break up the tightness in the ITB (see image above utilizing a foam roller)
•    Stretching will be used to provide proper leg length
•    Strengthening will be combined with stretching and, when proper muscle activation is achieved, return to sport is indicated

Stat Fact: ITBFS has been reported to cause of 12% of all running-related injuries (5).

Prevention of ITBFS

If you do not have ITBFS but reading articles on running forums and Running World have scared you into learning about the pathology, then this is the section for you.  Remember, an ounce of prevention can go a long way.

Proper Warm-up
To stop ITBFS before it begins, a proper warm-up is necessary prior to any workout.  This warm-up should not be a light jog!  A good warm-up involves at least of 5-10 minutes of multi-directional movements of the legs and arms.  Sport specific warm-up and dynamic (moving) stretching for at least 10 minutes must also be utilized to properly warm-up and stretch your muscles (3).  Imagine trying to stretch a rubber band that’s been in the freezer.  Not a good idea, we promise.

Example Warm-up for Jogging:
•    10 minutes of jogging which includes repeated bouts of: high knees, butt kickers, skipping, side-stepping, karaoke, backwards running and high knee hip rotation
•    10 minutes of marching with legs raises in front, leg raises to side, skipping, leg swims (forward and side-to-side), lunges, side lunges, higher speed training

Proper Cool-Down

After each workout a cool-down of at least 10-15 minutes is recommended.  This warm-down should not just be walking, jogging, smoking a cigarette or drinking a coffee (or any combination of those).  A proper cool-down encompasses some jogging at a slightly lower intensity than the main workout, dynamic stretching, isometric stretching and relaxed stretching (1).

Example of Cool-down for Jogging:
•    5 minutes jogging that includes walking lunges and high knees.
•    5 minutes of isometric stretching: standing legs spread stretch to each side, standing calf stretch, seated IT band stretch (see image), IT band foam rolling or tennis ball rolling (these may be painful in the beginning), side lunge stretch (all of these stretches should be performed for at least 30 second holds)
•    5 minutes of relaxed stretching: seated legs spread stretch, forward lunge stretch, semistraddle, side quadriceps stretch, lunging IT band stretch.

Strengthening

As previously mentioned, most biomechanical ITBFS is caused by weak upper gluteus muscles.  However, simple squats won’t fix the problem because running relies on eccentric strength of the hip extensors (hamstrings, glutes).  Eccentric strength refers to muscle lengthening as opposed to concentric strength which refers to muscle shortening.  In a bicep curl, the curling of the dumbbell towards your shoulder is the concentric phase of the exercise and the lowering of the dumbbell towards your side is the eccentric phase of the exercise.  It is essential to meet with a strength and conditioning professional or physical therapist to help design a proper training program to strengthen this muscle properly and apply correct training principles.  Poor training = poor results and nobody likes walking around with a bum leg.

Example Strengthening of the Gluteus Maximus

Overview

The amount of repetitions and sets will vary depending on your primary goal and current level of conditioning.  The ultimate goal is 3 sets of 10 repetitions each.  If the exercise is too easy, add weight to increase difficulty.  Some exercises will be more difficult.  In these instances, you should reduce the number of repetitions to prevent injury and slowly work your way up to three sets of ten.

Beginner:

Bridging:

Lie on your back with your knees bent and feet shoulder width apart, push through your heels to lift your butt off the ground as high as you can (possibly into hyperextension).  Hold this position for a second and then lower your butt back to the floor.  This is one repetition.

Clams:

Lie on your side and bend your knees to 90 degrees and your hips at 60 degree with your legs one on top of the other.  Now lift your top leg open like a clam, hold for a second and then return your knee to the starting position.  Brilliant!  Complete 3 sets of 10-20 repetitions on each side.

Intermediate:

Single Leg Deadlift:

This exercise is similar to the single leg squat.  To begin, stand on one foot and bend your knee slightly (~10 degree).  Now bend at your hip bringing your chest towards the floor and touch the ground next to your foot with the opposite hand.   Hold for a second and return to the standing position.  Repeat 3 sets of 10 repetitions on each side.  To advance, you can add dumbbell weights in each hand.

Band Seated Abduction:

While seated, take a resistance band and wrap it around your thighs.  Once in this position, rotate your hips outwards by opening up your legs (similar to the clam exercise, but seated).  You should feel a burn in the lateral aspect (the outside) of your hip.

Advanced:

Kneeling Glute-Ham Fall:

Begin in the tall kneeling position (see picture) and have a partner hold onto the back of your heels to stabilize you.  Now lower yourself as slow as possible to the floor maintaining your upper body in a straight line as you lower yourself to the floor from your knees.  This can be advanced by holding a weight to your chest during the exercise (2).

Hip Thrust:

Hip thrusts are similar to the glute bridge but with weight involved in the exercise.  Begin with your shoulders higher on a couch or bench.  Place weights across your hips (preferably a barbell) starting in the seated position (See picture at right).  Press your hips towards the ceiling and hold at the top of the movement for 3 seconds then lower your hips to the starting position.  Remember to lower yourself slowly on the way down.  Perform 3 sets of 15 repetitions (2).

Time to hit the road with your new-found gluteal strength!

References:

1.    Kurz, T. Stretching Scientifically. Stadion Publishing Company, Inc 1994.

2.    Contreas, B. Dispelling Glute Myth. 2009. Available at: http://www.tmuscle.com/free_online_article/sports_body_training_performance/dispelling_the_glute_myth. Accessed January 23, 2010.

3.    National Strength and Conditioning Association. Essentials of Strength and Conditioning Conditioning. Human Kinetics. 2000.

4.    Thruston, J. Health Clubs Popular every January. 2010. Available at: http://www.post-gazette.com/pg/10014/1028048-55.stm. Accessed January 23, 2010.

5.    Cosca DD, Navazio F. Common problems in endurance athletes. Am Fam Physician. 2007 Jul 15;76

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by Tania Houspian, PharmD 2011

You can picture it now: Your New Year’s resolution to get in shape finally realized. You’re on the beach in your Speedo with your muscles glistening in the sun. Ok, maybe that’s not exactly what you are imagining the finished product to look like. Perhaps your New Year’s resolution was geared more towards building bigger muscles and getting in better shape rather than becoming the next World’s Strongest Man (skin bronzer, shaving, and Speedos may not be your style).  Nonetheless, you do want to become more muscular.  If so then creatine is the one supplement all your Google searches for “build more muscle” will undoubtedly produce.  Creatine is possibly the most widely used and talked about dietary supplement in the world of bodybuilding.   It’s definitely something a lot of people come into pharmacies and nutrition stores looking for. The question, of course, is “Does it work?”

Before we answer that question here’s another one: What is creatine?

Creatine is not, I repeat, is NOT a steroid. Creatine is a protein your body (specifically your liver) makes. You also get creatine from foods like meat and fish. The creatine that is made by your liver or that is absorbed from food is then stored in muscles. An average 70kg (154 lbs) person has about 120g of creatine stored in their muscles and metabolizes about 2g of creatine each day (which is easily replenished from your diet or liver).  In the muscles, creatine acts as a battery charger.  In this case the battery is your body’s energy stores called ATP.  When muscles use up ATP to perform an action it is converted into ADP. Creatine is able to convert ADP back into ATP, which can once again be used by your muscles to perform actions.  This is a quick and easy way for the body to create more energy (twice as fast as the bodies normal way of deriving ATP from glucose).  Sounds great, right?  The downside is that the creatine is depleted pretty quickly and the body has to go back to breaking down glucose to make more ATP.  So when an athlete takes creatine, their hope is that it will help their muscles maintain the ATP levels for a longer period of time subsequently allowing them to train longer before becoming fatigued.

Aside from increasing the amount of work your muscles can perform before becoming fatigued, there are other theories about how creatine helps build more muscle:

1. Creatine pulls water into muscle cells via osmosis (remember osmosis from high school chemistry?), helping keep muscle cells hydrated and making your muscles appear rounder and fuller…possibly the origin of the common gym phrase, “Getting swoll”

2. By delaying the muscles’ use of glucose to generate ATP, creatine also helps delay the creation of lactic acid (a byproduct of glucose use). Lactic acid is what makes your muscles burn and causes you to feel sore the morning after a tough workout (yes, lactic acid is to blame for the “I was just hit by a big rig” sensation).

So far we have discussed theories about creatine’s ability to improve muscle building.  What we really want to know is if any of them have been proven.  The answer is yes and no. Given the popularity of creatine as a workout supplement there have been hundreds of studies done to examine its efficacy and safety. The studies reviewed asked participants to consume 20 grams of creatine supplements a day for five days (called creatine loading). Then the subjects were asked to consume 5 grams of creatine per day for 21 days. Theoretically, this would increase the stores of creatine in their muscles. The participants were then asked to perform various exercises and their results were compared to their pre-supplementation results. The studies show that creatine does help increase body mass and it does help increase endurance in short-duration, high-intensity exercises (they specifically looked at number of bench press reps, leg press reps, and vertical jump height). However, creatine did not help the men in long endurance exercises such as running a 12 mile race (creatine actually hurt test subjects in long endurance exercises, possibly because they were carrying around excess body mass).  Creatine also did not decrease the amount of post-workout soreness reported by the subjects. The amount of soreness felt was the same before using creatine and after the supplementation period.

The Verdict: Creatine is not a wonder supplement.  You can’t take it, go to sleep, and wake up with bulging muscles.  It is, however, something you can take if you are serious about working out as it may help you increase your stamina and strength with specific workouts.

Now to the most important information: Is it safe and are there any side affects?

Initially, there were reports of creatine causing dehydration, cramping, and kidney & liver damage.  Athletes taking creatine were subsequently warned to not work out on hot days and to be cautious of any cramping the experienced.  That sounds pretty ridiculous to us: if you’ve ever worked out hard you know that cramping is bound to happen from time to time.  To test out these claims more studies were done. The main study on this subject was performed on 14 football players who were told to consume creatine for 8 weeks.  They chose football players as the athletes to use as guinea pigs…I mean test subjects…because football is considered a high-intensity, short-duration exercise (which is exactly the kind of activity creatine is supposed to aid in).  During the 8-week time period the athletes’ kidney function, liver function, and over health were closely monitored. Their results regarding creatine efficacy paralleled those of other previous studies showing that body mass increased and the athletes’ abilities to perform high-intensity, short-duration exercises did improve.  As far as toxicity goes, no signs of kidney or liver damage were seen in any of the patients.  In addition, none of the football players became dehydrated or had more cramping than they did at baseline.

Before we go waving our “Creatine is Safe” flag, a few things should be pointed out.  First, the studies were done on healthy, young males.  People who have liver or kidney problems to begin with should not further challenge their organs unless they are under the close supervision of a health professional.  Studies have not been done with people who have kidney or liver problems so it is hard to say how it may affect them.  Second, all these studies were short term (8 weeks was the longest one performed) so no one really knows the long-term effects of taking creatine.  Many of the problems initially reported with creatine supplementation could have been due to impurities in the creatine supplement people were purchasing thus it’s always important to buy supplements made by a well known and trusted company (i.e. don’t order it off the web from some no name company just because shipping is free).  In addition, be sure to consume plenty of water when using creatine.  Remember that creatine pulls water into your muscles (and out of your body’s circulation).  You need to make sure that you are replacing this displaced water while using creatine to prevent dehydration.

The Final Verdict: If you are serious about working out and are looking for a supplement to provide you with additional stamina to help you strength train for longer periods of time then creatine may be the way to go.  Some things to keep in mind when shopping around:

1. Most of the studies used creatine monohydrate powder as their creatine source (there are more expensive formulations with fancy names but this formulation seemed to work well in the studies).

2. No consistent standards were set for the loading phase of creatine use but 20 grams per day (split into 4-5 grams doses throughout the day) for 5 days seemed to be the most common approach. Note, however, that consuming that much creatine is going to upset your stomach.

3. It was recommended that the average person who wants to gain body mass should supplement with 2-5 grams of creatine per day when working out.

4. Make sure you’re buying high quality creatine from a reputable manufacturer at a reasonable price.

Now go hit the gym mister.

References:

Bemben M, Lamont H. Creatine Supplementation and Exercise Performance Recent Findings. Sports Med 2005; 35 (2): 107-125

Cancela P, Ohanian C, Cuitiño E, et al., Creatine supplementation does not affect clinical health markers in football players. 2008 Sports Med 42: 731-735 .

Dalbo V, Roberts M, Stout J, et al. Putting to rest the myth of creatine dehydration and supplementation leading to muscle cramps. Br J Sports Med 2008 42: 567-573

Herda T, Beck T, Ryan E, et al. Effects of Creatine Monohydrated and Polyethylene Glycosylated Creatine Supplementation on Muscular Strength, Endurance, and Power Output. 2008. The Journal of Strength and Conditioning Research.

Lopez R, Douglas C, McDermott B, et al. Does Creatine Supplementation Hinder Exercise Heat Tolerance or Hydration Status? A Systematic Review with Meta-Analyses. 2009; Journal of Athletic Training. 44(2), 215-223.

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by Leah Frankel, MS, RD

Have you ever looked at your recently-turned-vegetarian friend and wondered what the heck they are thinking? With more and more people now considering themselves vegetarians it makes us wonder, “How do they do it?”  You’re probably wondering why someone would ever want to give up meat. Additionally, aren’t vegetarians missing some key life-sustaining nutrients.  We are omnivores for a reason.  We’ll learn about the different varieties of vegetarians, why people chose a vegetarian lifestyle and what nutrients vegetarians need to be sure they include in their meals to have a well-rounded diet.

Types of Vegetarians

By definition, a vegetarian is someone who doesn’t consume meat, poultry or fish.  The spectrum of vegetarians is vast and we’re here to help you decipher the differences. Even within each classification of vegetarian, there are variations depending on the individual’s needs or reasons for becoming a vegetarian.

Pescatarian: A pescatarian is someone who eliminates all poultry and meat but consumes fish and seafood. This has become increasingly popular due to health advantages of fish consumption or as a first step in becoming a vegetarian.

Semi-Vegetarian: Someone that follows a semi-vegetarian diet follows a vegetarian diet the majority of the time but occasionally eats meat, fish or poultry.

Lacto-ovo Vegetarian: People who follow a lacto-ovo vegetarian diet avoid meat, poultry and fish; however they do eat dairy (lacto) and eggs (ovo). In addition, some people are either lacto vegetarians (consuming dairy, but not eggs) or ovo vegetarians (consuming eggs, but not dairy).

Vegan: A vegan is a person that, in addition to not consuming meat, poultry or fish, does not eat any foods that are of animal origin including eggs, dairy, gelatin and honey. In addition, many vegans refrain from wearing leather or other products made from animals, as well as products that are tested on animals.

Reasons to “Go Veggie”

Religious reasons: A variety of religions promote vegetarian or vegan diets including Buddhism, Jainism, Taoism, Hinduism, and Seventh day Adventists. Each religion encourages a vegetarian diet for a variety of reasons including health benefits (in the case of the Seventh day Adventists) and respect for living creatures (as seen with Buddhism).

Health reasons: There are a number of health benefits associated with following a vegetarian diet including:

• Lower rates of obesity

• Decreased risk of chronic diseases including type 2 diabetes, heart disease, high blood pressure and certain types of cancer

• Longer lifespan

• Reduced risk of food-borne diseases

• Nutrient intakes that are closer to current nutrition recommendations

Ethical reasons: Some people choose to eliminate meat from their diet due to the treatment that animals receive, including how they are raised, transportation to slaughter houses, processes used to slaughter animals and believing that animals have rights, similar to those of people.

Environmental reasons: There are a number of benefits for following a vegetarian diet in terms of protecting the environment including: preserving water resources, preventing water pollution, preserving the earth’s ecosystems, and reducing the consumption of the earth’s resources.

Getting Your Vitamins from A to Zinc

In order to plan a well-rounded vegetarian diet there are a few nutrients that vegetarians and vegans need to be cognizant of and be sure to incorporate into their diet:

Protein: Most people assume it will be difficult to meet their protein requirements as a vegetarian, however most American’s consume twice as much protein as they need; most vegetarians are able to meet their protein requirements with a little planning. Daily requirements for protein depend on gender and body weight.  Symptoms of protein deficiency include edema (swelling, usually on the extremities), weight loss, thinning or loss of hair, general weakness, slowness in healing of wounds and bruises, headache, and difficulty sleeping. Vegetarian sources of protein include: beans, lentils, tofu, chickpeas, dairy (for lacto- or lacto-ovo vegetarian) and eggs (for ovo- or lacto-ovo vegetarian).

Vitamin B₁₂: Vitamin B₁₂ is only naturally found in foods derived from animals. A lacto-ovo vegetarian likely will have an adequate intake but a vegan may not. Options for meeting your vitamin B₁₂ requirements include taking a B₁₂ supplement (pill form), eating foods fortified with vitamin B₁₂, or receiving regular vitamin B₁₂ injections from your physician (usually monthly).  Symptoms of vitamin B₁₂ deficiency include anemia (particularly one subtype called megaloblastic anemia), fatigue, weakness, constipation, loss of appetite, weight loss, numbness or tingling in hands and feet, depression, confusion, and dementia.  Daily requirements for vitamin B₁₂ vary by age and gender.  egetarian sources of vitamin B₁₂: fortified cereals, nutritional yeast, soymilk, and soy products.

Iron: There are two types of iron: heme iron and non-heme iron. Heme iron is the iron found in hemoglobin (which carries oxygen in a red blood cell).  This form of iron is only found in animal products and is more readily absorbed than non-heme iron. However, non-heme iron’s absorption is improved when consumed with vitamin C (so be sure to include vitamin C in your iron-enriched meal).  Daily iron requirements vary by age and gender.  Symptoms of iron deficiency include anemia, fatigue, pale skin, weakness, shortness of breath, headache, dizziness, cold hands/feet, and brittle nails.  Vegetarian sources of non-heme iron: pistachios, cashews, chickpeas, sesame seeds, dried fruits, and spinach.

Calcium: Since vegans and ovo-vegetarians don’t consume dairy, it’s important to ensure adequate calcium intake. Symptoms of calcium deficiency include twitching, seizures, and tetany (extreme stiffness and rigidity in your muscles).  Vegetarian sources of calcium: kale, collard greens, broccoli, legumes, figs, almonds, tofu, and fortified soymilk.

Omega-3 Fatty Acids: The primary source of omega-3 fatty acids is fish, so unless you’re a pescatarian it can be difficult to have an adequate intake. Vegetarian sources of omega-3 fatty acids do not contain the active form of the nutrient that your body needs so supplements with flax seed oil may be necessary. Daily omega-3 fatty acid requirements vary by age.  Symptoms of omega-3 fatty acid deficiency include fatigue, dry/itchy skin, brittle hair, weak nails, constipation, depression, and poor concentration.  Vegetarian sources: soy, walnuts, canola oil, flaxseeds and pumpkin seeds.

Will following a vegetarian diet make you healthier? Not necessarily. As people often forget, vegetarian diets can include plenty of unhealthy foods including french fries, donuts, pizza and ice cream. However, most vegetarians consume more fruits and vegetables, and eat less unhealthy fats (trans and unsaturated) than their meat-eating counterparts. Not ready to completely change your diet? Try going veggie once a week and discover fun new vegetarian dishes!

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by G. John Mullen, DPT 2011

Neck pain: We’ve all had suffered through it at least once in our lives as it is one of most common areas of the body to cause pain.  However, it may be hard to diagnose the primary cause of your neck pain.  Let’s pretend you sit at a desk for 40 hours a week for work/school, and then come home and sit at a desk watching Hulu for a few more hours. Just a hunch, but I think the excessive sitting may be causing some of your neck pain.  Sitting this long is not natural for once nomadic humans.  In addition to sitting for these long hours, most people make it worse by maintaining poor posture while sitting (which is not entirely your fault…humans were not designed to sit for the long durations that our modern lifestyles require).  Despite our societal evolution, our anatomy has not adapted.  As a result, we must actively adapt our bodies to the new societal demands.  Lucky for us, we can make these changes to help improve and possibly prevent most unnecessary neck pain.

Stat Fact: It is estimated that 70% of all muscle injuries that occur without a known accident are sprains or strains.

Neck Anatomy:

The cervical spine is composed of many muscles that are contorted, stretched and shortened with poor posture.  These muscular changes can cause pain in various areas of the spine and in other body parts (shoulders, middle back, etc.).  With sustained poor posture, tiny muscles in the back of your head (suboccipital muscles) tighten or shorten.  Unfortunately, the body compensates by shortening, stretching or elongating the muscles in the front of your neck (your deep neck flexors).

Ways to tell if this is causing your pain…

If you are having neck pain and you think it’s from your poor posture, here are some telltale signs your neck pain is due to your posture:

• Persistent neck or shoulder blade aching

• Symptoms worsen with sustained poor posture

• Muscle imbalances (weak deep neck flexors and weak rhomboids)

Some simple tests you can do to test yourself:

1. Deep neck flexor test:

To perform this test lie down on your back and lift your head off the ground by tucking your chin in tight, as if you’re making a double chin (some people have to try harder to achieve this).  While holding your head 1 inch off the ground, keep your chin tucked as long as humanly possible (shaking and the urge to urinate may be present if one has extreme muscle weakness).  If you unable to hold your neck folds for approximately 30 seconds then you have weak deep neck flexors.

Stat Fact: Patients with neck symptoms (pain, for example) produced 15% less pressure than patients without neck symptoms in the deep neck flexor test.  The bottom line: people with neck pain are usually weak in their deep neck flexors.

2. Neck Rotation Test:

Another simple test to be done at home is a neck rotation test.  Rotate your neck to each side slowly and if your symptoms or pain increases as you rotate more, then your neck pain is probably caused by posture problems.

What to do next?

You have a few of the neck symptoms described above and your neck muscles aren’t as strong as Žydrūnas Savickas…don’t be discouraged there is hope for you!  First and foremost, correcting your posture is the number one cure for this ailment.  I know holding good posture is hard, but so is eating 66 hot dogs in 12 minutes and that didn’t stop Joey Chestnut did it?  A few tips for holding proper posture while at a computer or sitting down:

• Keep your feet on the floor!  You’re not a six year old kid in elementary school.  Put both feet on the floor and keep them there!

• Keep your back against the chair, especially your upper back.  If your back is not against the chair there is a high chance you are leaning forward.

• Keep your chin tucked.  You’re not finishing a 100 meter sprint against Usain Bolt.  Keep that chin tucked.

• Keep your shoulder blades close, don’t round that back!  I know many people dreamed of being a Teenage Mutant Ninja Turtle growing up, but we hope you’ve outgrown that fantasy.  No need to round out your back as an adult.

Stretches:

Next is a routine of stretches we recommend doing in the shower on a daily basis.  All of these stretches should be done twice for 30-45 seconds each.

1. Armpit Sniffer:

The arm pit sniffer is a favorite of ours for numerous reasons.  While standing, look down towards your armpit as if you were checking to see if that Old Spice has kicked in.  If done correctly, you should feel a slight pull on the neck of the opposite side.  This is stretching the levator scapulae, a muscle that is commonly tight with poor posture.   The picture shows the person pulling their head toward their armpit, but if this muscle is really tight, just looking in the direction will provide a proper stretch.

2. Corner Stretch:

This stretch is used to stretch the pectoralis muscles that are often tight due to extended periods of time sitting or at a computer.  To complete this stretch, find a doorway and put the inside of your bent arm on the surface of the wall at shoulder height.  To feel the stretch turn your body away from the arm, and you should feel the stretch in chest (amazing ponytail as seen in the photo is optional).

3. Scalene Stretch:

To complete this stretch, hold on to something for support because you will be tipping your head backwards and towards the opposite shoulder.  Tip your head slightly back and to the side, the picture shows the person pulling his head back, this should only be done if you do not feel a stretch in the front of your neck with the initial movement.

4. Upper Trapezius stretch:

This is the simplest of all the stretches.  Without rotating your neck, tip your head, as f you were trying to touch your ear to your shoulder.  If you do not feel a stretch on the  opposite side you can use overpressure with your hand to elicit the desired stretching sensation.

Strengthening:

Strengthening exercises should be performed with high repetitions to help build endurance.  We recommend 5 sets of 10 repetitions, 3 times a week for best results.  These exercises may seem simple, but if used properly they can alleviate your nagging neck pain.

1. Chin Tucks:

Similar to the deep neck flexor test done earlier, lie on your back and tuck your chin, lifting your head 1 inch off the ground.  Make sure you hold the double chins in your neck.  Hold for 30 seconds (or as long as you are able to if you cannot hold for 30 seconds) each set and complete 5 sets 3 times each week.  And, yes, this exercise falls into a category of exercises know as “Not sexy but very effective!”

2. Scapular squeezes:

Begin this exercise sitting down and, just as the name suggests, and squeeze your shoulder blades together.  By pinching your shoulder blades together, your chest will stick out slightly.  Make sure not to lift your shoulders towards your ears while holding this position!  Hold this position for 30 seconds each repetition and complete 5 repetitions per day 3 times a week.

3. Upper Cuts:

Begin with your knees bent 15 degrees and as you start the upper cut movement, punch towards your opposite shoulder (your bicep should come towards your mouth) and push through your legs.  You can make the exercise more difficult holding a weight in your hand while punching as seen in the photo.  This exercise is used to strengthen the serratus anterior.

Stat Fact: Neck musculature is estimated to contribute 80% to the stability of the cervical spine.

These are some of the exercises and stretches that can be used to help people minimize neck pain.  Next time you’re sitting at your desk, think twice about leaning forward to read the computer screen.  If your neck pain persist or worsens after doing these exercises for a few weeks, talk to your medical doctor about additional treatment options.

References:

Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001;344:363–70.

Chiu TT, Law EY, Chiu TH. Performance of the craniocervical flexion test in subjects with and without chronic neck pain. J Orthop Sports Phys Ther. 2005 Sep;35(9):567-71

Ekstrom et al, Surface Electromyographic Analysis of Exercises for the Trapezius and Serratus Anterior Muscles, J Orthop Sports Phys Ther 2003;33:247–258.

Childs J, Cleland J, Elliott J, Deydre T, Wainner R, Whitman J, et al. Neck Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38(9):A1-A34.

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