House Call, MD

by Kelly Erickson, MD 2010 | erickson@myhousecallmd.com

We, at House Call, MD, are big fans of the “snuggle”.  There are few people on this planet will not benefit in some way from a hug, massage or simple back rub.  A recent New York Times article suggests that we may be on to something (1).  While outright snuggling may create interesting and awkward scenes in the workplace, recent studies are showing that positive interactions involving touch may increase in human performance.

Before we dive into the details of the research on this topic and the science behind them, let’s start with some simple logic: If touch makes us “feel better” and “feeling better” makes us work harder, then it follows that positive or cooperative touch can improve performance.  Seems fairly reasonable to us.  Now on to the science behind the theory.

First, we must show that touching someone is a means of communicating—right?   Some of the most compelling studies regarding the role of touch in communicating emotion are currently being performed at UC Berkeley.  The most recent study sought to show that a wide array of emotions could be conveyed between two complete strangers using only touch.  What is interesting to us is how they conducted their study…

Imagine you are a freshman in college taking a Psychology course and, as part of your grade, you are required to participate in a study currently taking place on campus.  As part of the study you are taken to a small room and blindfolded (and yes, this does sound like the opening scene of a cheesy horror film, but stick with us).  After a minute, an individual enters the room, slaps your wrist, and walks out.  You are then given a list of emotions and asked to identify the emotion the other person was trying to convey to you.  You circle your answer (What would you answer, by the way?), re-blindfold yourself and wait for the next assault.  An individual walks in for the second time, hugs you, and leaves.  You are given the same list of emotions to choose from…etc.

The experiment showed that touch, independent of words, sounds or facial expressions, functions as a distinct means of communicating emotion.  The emotions that were successfully communicated in this study include: anger, fear, disgust, love, gratitude, sympathy, happiness and sadness.  Pretty impressive, right?

You may still be thinking “OK, so how is snuggling supposed to make me perform better?”  This is where the fun comes in.  Michael Kraus of UC Berkeley conducted a study examining the role of “tactile communication” (a.k.a. touching) and its effects on the performance of NBA players (2).  The study hypothesized that players who touched fellow teammates more often throughout a game would be more successful on the court.  They believed that the same would be true for entire teams as well (i.e. the more high-fives and butt pats, the better the team would play).  They watched each individual player in the NBA for an early season game and tallied the number of times the player touched a teammate. “These celebratory touches included fist bumps, high fives, chest bumps, leaping shoulder bumps, chest punches, head slaps, head grabs, low fives, high tens, full hugs, half hugs, and team huddles.”  Can you imagine a bunch of scientists sitting around a television tallying “chest bumps”?  Welcome to the wacky world of UC Berkeley.  After assigning each player a score based on the number of touches throughout the game, the researchers quantified each player’s performance throughout the season in terms of points scored, rebounds gained, successful passes completed, and a number of other parameters that make a player valuable.  The researchers found that the more a player touched his teammates in that early season game, the more successful the player was that season. Teams that had the highest number of positive touches between players were also the most successful teams in the NBA!

According to the study, the Boston Celtics and the Los Angeles Lakers were at the top of the list of the touchiest teams, while the Sacramento Kings and Charlotte Bobcats were the least touchy teams in the league (1).  And the league’s most touchy-feely player?  Kevin Garnett of the Celtics (see photo of picture-worthy hug at left).  While the study showed a correlation between touching and performance, they did not prove that touching causes improved performance.

This observation has been studied in other settings as well.  Tiffany Field, one of the more prolific touch researchers, studied women with prenatal depression.  In the study, they compared participants whose partners gave them a regular massage to a control group in which the subjects got didily-squat (isn’t that sad?).  Guess what they found? Yep, those receiving regular rub-downs reported both a decrease in pain as well as improved relationships with their partners (3).  The same group of researchers studied autistic children and showed that touch therapy (which consisted of 15 minutes of physical contact two times per week for four weeks) was associated with less touch aversion, off-task behavior and stereotypic behavior and improved attention, behavior regulation, social behavior and initiating behavior (4).  Put simply, autistic kids were able to more easily control their behavior (this is one of the biggest challenges of the disease).

What is the science behind these observations?

Lets look at two hormones the body produces in relation to touch: oxytocin and cortisol.

Oxytocin

Oxytocin is the ultimate snuggle hormone.  It is best known for its action in pregnant women and is particularly responsible for milk “let-down” (a.k.a. allowing the milk made in the mammary glands of the breast to move to a “holding chamber” so that when the baby sucks on the nipple, milk is actually released).  Interestingly enough, the very act of suckling causes an increase in release of oxytocin by the pituitary gland (we have no political position regarding that statement.  Use this newfound knowledge at your own risk).  It is self-perpetuating cycle to make sure babies get the food they need!  In terms of pregnancy, oxytocin also prepares the cervix for the birthing process (“Pitocin”, as oxytocin is called in this setting, is used as a topical gel to move things along and get the baby out faster).

Oxytocin is not only found in pregnant women…no need to feel left out, gentlemen.  Both men and women release oxytocin in relation to touch.  Studies have even found an increase in its release with warm contact on the skin.   Increases in oxytocin levels have been correlated with an increase in trusting behavior and decrease in fear.  It has also shown to be associated with generosity, empathy and even sexual arousal.   All of these emotions contribute to the formation of a bond between individuals.

Cortisol

On the opposite end of the spectrum, cortisol is commonly referred to as the “stress hormone.”  It raises blood pressure, spikes your blood sugar and suppresses the immune system among other things.   The body naturally increases its levels of this hormone in times of stress and anxiety (Remember “fight or flight” from high school biology?  This is a related chemical reaction).  Interestingly, one of the actions of oxytocin is the inhibition of cortisol.  One would think that a peak in cortisol levels in situations like an NBA game would help with performance.   The research, however, shows that it may actually be beneficial to have some level of suppression of cortisol in this scenario.

Therefore, when an NBA player high-fives his fellow teammate, he is triggering a biochemical signal in his teammate’s mind and body that says, “You can trust me.”  Perhaps it is this sense of security that allows players to push themselves physically and out-perform their rivals.  So next time you are on the spot, whether it be before shooting the game-winning free throw or as you sit down to take that final exam, giving the person next to you a motivating high-five will make a lot more sense.  It may be the “secret-weapon” you have been looking for.

Questions? E-mail Kelly: erickson@myhousecallmd.com

References:

1. Carey, B. Evidence That Little Touches Do Mean So Much.  The New York Times.  February 22, 2010.

2. Kraus, M, Huang, C,  and Keltner, D. Running Head: Touch, Cooperation and Performance.

3. Field T, Figueiredo B, Hernandez-Reif M, Diego M, Deeds O, Ascencio A.  Massage therapy reduces pain in pregnant women, alleviates prenatal depression in both parents and improves their relationships. J Bodyw Mov Ther. 2008 Apr;12(2):146-50. Epub 2007 Oct 2.

4. Field, T., Lasko, D., Mundy, P., Henteleff, T., Kabat, S., Talpins, S., Dowling, M. Brief Report: Autistic Children’s Attentiveness and Responsivity Improve After Touch Therapy. Journal of Autism and Developmental Disorders.   Volume 27(3), June 1997, pp 333-338

by Tania Houspian, PharmD 2011 | houspian@myhousecallmd.com

You’re fiancé is sick. His nose is running, he’s sneezing every two seconds while concurrently coughing up a lung.  In between all these bodily functions, he still manages to complain about how sick he is.  On your side of the bed, you’re struggling to get a good night’s sleep because you have work early the next morning. You drag yourself out of bed and head to the local 24-hour pharmacy hoping to find something (really anything) to help his symptoms and your chance of getting some sleep.  Instead of finding the remedy to soothe his symptoms, you develop a symptom of your own: a headache.  As you look around the never-ending aisles of drugs, you realize you have no idea where to start.  They all promise to alleviate every symptom under the sun.  What’s the difference between them all?  Your head begins to pound.

Let’s back up the story to the point at which he caught the cold. It’s called the common cold because, well, it’s common.  It’s all around us.  It turns out that there are over 200 viruses that can cause the “common cold.”  So yes, you’re surrounded and outnumbered.  People usually get the common cold by touching the virus (i.e. touching something someone with a cold sneezed on) and then touching their eyes or nose (yes, you can get sick from touching your eyes with infected hands).  We hate to admit it but we are the ones giving the virus a free ride into our bodies.  Another way to catch the virus is by inhaling or swallowing a droplet that someone expelled via sneeze or cough.  Droplets from a sneeze can travel up to 30ft away (impressive and terrifying at the same time) and infect someone on the opposite side of the room. Now you see why your mother always told you to cover your mouth and wash your hands after you sneeze?

So let’s say your fiancé is a teacher and caught the virus from one of his students at school whose mother never taught him to cover his mouth when he sneezes (not a rare scenario since 75% of viral infections are transmitted by children).  About 1-2 days after catching the virus, he started to complain of a sore and scratchy throat. Day 2 started off with a symphony of sneezing and sniffling.  Then there’s the predictable transition in your nose: clear discharge slowly becoming hazy and booger filled later on as the infection progresses.  Day 2 -3 is when things heat up (i.e. you develop a fever).  Children and older adults are more likely to develop a fever while everyone else usually just gets that general feeling we medical professionals call “yuck + aches.”  Days 4 and 5 bring coughing.   Early on, nothing came out when he coughed (called a “dry cough”) but as the cold progressed he started coughing up sticky mucous clumps (predictably called a “wet cough”).  This is the general scheme of how the common cold progresses.  At the same time, every individual is different and every virus is different.  The common cold is also different from the flu which has similar but more severe symptoms that last longer.  The common cold usually last 5-12 days while the flu can last anywhere from 2-3 weeks.

Now lets go through each symptom and outline the medications of choice to minimize the suffering.  Remember, there is no cure for the common cold for many reasons, one of which being the fact that so many different viruses can cause it.  All the recommendations below help reduce symptoms so you can go on with your life (and stop his complaining) while his body fights off the cold but they are not “cures” for the cold.  Your body will take care of that on its own.  When shopping for medications, be sure to look at the Active Ingredients.  This is what you are paying for.  Active ingredients are the components of the medication that work to improve your symptoms.  As you browse, you may begin to notice that many of the medications contain similar ingredients…not a coincidence.  What matters when shopping for the right treatment is the active ingredient, not the fancy name and logo on the front of the box.

Symptom 1: Sore/Scratchy Throat

Complaint: “It hurts to talk. It hurts to swallow. It even hurts to breathe.”

A sore throat can make it hard to drink and eat, both of which are very important in helping your body fight off a cold.  Common components of medications that help soothe a sore throat are Benzocaine, Menthol, Phenols, and Dyclonine. Benzocaine and Dyclonine are painkillers and stop your nerves from feeling the sore throat. Menthols are extracted from peppermint or other mint oils and, similar to phenols, produce a cooling sensation in the throat.  They’re all equally effective and come in two different forms (pick whichever better suits your fancy).

• Lozenges: Hard candies you can suck on which release the medication into your mouth and help relieve the pain.  Some common brands include Halls, Cepacol, or Cholraseptic. You can take one lozenge every 2 hours to relieve the soreness.

• Liquids: Usually sprayed, swished, or gargled then spit out. You can use them up to four times a day.

Whichever formulations you choose, remember to try not to eat or drink for an hour after using the medication since doing so will wash away the medication.

Symptom 2: Runny Nose (or “Sniffles” for the under 10 crowd)

Complaint: “My nose has turned into Niagara Falls and I’ve gone through enough Kleenex to fill a landfill!”

You can either blow your nose or do what you did in second grade (remember taking a big sniff and swallowing your spoils…yum).   You can also try something that will stop the flow (the more socially acceptable approach).  The class of medications usually used to relieve the sniffles is called decongestants.  Decongestants cause your blood vessels to contract so that less fluid is allowed to leak out of the capillaries in your nose and, viola, the sniffles go away.  One problem with decongestants is what is called “reflexive vasodilation.”  When the medication wears off, the blood vessels in your nose dilate causing the return of Niagara Falls.  An unfortunate side effect of temporary relief.  Decongestants come in two forms: topical and oral.

Topical decongestants come in little spray bottles that you insert in your nostril, delivering the medication directly to your nasal capillaries.  Some common topical decongestants are:

• Short-Acting (will relieve runny nose for 4-6 hours)

  • Ephedrine

  • Epinephrine

  • Naphazoline

  • Phenylephrine

  • Tetrahydraoline

• Medium-Acting (8-10 hours)

  • Xylometazoline

• Long-Acting (12 hours)

  • Oxymetazoline (Afrin)

When shopping for your decongestant, take into account how long you want the medication to work.  They are included in many different brand name decongestants so be sure to turn the bottle around and read the back where it tells you the “active ingredients.”  Oxymetazoline is a popular one since it works the longest and can be found as the brand name “Afrin.”  An important note about topical decongestants is that using them longer than 3-5 days will actually cause a condition called rhinitis medicamentosa (fancy word for your runny nose will get WORSE…a much more severe form of reflexive vasodilation).  Take Home Message: don’t over these medications and start to wean yourself off of it after 3 days.

Oral decongestants come in tabs and take longer to work since you don’t apply them directly to your nose.  The two most common ones are Phenylephrine and Pseudoephedrine.  Phenylephrine is shorter acting (about 3 hours) while pseudoephedrine can work for up to 12 hours with one dose.  All pseudoephedrine-containing medications (brand name is usually Sudafed) are stored behind the counter at the pharmacy.  You have to show your ID to prove you’re over 18 and sign a document in order to purchase it.  Why?  It turns out that people have figured out a dangerous way of making an illegal drug using pseudoephedrine and the government would like to discourage such activities.  If you have high blood pressure or are pregnant/breastfeeding, avoid using this product since it causes blood vessels to constrict which is unfavorable in any of those conditions. Also, oral decongestants can cause you to become more alert and energized so avoid taking them close to bedtime…unless you want to pull an all-nighter when you’re sick.  We wouldn’t recommend it.

Symptom 3: Sneezing

Complaint: “AAACHOOOOOO! If I sneeze one more time my head may explode.”

Sometimes a sneeze feels great.   When you’re sick, it just hurts. So what can you do to make them stop?  Antihistamines are typically used for allergies but they also decrease mucous production throughout your body.  Take an antihistamine and you can say goodbye to sneezing, runny nose, itchy throat, and runny eyes. Yes, antihistamines are amazing. The downside is they can be very sedating.

• Most sedation: Diphenhydramine (Benadryl), Clemastine fumarate (Tavist)

• Intermediate sedation: Pyrilamine maleate (Theracof), Pheniramine, Brompheniramine (Dimetapp), Chlorpheniramine (Chlor-Trimeton), and Tripolidine (Actifed)

• Least sedating: Loratadine (Claritin) and Cetirizine (Zyrtec)

If you’re about to go to bed, taking Diphenhydramine may not be such a bad idea since it’ll help you fall and stay asleep.  If you’re about to go to work, Loratadine is the better choice.  It’s all a matter of what you need at that time.

Symptom 4: Fever

Complaint: “I’m hot then I’m cold. I feel like Katy Perry.”

Treating a fever is tricky because a fever can be an indication of a more severe illness than your garden-variety common cold. If you have a fever for more than 24 hours you need to see your doctor.  If you have a fever and you’re taking medications to help reduce it but the fever continues to get worse even after three days of treatment, definitely go see your doctor.  The best medications to take for a fever are Acetaminophen (Tylenol) or Ibuprofen (Motrin, Advil).  They both work equally well to lower a fever.  They both come in many forms including tablets, capsules, liquid capsules, liquids, and suppositories so pick whichever you’re most comfortable with.

Tylenol overdoses are more common than we would hope and are very dangerous (Tylenol can wreak havoc on your liver).   Be sure you are not taking too much and follow the directions on the bottle carefully. The maximum amount you can take is 4000mg (4 Grams) per day. Ibuprofen is safer but it’s recommended that you take no more than 1200 mg a day.

If you have a child with a fever, just go see your doctor.  Fever-reducers are much more complicated and dangerous in children so working with a pro is recommended here.

Symptom 5: Cough

Complaint: “Between sneezing and coughing I have no time left for breathing…which I can’t do anyway since my nose is so stuffed up!”

There are two types of cough (as we previously mentioned): nonproductive and productive. Nonproductive coughs are dry hacking coughs during which time nothing comes out (i.e. nonproductive).  Productive coughs are the ones where you get a nice surprise in your mouth at the end (yup, a gooey ball of mucous). These two types of coughs are treated differently.

For nonproductive coughs, try Dextromethorphan (Robitussin) or Diphenhydramine (Benadryl).  We don’t know how Dextromethorphan works and some doctors claim that it really doesn’t.  It’s one of those medications that has been around for such a long time and used so frequently that nobody bothered to study it.  Diphenhydramine (yes, our friend the antihistamine is back) is actually one of the best treatments for a cough caused by the common cold.  It’s great at bedtime if you want to fall asleep and will prevent you from waking up coughing. No cough and a good night’s sleep sounds pretty awesome to us.

For productive coughs, Guaifenesin (also called Robitussin) is the way to go. Guaifenesin won’t stop your cough but it will make it easier to cough up the mucus in your airway so that you will eventually stop coughing.  Out is better than in.  It’s important to drink lots of water when taking this medication (and when your sick in general).  Drinking water helps the drug loosen up the mucous, making it easier to cough out.  Getting rid of all this mucous will help eliminate the infection as opposed to stopping the cough and keeping the virus-infected mucous in your throat and lungs.

You now know the basic components of just about every cold and flu medication on the market.  There are tons of combination products that mix and match ingredients to suit the limitless permutations of symptoms.  Next time the common cold strikes, turn the bottle around read the ingredients.  You know how to treat each of your symptoms in a much more strategic fashion.  If you forget, you can always ask your friendly and knowledgeable pharmacist (or just print out this article and take it with you to the drug store).

We’ve gone over the most accepted treatments of common cold symptoms.   What about all that other stuff you find in the aisle?

The “Other Stuff”

Airborne

When Airborne hit the market in 1999, who wasn’t swearing that it could cure the common cold?  Nine years later, Airborne Health, Inc. found itself waist-deep in class action law suits for making claims about therapeutic efficacy that it couldn’t support with medical research.  All the lawsuits were settled out of court and Airborne Health, Inc. paid truckloads of money to make the lawsuits go away.  The main problem was that Airborne claimed it could “prevent or reduce the risk of colds, sickness, or infection; protect against or help fight germs; reduce the severity or duration of a cold; and protect against colds, sickness, or infection in crowded places such as airplanes, offices, or schools.”  Not a single clinical trial was done to prove that any part of that statement was correct.  If you’ve checked out their website or commercials, you know that a lot has changed.  Now they only claim that, “The Airborne health formula helps to support your immune system through its blend of vitamins and minerals.”

The verdict?  Their new advertising campaign is much more accurate.  Airborne is simply a combination of vitamins and minerals that your body will generally be getting from a well-balanced diet.  It never hurts to take a multivitamin to compensate for any dietary deficiencies but that’s all Airborne is.  It has higher amounts of specific vitamins, like vitamin C, than your average multivitamin.  The adult tablets have 1000mg (1gram) of vitamin C.  If you took the tablets the way they recommend you do (every 3 hours while awake) you would be consuming up to 5 grams of Vitamin C per day.  Doses that high aren’t necessarily bad for the average person but they can cause kidney stones in certain individuals.  In addition, there is no benefit to taking that much vitamin C (unless you enjoy a good dose of diarrhea which doses that high can cause).  Doses of 2-3 grams per day have been shown to help reduce the duration of cold symptoms but do nothing for the severity of the cold.  Also, Vitamin C does not work as a preventative measure.

The Final Verdict: Sure, go ahead and take airborne as long as you realize you are taking an overpriced yet tasty (yum, pink grapefruit) multivitamin.  Oh, and it’s not a miracle cure.  Did we mention that?

Zicam

Zicam brand makes every form of medication you could ask for.  From nasal swabs to lozenges, they are working hard to please the full spectrum of consumers.  Their line of products called “Symptom Relief” contain the spectrum of medications we discussed earlier (from menthol to Tylenol) so make sure you read the back before you buy any of them.   You may be just able to buy a bottle of Tylenol and a decongestant for less money.  The Zicam uniqueness is found in their line of “Cold Remedy” products.  The active ingredients in this line of products are Zincum Aceticum and Zincum Gluconicum (different forms of Zinc). One line of zinc-containing products (Zicam Cold Remedy Nasal Gel, Zicam Cold Remedy Nasal Swabs, and Zicam Cold Remedy Swabs, Kids Size) was completely removed from the market because they caused people to lose their sense of smell (definitely not a good thing).  These were zinc-containing products that were applied directly to the inside of the nose.  NOTE: If you have any at home, throw it away!  The company is currently considering the FDA’s request to discontinue the product…until the controversy settles, don’t use them.

Back to the other zinc-containing products: The makers of Zicam believe that zinc prevents the rhinovirus (one of the viruses that causes a cold) from invading human cells.  Some studies have found that zinc-containing products can shorten the length of time cold symptoms last and minimize the severity of the common cold if they are taken within 24 hours of symptom onset.  Other studies claim that these initial studies were poorly designed and that zinc does little to help with the common cold.  Who should we believe?   Let’s think about this logically.  If Zicam prevents the rhinovirus from invading human cells but there are over 200 different viruses that cause the common cold, the odds of Zicam helping your particular cold seem slim.  On the other hand, rhinoviruses are the most common cause of the common cold so the odds go up a bit.

The Final Verdict: It really depends the particular virus you have.  If you take Zicam as soon as you develop cold symptoms and you don’t get better, you probably don’t have a rhinovirus.  At this point, refer to all of the medications outlined above that have been proven effective for your cornucopia of symptoms.

You are now officially an informed consumer!  Next time you’re in the pharmacy shopping for treatments for your cold symptoms, flip the box around and strategically target your symptoms of choice with the correct active ingredient.  No need to suffer any longer!  We wish you a sneeze-less, cough-less, and complaint-less night.  Go get some shut eye.

Questions?  E-mail Tania: houspian@myhousecallmd.com

by G. John Mullen, DPT 2011 | mullen@myhousecallmd.com

Fantasy baseball drafts and spring training are in the air…you can almost smell the finely cut grass, taste the $10 hot dogs and feel the $20 beer in your hand.  At the same time, the beginning of the season comes with big question marks hanging over the heads of players with injuries: Tommy John surgery, alcohol related rehabilitation, and hamstring strains (aka “pulling a hammie”) to name a few.  Most regular folk have experienced a hamstring strain and know it does not get better without a fight and a bottle of Georgia Moon (maybe not the later for everyone).   Before we get into treatment lets hit the basics of the hamstring.

Stat Fact: One-third of hamstring strains will recur with the highest risk of recurrence occurring 2 weeks after the initial injury.

Getting to Know Your Hammies

The hamstring is the predominant muscle in the back of your thigh.  The hamstring is composed of three muscles (biceps femoris, semimembranosus, semitendinosis…in case you were wondering) and their primary collective action is to flex the knee.  The most common cause of a hamstring strain is from the “eccentric use of the hamstring” while running. The eccentric use of the hamstring is highest when your leg is extending, off the ground, and swinging forward prior to hitting the ground for your next step.  This stage is termed the “terminal swing” (and yes, we realize this sounds more like a carnival ride than a leg movement).  The eccentric load is highest due to the amount of stretch it places on the hamstring muscles (this is similar to the strain you feel in a straight leg raise).

How do you know if you’ve hurt your hamstring?

Hamstring injury usually presents with a pop, pain in the back of the leg and decreased strength and range of motion.  The strain can occur in any of the three hamstring muscles at any point in the muscle, but the most common site for a strain is either behind the knee or near the butt.  Hamstring strains are classified by the amount of pain, weakness and loss of range of motion associated with the injury.  They are commonly graded on a 1-3 scale with I being mild, II is moderate and III is severe.  The duration of the injury depends on the site and size of the injury.  If you have a large tear near your butt, you’re what we physical therapists call “pretty screwed.”

Stat Fact: The attachment of the biceps femoris is at the outside of the knee (where the complete tear is identified in the picture above).  This particular region is the most commonly strained part of the hamstring muscles because it undergoes the highest amount of stretch amongst the hamstring posse.

Hamstring Hangover

The goal of rehabilitation is to return the athlete to their prior level of performance while minimizing the risk of injury recurrence.  Multiple factors contribute to a high re-injury risk of the hamstring: (1) persistent weakness in the injured muscle, (2) reduced flexibility due to scar tissue, (3) impaired movement/biomechanics due to injury.  Strengthening the hamstring is a fundamental component of rehabilitation and needs to include eccentric (muscle lengthening) and concentric (muscle shortening) exercises.  In addition to strengthening your hamstrings, the muscles attached to the pelvis are often weak and require assessment and strengthening. Rehabilitation of grade I and II hamstring strains can be broken into three distinct phases:

Phase I:

The goal of the Phase I is to decrease swelling, pain and scar tissue formation. You should avoid excessive stretching of the hamstring in this phase since over stretching can increase scar tissue formation. To avoid over stretching, limit your knee flexion range of motion by taking shorter strides while walking or using of crutches.  Ice should be used 2-3 times per day for 15-20 minutes with an ice pack to decrease swelling and pain (no more than 15 minutes at a time as longer amounts of time may increase swelling).  Exercises in Phase I should not stress the injury site. The most common exercises prescribed during this phase are single leg balance (seen in the picture to the left), isometric abdominal exercises, and lateral stepping drills (grapevine/karaoke).  Advancement from the first stage of rehabilitation includes normal walking and stride length without pain, light jogging without pain, and a lack of pain while resistance is applied with the knee bent to 90 degrees (lay on your stomach with your knees bent to 90 degrees and have someone gently pull your ankle down to the floor…pain = no good). Phase I is typically 5 days long but as doctors love to specify that “it depends.”  It always depends.

Phase II:

The goal of Phase II is to increase intensity of exercises, increase range of motion and to begin eccentric exercises. Ice is typically used after training to decrease pain and inflammation associated with exercises.   In Phase II exercises, we increase speed and intensity of agility drills.  Side to side agility drills should be utilized to decrease the risk of overstretching the muscle.  At the end of Phase II, you can progress agility and strengthening drills to include forward and backward movements (supine bent knee bridge walk-outs…Google it).  Eccentric strengthening is initiated and incorporated as functional movements (light jogging, moderate high knees) instead of isolation exercises.  To progress to Phase III, the participant must be able to 1) pull with the full strength of your hamstring against resistance with your knee bent to 90 degrees and 2) forward and backward jogging at 50% of maximum speed without pain. Phase II typically last 1-2 weeks.

Stat Fact: Mobilization (lengthening) of skeletal muscle 5-7 days after injury can enhance fiber regeneration.

Phase III:

Phase III involves sport specific movements with no range of motion restrictions but sprinting and high accelerations should be avoided until return-to sport-criteria are met.  Ice should be used as needed after rehabilitation exercises.  Exercises in Phase III involve sport-specific exercises emphasizing quick direction changes and proper technique.  Trunk stabilization should be improved with movements in multiple planes of motion. Single leg bridges and single limb windmills (see picture) are examples of high intensity exercises.  In order to be cleared to return to the sports you need full range of motion, strength and functional abilities (cutting, running, jumping). Phase III usually lasts 1-2 weeks.  The total time for hamstring recovery is typically 3-5 weeks.

Prevention:

To prevent hamstring strain, we recommend a combination of stretching and strengthening exercises. Research studies have not shown any significant benefit to stretching your hamstrings therefore static hamstring stretching is not the best prevention tip.  However, scientists believe that an improper length of the quadriceps and hip flexors are a risk factor for hamstring strains.  Therefore, increasing flexibility of these muscles is mandatory to prevent hamstring strains.  Additionally, research showed that eccentric hamstring training prevents strains.  Eccentric hamstring training should be incorporated into a preseason and in-season training program for all athletes at risk for hamstring injuries.  An exercise routine for eccentric hamstring training can include Romanian dead lifts, knee fall downs and single leg Romanian dead lifts (see picture above). Lastly, exercises that incorporate the lower extremities and pelvis are associated with a decreased risk of hamstring strains.  Examples of these exercises include high knee marching, forward-falling running drills, and explosive starts.

Reiteration:

Prevention is the key here!  Make sure warm-up for 10-15 minutes (and by “warm-up” we mean activity that raises your heart rate and gets you sweating) before any work out.  Incorporating a proper warm-up, eccentric hamstring training and proper hip flexor and quadriceps muscle length will decrease your chance of the ending up with a hampering hamstring.  Everyone wins!

Questions?  E-mail G. John Mullen: mullen@myhousecallmd.com

References:

1. Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther. Feb 2010;40(2):67-81.

by Kelly Erickson, MD 2010 | erickson@myhousecallmd.com

With record-breaking storms keeping many Americans trapped indoors this winter, it is hard to imagine that summer will ever come.  Daydreaming about your spring getaway or summer vacation to Europe may be your only respite from the cold.  But when you consider vacation, especially one that takes you multiple time zones away from home, one of the major drawbacks is coping with the even harsher reality of “jet lag”.  Whether it requires you to sleep when you arrive at your destination rather than enjoying immediate exploration or demands that you take yet another day off from work once you return home, jet lag is undeniably inconvenient.  Here we will explain the causes of jet lag and how to best prevent it from hindering your well-deserved adventures.

What is jet lag?

According to a recently published article in The New England Journal of Medicine, jet lag is a “recognized sleep disorder that results from crossing time zones too rapidly for the circadian clock to keep pace.”  It is a constellation of symptoms that can include insomnia, daytime sleepiness, fatigue, poor physical performance, cognitive impairment and gastrointestinal changes.  What the scientists meant to say was that you are going to feel lousy.   Jet lag is most commonly experienced after crossing at least 5 or 6 time zones (the East Coast-West Coast trip doesn’t apply here!).  Jet lag is most commonly confused with “travel fatigue”, which is the unfortunate result of the combination of sleep deprivation, stress caused by traveling, diet changes, etc.  While travel fatigue can be easily treated with a little rest and T.L.C., jetlag is a horse of a different color.

How does this “jet lag” nonsense happen?

The body’s circadian clock is located in the suprachiasmatic nucleus (SCN) of the hypothalamus (imagine a point directly between your eyes and two inches towards the back of your head…eureka, you’ve found it!).  It communicates with the retina, allowing it to sense light and dark.  Based upon our regularly predictable cycle of waking and sleeping, the SCN promotes alertness or sleepiness in sync with our daily routine by regulating the secretion of melatonin from the pineal gland.  The system works such that light inhibits the secretion of melatonin.  Therefore, melatonin has often been referred to as the “dark hormone”, because it is only secreted when there is no stimulation by external light (aka nighttime).  The problem with this system is that our circadian clock does not adapt quickly to changes in the cycle (i.e. flying half-way around the world in single day).  Therefore, in the same way that “motion sickness” is the result of desynchronization between visual and spatial stimuli in the setting of movement (didn’t know that, did you?), jet lag is the body’s response to the imbalance between a predicted sleep-wake cycle and a change in external light and dark stimuli.

How to Beat It:

1.  Re-sync your clock. This is accomplished with 2 strategies.

• Timing of Light Exposure: Based on what we now know about the circadian clock, we now understand how light can be used as a powerful tool to “trick” the circadian clock and therefore advance or delay it.  Although it may seem logical to think that sleep itself resets the clock, it is actually exposure to light and dark that is most effective.  What does this mean?  Studies have shown that light exposure should be used as follows after travel. Eastward travel: Upon arrival seek exposure to bright light in the morning.  This will help delay your circadian clock.  Westward travel: Seek exposure to bright light in the evening, which will help advance your circadian clock.

• Taking Melatonin:  Because light inhibits melatonin secretion, recommendations for melatonin are the opposite of those for light exposure.  When melatonin is taken in the evening, it resets the body clock to an earlier time and when taken in the morning, it causes the clock to be set to a later time.  Guidelines for melatonin use are, once again, broken down depending upon the direction of travel.  Eastward travel: Take 0.5mg-3mg at bedtime to shift your circadian clock to an earlier time and help you fall asleep.  Westward travel: Take 0.5mg during the second half of the night to shift circadian clock to later time and allow you to continue to sleep.  When traveling westward, the most common sleep disturbance is difficulty staying asleep.  Therefore, melatonin should be taken after awaking in the middle of the night in your new time zone.

2. Plan out your ZZZZZ’s. When planning a trip, you buy your airlines tickets in advance, purchase your travel books and research all of the best sites to visit.  Why not spend a few extra hours sleeping before you leave to help ease the jetlag when you arrive?  More sleep plus less jet lag sounds like a good deal to us.  In general, this means shifting the timing of your sleep 1-2 hours earlier for a few days before eastward travel and 1-2 hours later for a few days before westward travel.

3. Medication. When all else fails, manage your symptoms with some good old-fashion meds.

• Downers (aka sleeping pills):  Studies have shown that 10mg zolpidem at bedtime helps patients get a good night’s rest after long-distance travel and helps to reduce the symptoms of jet lag.  It’s best if you give the medication a test-run before you leave to ensure that you do not have any unwanted side effects while in the safety of your home country (amnesia and confusion…not so fun in a new city where you don’t speak the language).

• Uppers: Caffeine, while generally discouraged for those attempting to overcome jetlag, can be used in small doses early in the day to increase daytime alertness and decrease sleepiness.  Small doses for those of you who missed that part the first time.

The Take Home Message: Jet lag sucks (as the scientists so eloquently explained) but can be mitigated with some planning, preemptive measures before you leave home, and a little proactive management once you’re on the ground in your exotic location of choice (our advice: print out this article so you can remember all these tips when it’s go time).  There’s no reason to feel like poop during your valuable travel time.  Vacation, here we come.  Now get packing!

Questions?  E-mail the author: Kelly Erickson, MD 2010 | erickson@myhousecallmd.com

References:

1.  Sack, Robert L.  Jet Lag.  The New England Journal of Medicine 2010; 362:440-7.

2.  Herxheimer, A., Sanders, M., Mahowald, M., Sokol, H.N., Jet Lag. UpToDate, 2010.

3.  Herxheimer, A, Petrie, KJ. Melatonin for the prevention and treatment of jet lag. Cochrane Database Syst Rev 2002; :CD001520.

4.  Jamieson, AO, Zammit, GK, Rosenberg, RS, et al. Zolpidem reduces the sleep disturbance of jet lag. Sleep Med 2001; 2:423.

5.  Morris HH, 3rd, Estes, ML. Traveler’s amnesia. Transient global amnesia secondary to triazolam. JAMA 1987; 258:945.

by G. John Mullen, DPT 2011 | mullen@myhousecallmd.com

With the Vancouver Winter Olympics in full swing, tendon injury is a hot topic on news channels across the globe.  Sports fans from every nation will be cheering on their favorite athletes and crossing their fingers for speedy recoveries from accidents incurred during the intense competition in the coming weeks.  Shoulder pain, elbow pain, ankle pain?  These joints are common sources of pain for professional athletes and law-abiding citizens alike.  Whether you have golfer’s elbow, tennis elbow, speed skater’s knee, shoulder impingement, jumper’s knee, Achilles tendon pain, you are suffering from a “tendinopathy.”  Tendons, which connect muscles to bones, are composed of collagen.  Tendinitis is the most common term associated with tendinopathy. Tendinitis is the acute injury of a tendon and is typically associated with inflammation (note that “-itis” means inflammation). Tendinosis is a term used less commonly but refers to the process in which tendinitis becomes chronic (lasting greater than 3 weeks). To understand the disease of tendinopathy, it is essential to understand the design of a tendon, common causes, treatments for the different types of tendinopathies and what you can do to prevent these disorders.

Stat Fact: The prevalence of Achilles tendinosis has been estimated to be between 11% and 24% in runners, whereas the prevalence rate for patellar tendinosis in basketball and volleyball players has been recorded as high as 32% and 45%, respectively⁴.  That’s a lot of tendon inflammation.

Tendon Architecture

As we mentioned earlier, the tendon is primarily composed of collagen, more specifically type I collagen (there are 29 different types of collagen in the body but 4 main types make up 90% of our collagen).  Tendon tissue has a poor blood supply (only 1/3 of the blood supply that muscles have) which means that it takes tendons notably longer than muscles to heal.  Following an acute injury, the tendon strained becomes inflamed (filled with cells trying to repair the tissue).  After chronic use of the tendon, type III collagen becomes predominant.  This change in collagen will make the tendon larger due to increased collagen rather than from inflammation.   Along with the increase in collagen comes an increase in water in the tendon as well.  These two changes make the tendon thicker which you notice as increased stiffness.  At the same time, the tendon becomes more compliant leading to an increased rate of tendon strain after a chronic tendon injury.  Cadaveric studies suggest after a chronic tendon injury, the strain increases causing a decrease in stiffness and strength.  Strain is “the amount of displacement with an external load placed on the object” or, in the cadaveric study, “the amount of displacement increased after injury.”  Essentially, it means the amount of laxity (“looseness”) in the tendon after injury.

Common Causes

The majority of tendinopathies are due to overuse and are caused by such activities as:

• Rapid increase in usage (New Year resolutions…)

• Not warming up properly

• Changes in footwear (for lower extremity tendinopathies)

• Weak surrounding muscles

• Improper muscle length or flexibility

Stat Fact: Achilles tendinopathy is a common overuse injury, accounting for 11% of all running injuries².

Tendinitis Treatment

Tendinitis is an acute tendon injury associated with inflammation. Tendinitis is caused by an accident that causes damage to the tendon or chronic use leading to tendon irritation.  The length of this inflammation is variable, therefore the term tendinopathy is used to classify all the tendon injuries (you know doctors don’t like to put timelines on healing!).  The majority of treatment for tendinitis consists of anti-inflammatory medication or a cortisone shot (used only in extreme situations) administered by the physician.  The list of anti-inflammatory drugs is extensive, including as Ibuprofen, Motrin, Naproxen, Celebrex, and many more.  Physical therapists can help reduce inflammation with a number of treatment modalities (electrical stimulation, low level laser therapy, ultrasound, ice) that can decrease pain and inflammation.  The last and the most important treatment for tendinitis is a temporary discontinuation of the activity that caused this inflammation.  As stated, true tendinitis is from an acute accident therefore discontinuing that activity while the tendon heals makes sense…let’s agree to agree on this one.

Tendinosis Treatment

Treatment of tendinosis is more researched than the tendinitis.  In general, injuries that present to physical therapy and primary care doctors are tendinoses.  Remember, tendinosis develops from long-standing tendinitis and is often mistaken for tendinitis due to the increase in tendon size.  However, this increase is size is due to remodelling of collagen as opposed to the inflammation we see in tendinitis.  Recent studies show that exercise is beneficial for healing tendinosis.  More specifically, eccentric overload training appears to have optimal results.  What is “eccentric overload training”, you ask?  An eccentric exercise is an exercise that lengthens a muscle.  For example, if you are performing a squat, lowering your body down is the eccentric phase of the exercise on your thighs and returning to the start position is the concentric phase for your thighs.  Overload eccentric exercise training studies suggest eccentric training increases stiffness of the tendon and help change the tendon back to type I collagen.  Increasing the tendon stiffness provides the support your muscles need to contract so that it can maintain the muscle in the position where it produces the most force.  Let’s look at another example:  Achiles tendinitis is common in runners.  Mix in a little hard headedness and a desire to keep running despite injury and you have yourself the perfect storm for the development of a tendinosis.   To treat this population of patients, a 12-week exercise program consisting of heel drops has shown excellent results.  This program uses high repetitions of the exercise: 3 sets of 15 repetitions two times a day with progressively increasing external weight (you can add weight to backpack that you wear during the exercise)¹. One key during this exercise is to only perform the eccentric phase of the heel drop with your injured leg.  To do this, slowly lower yourself down on the injured leg (the eccentric phase) and then return to your tippy toes by concentrically using the healthy leg.  This type of eccentric exercise can be used in any type of tendinosis.

Stat Fact: In the study mentioned, participants noted a decrease in pain from an average of 81/100 to 5/100 where 0 represents no pain¹.

Double Stat Fact: Studies suggest that eccentric exercise can change tendon stiffness from a 14% loss in stiffness to a 10% gain in 14 weeks³.

Preventing Tendinopathy

Many times tendinopathies can be prevented with proper warm-up and progression of exercise.  Include proper stretching and eccentric muscle training to muscles at risk for your activity and you will have created an adequate prevention program.

Examples of eccentric exercises for common tendinopathies:

Heel drop for Achilles Tendinopathy:

Begin with your foot on a surface that allows your heel to drop below the height of your foot, while holding onto a handrail, banister or child (ok, maybe not a child) lower yourself slowly on the injured leg.  Push yourself back up on your non-injured leg.

Theraband ankle inversion for Posterior Tibialis Tendinopathy:

Begin in a sitting position and put loop theraband (an thick elastic band) in which the loop is on the inside of your foot.  Move your foot down and in without resistance and then attach the theraband around the foot with high tension.  In a controlled manner, allow the foot return to the up and out position.

Wrist Extension and Flexion for Golfer’s and Tennis Elbow

Begin in a sitting position and allow your elbow to rest on your thigh.  For tennis elbow, begin with your hand facing the floor, with a weight in your hand.  Slowly lower the weight and then use the other hand to bring the weight back up to the starting position.  For golfer’s elbow, begin in the same starting position, but with your hand facing the ceiling and then lower the weight to the floor.

Rehab Recommendations:

During recovery, the following recommendations should be followed for all eccentric exercises²:

• 3 sets of 15 repetitions

• Slow, controlled movements

• Exercise should elicit a moderate amount of pain

• Passive return to starting position with assistance from the non-injured side

• Increase load when pain is minimal or absent

• Perform exercises twice a day

• Avoid aggravating activities for 4-6 weeks during eccentric rehabilitation

References:

1. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med.26(3):360-366.

2. Chang H, Burke A, Glass R. JAMA patient page. Achilles tendinopathy. JAMA. Jan 2010;303(2):188.

3. Narici M, Maganaris C. Adaptability of elderly human muscles and tendons to increased loading. J Anat. Apr 2006;208(4):433-443.

4. Wasielewski N, Kotsko K. Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis? A systematic review. J Athl Train.42(3):409-421.