Tuesday, July 31, 2012

Stress Fractures: Are You At Risk?

With the Olympics now well under way, it never ceases to amaze me what the human body can do. Yes, the accomplishments and speed of the runners and swimmers is outstanding, but I see these guys in clinic everyday. What I don't see as often are the incredible gymnasts and divers that tumble and fly through the air. I am amazed, not so much that they don't injure themselves on their landing or entry into the water. They're too good at this level to miss by much. What amazes me is that they don't have more repetitive injuries like stress fractures.

Back in the "olden" days, stress fractures were extremely rare. They tended only to occur in highly repetitive activity. The old nickname was "march" fracture, due to the frequency they occurred in the military.  Other activities simply weren't done often enough to cause the fractures. These days, it would be a slow week at the sport clinic if I didn't see one or two stress fractures come through the doors.
In fact, in my practise, the group I most often see now, are middle aged females training for their first long distance race.

Risk Factors

1. Highly Repetitive Activity.
Sports involving running, where the body is exposed to the same pounding over and over are at most risk. Other activities like gymnastics, figure skating, rowing are also at risk, where the same motion occurs over and over.

2. Being Female
Simply being female is, unfortunately a risk factor for a number of reasons. Bone density may not be as strong, if periods aren't regular, it contributes to increasing risk, and if body fat is extremely low, it elevates the risk of stress fractures.
There is a syndrome called the female athlete triad, which consists of amenorrhea (lack of periods), low bone  density, and eating disorders (like anorexia), which should be screened for if a woman comes in with stress fractures.

3. Sports Where Weight/Appearance is an Issue
Any sport where the athlete has to "make" weight, like rowing or even boxing can put one at risk, as these athletes commonly have to drop their weight dramatically over a short period of time. Appearance sports like gymnastics, diving, figure skating etc, also contribute to weight/body image issues.

Bones at Risk

The areas at risk depend a lot on what the activity is that you are doing. Runners tend to experience stress fractures in the foot, most commonly at the 2nd metarsal, and the navicular (inside portion of the foot). They can also fracture the tibia, and more rarely in the hip.

Gymnasts and divers, who commonly put many times their body weight through their wrists, can cause stress fractures in the distal radius, and a number of small bones in the wrist. If growth plates are not closed yet, these can also occur in the elbow.

How Do I Prevent Stress Fractures?
At a non-Olympic level, the more cross-training you can do the better. Try to change the activity you do each day. If you're a runner, cycle of use an elliptical machine on alternate days.

Eat! Not a problem for most of us, but if you are involved in an appearance sport, get the advice of a dietician to ensure you are getting enough calories. I can't emphasize this enough. Find out how much calcium/Vitamin D you need for your age and sex. Don't worry about your appearance. You look great. Trust me.

Proper equipment is essential. Runners need to change out their shoes every 6 months, or approximately 500 miles, whichever comes first. Get the right shoe for your foot type. Get proper wrist protection if you dive or tumble. Make sure your skates and technique are correct if you are figure skating.

Women over 65 or those who have other risk factors should have a bone density done.

Have you ever had a stress fracture? Know anyone at risk? Let me know what you think!

APPENDIX: Quick Screen for Female Athlete Triad
1. Do you ever worry about your body weight/composition?
2. Do you limit/carefully control your food intake?
3. Do you try to lose weight for your appearance/weight due to your sport?
4. Does your weight affect the way you feel about yourself?
5. Have you felt that you have lost control of the way you eat?
6. Do you make yourself throw up after you eat?
7. Do you currently or have you ever suffered from an eating disorder?
8. Do you every eat in secret?
9. At what age was your first period?
10. Do you have regular monthly cycles?
11. How many periods have you had in the last year?
12. Have you ever had a stress fracture?

Answering yes to any of these questions should prompt a further evaluation by a trained sport medicine specialist.

Tuesday, July 24, 2012

Review: Daryl's Chocolate Elite Bars

I'll admit it. I'm a sucker for the convenience of protein bars. While I'm working, the portability and satisfaction a protein bar can give between seeing patients is too good to pass up. The trouble is, many of these bars have too many preservatives, too little fibre, and too much sugar.

A few years ago, I discovered a local manufacturer in Windsor, Ontario, Canada, that hand makes All-Natural High Protein Bars daily. No preservatives, natural sweeteners (honey, molasses), high fibre, and high in protein. Perfect - on paper. Do they taste all right?

Chocolate Elite

Truly outstanding. Daryl's Hi-N-R-G Bars bars make 6 different bars, but my favorite are the "Chocolate Elite" Bars. I enjoy the texture of the toasted oats, with sweetness coming from just a little bit of honey and molasses. (The drizzle of chocolate on top doesn't hurt either!) The tartness of the dried fruits (cranberries, blueberries, raspberries, and blackberries) are a great balance.

Chocolate Elite

In Protein bars, I like to see a protein:fat ratio of 5-6 grams protein to 1g fat, and these bars are certainly in that ballpark. The fibre content is outstanding, and the total sugars relative to carbs is low making them a good low glycemic choice.
My one caution to people is that at 288 calories per bar, if you are watching total calories, either cut them in half, or consider them as a treat.

I love finding great products close to home, and am proud to see a Canadian Company doing a good job.

Have you had these before?
Let me know what you think!

Thursday, July 19, 2012

Dark Chocolate is Officially Good For You

In a formal press release yesterday, the European Food Safety Authority (EFSA) supported high end chocolatier  Barry Callebaut's scientific claim that "cocoa flavanols have a positive impact on blood flow". Specifically, his company was able to show that cocoa flavanols helped maintain endothelial dependent vasodilation.

Put more simply, this allows blood vessels to relax and open up, allowing for better blood flow. The health benefits of this may help lower blood pressure, and decrease risk of cardiac related events. Of course, none of this extrapolation has been proven yet, but the basic science has.

In real world terms Callebaut's labs showed that 200 mg of cocoa flavanols (equivalent to 10g of high flavanol dark chocolate, or 1/10 of a chocolate bar!) could positively influence circulation.

The next stage in Europe is for the EU Commission to approve the health claim, which seems quite likely at this point, and if so, would allow Barry Callebaut to apply the claim on packaging, and market chocolate with high flavanol content as "good for you".

Take note:  It was the high cocoa flavanol content that produced the positive result. In most conventional chocolate making, this is destroyed, so would not have the same benefits.
Generally speaking, the darker the chocolate, the higher the flavanol content. In Europe, dark chocolate is defined as a minimum of  35% cocoa solids.

What to make of this?
It certainly appears that flavanols may benefit vascular risks, but as always, in moderation. The benefits were shown with the equivalent of ONE piece of a standard chocolate bar, and more is certainly not always better.
Europeans tend to be much better in moderation than their North American counterparts, and I think moderation is the key here.

For today, savour your piece of dark chocolate, and feel better about it!

Let me know what you think!
Will you start eating more dark chocolate?

Wednesday, July 18, 2012

5 Tips To Running Smoothly

It's been as hot as I can ever recall July being in Southern Ontario this year. The heat has made it awfully difficult to enjoy my runs, but keeping cool and running efficiently has helped. I wanted to pass on some simple techniques to make your running a little smoother.

1. Relax.
Easy to say, hard to do. I like to think about every muscle group from head to toe (literally), and make sure I'm not tensing up unnecessarily. I especially focus on this while on the treadmill, where it can get awfully boring! I start at the head and work my way down, ensuring I'm as relaxed as possible. Make sure you're not clenching your jaw and your facial muscles are relaxed. Don't tense your arms and don't ball up your fists. Shake your hands out gently. Make sure your legs flow freely and loosely.
Staying loose allows your running form to begin to flow more naturally and smoothly. Unnecessary tension can lead to early fatigue.

2. Breathe Rhythmically.
Again, really easy to tell you to do, but difficult to achieve practically. I like to tell newer runners to try and inhale and exhale for as close to an equal length of time as possible. If you can, try to inhale through your nose and exhale through your mouth. This slows the inhalation phase, and keeps the mouth from drying out. The nose also filters out a little of the air pollution and smog we've been experiencing with all this heat!
I also suggest maintaining a fixed rhythm of breathing with your foot strikes, although each individual needs to find the rate that work best for them. For example, perhaps it's 4 strides for every breath in, and 4 strides for each breath out for you. For an elite runner it could be as slow as every 6 or 8 steps for each breath. Again, try and keep it as even as possible.

3. Efficient Forward Motion.
The goal in running, ultimately, is to move a body forward through space. So, try to picture your body moving as smoothly, and in as straight a line as possible. Think of your arms and legs as pistons propelling your body, and moving only up and down. Try to avoid swaying side to side. Envision your arms moving in smooth arcs taking you forward.

4. Look Forward, Not Down.
I see far too many people looking down at their feet when they run. Not only is this potentially dangerous, as you aren't paying attention to traffic and your surroundings, but it also leads to poor form. Keep your head up, and focus your vision on a spot about 50 yards down the road. That "spot" should remain relatively steady as you move forward. If it seems to be bouncing, your stride is getting too long.

5. Focus on Foot Strike.
Finally, really focus on your foot strike. Land gently on your heel, and roll forward, all the way to your tiptoes. Think of your foot as a rocker bottom, and try to roll through the entire length of your step. Think about springing off your toes to maximize your next stride. Using this technique will cushion your foot stike, and explode into your next step.

Although this is condensed into 5 steps, it's quite a bit to think about. On your next run, pick one of them, and really focus on making a small change. Keep adding more, and as they become second nature I think you'll soon find your runs effortless!

Let me know what other techniques you use!

Monday, July 16, 2012

A New Debate on Milk?

While I generally enjoy Mark Bittman, his most recent article on the necessity of milk, or lack thereof, is controversial at best. His premise that it's "a pretty good sign that we’ve evolved to drink human milk when we’re babies but have no need for the milk of any animals" makes no sense.

Being of Asian descent, I can certainly attest to the fact that there are many, many people who are lactose intolerant, but well done, double blind, randomized trials (NEJM), show that even individuals who are truly lactose intolerant can easily tolerate a cup (250 ml) without significant clinical effects.

Mr Bittman quotes Neal Barnard, who states,“Sugar — in the form of lactose — contributes about 55 percent of skim milk’s calories, giving it ounce for ounce the same calorie load as soda.” Not sure where this data comes from but 1 cup of skim milk contains 86 calories, 12 g of which are from carbohydrates. This equates to 48 calories or, yes 56% calories from sugar.
The logic falls apart when you do the calculations for soda. 1 cup of Coca-cola (from their website) contains 100 calories, of which 27 g are carbs, equating to 108 calories, which is actually >100% calories from sugars! I'm not sure where Neal Barnard calculated his data from, but this sort of misinformation is not helpful, and potentially harmful. There really is NO comparison between the value of milk and soda in any sense.

I completely agree that other dairy sources such as hard cheeses and yogurt are better tolerated and digested than milk, but don't think milk should be discarded for soda!

I am happy that Mr Bittman has solved his own personal health problems, but to make an argument that we should stop drinking milk is based on misinformation at best, and possibly harmful at worst.

Let me know what you think!

Sunday, July 15, 2012

Quick Recipe: Hummus

Very rarely does my daughter request something healthy in her lunch, so when she asks for hummus, I really can't complain. Hummus is essentially a chickpea dip, which is OK by me. Chickpeas are an outstanding source of protein, fibre and zinc. The taste and texture is fabulous.

Promise me you'll never buy store bought hummus again. This recipe takes less than 5 minutes to construct, has no preservatives, very little fat, and tastes  fresher and brighter than anything you can buy in a package. Oh - and also costs less than a quarter of what you'll pay for at the grocery store.

Preparation Time: 5 minutes.

1 14 oz can of chickpeas (garbanzo) beans
1/2 tablespoon tahini
1 tablespoon freshly squeezed lemon juice
1 tablespoon extra virgin olive oil
1/4 teaspoon smoked paprika
1/4 teaspoon cinnamon
salt and pepper to taste

Pour all ingredients into a mixing bowl and blend to desired consistency with an immersion blender.
I like to leave mine a little chunkier than smooth, so it sticks better to whatever you dip.
Serve with crunchy vegetables like carrots or celery or cauliflower, and/or flatbreads, pita triangles or bread.

I sometimes change up the spices, but the smokiness of the paprika is always the best thing for me!
Let me know what you think!

Saturday, July 14, 2012

Practical Concussion Management

The first job as a physician is "First, do no harm". Perhaps nowhere is this more important than in treating concussions in sport. If you are unsure what to do, always remember - don't make the situation worse.
If you're attending a game, on the sideline, in the stands, where ever, this is perhaps the best advice I can give you.

Having said that, here are a few practical things to consider if you witness a head injury at a game.

1. Principles of First Aid.
I try and start with the classic ABC's. Does the athlete have an adequate airway? Are they breathing? Do they have a pulse (circulation).  If you can ensure these things are happening, you're doing awfully well already. This can all be assessed within seconds.
Please take note: The "do no harm" part of here is, don't let the neck move until you,or someone who is qualified ensures that the neck has not been injured.

2. Assess The Athlete's Symptoms.
If the athlete is still breathing and conscious, then you're allowed to take a breath now too. The assessment tool I use on the sidelines is called the SCAT2. This stands for the "Sport Concussion Assessment Tool" and allows for a standardized means of assessing and following an athlete's symptoms. When I'm covering events I have a version of it with me on my iPad (there's an app for everything, right?).

The initial portion runs through possible concussion symptoms which can include:

  • headache
  • nausea
  • "not feeling right"
  • sensitive to light and or noise
  • anxiety
  • difficulty concentrating or remembering
  • etc.

I follow this with a modified Maddocks score, assessing the athlete's short term recall, using questions like:

  • Where are we playing today?
  • What period are we in?
  • What team did we play last week?
  • Did we win or lose the game last week?
  • Which team scored last?
Finally, I assess their concentration and recall with a number of short tests.

3. Assess Physical Symptoms.
Completing the SCAT assessment involves some balance and co-ordination exercises, and a standardized score is generated from the testing. This is useful as a baseline result, and for comparison as the athlete recovers over time.

Returning to Play
This is the million dollar question, whether you are a pro athlete, playing for your school, or just playing in a recreation league on weekends.
My answer is ALWAYS to err on the side of caution. Sport is a true love of mine, but your brain will always take priority for me.

Initially, on the sideline, if an athlete is displaying any signs or symptoms of a concussion, they need to be taken out of the game immediately.

If they have post concussive symptoms, such as headache, difficulty concentrating, noise/light sensitivity, I tell them they should have complete rest, until those symptoms clear. This means NO video games, NO TV, NO loud music. Once these symptoms have resolved entirely at rest, I allow a graduated return to activity.

  • Step 1 involves usual daily activity.
  • Step 2 involves increasing cardio output like riding a stationary bike.
  • Step 3 involves more sport specific activity, with NO contact. For example, shooting drills in soccer, running receiving routes in football, skating drills in hockey
  • Step 4 involves full contact practice with their own team.
  • Step 5 involves full game play.
At each stage, if any symptoms recur, they MUST stop and go back to the previous step until symptom free at that stage. 
Unfortunately, there are no hard and fast guidelines as to how quickly one can proceed through these stages, but I tend to be fairly aggressive, as long as symptoms do NOT recur.
I continue to repeat portions of  the SCAT assessment frequently throughout.

Final Thoughts.
This post is far from complete and far from all-encompassing, but more to serve as a starting point, and food for thought. The realm of concussions is still cloudy, and despite much more awareness and assessment, our ability as physicians, is still one of preventing further damage, rather than curing anything. I'd rather see my athletes live a long productive life off the field, than miss out on that potential by letting them back too soon.

Let me know what you think! This one's a big topic!

Monday, July 9, 2012

Train Like An Olympic Athlete

With the London 2012 Games coming upon us, I thought it might be interesting to see what it takes to get to this level of competition.

I have been fortunate in having the opportunity to meet, treat, and travel with a few elite level athletes. What has been most striking for me, is what sets these people apart. Sure, they are faster, stronger, and more skilled; but the real difference is what goes on their heads.

The Good Life?

It's funny - When we think of Olympic Athletes, we often get the image that they are living a great life outside their training. Nice house, nice car, get to eat well, get to travel to wonderful places, make a lot of money. . .

Far from it. Except for a very few countries, winning a medal itself, merits very little monetary value.
In Canada, a gold medal will earn you $20,000. Silver and bronze medalists will receive $15,000 and $10,000 respectively. The USOC pays a similar amount of $25,000 , $15,000, and $10,000 for each medal.

Other than that, there is very little pay for training year round for a chance to compete once every 4 years. Housing tends to be the cheapest rental available, hostels when travelling, and a lot of fast food. Unless one is able to get endorsements or private sponsors, this is NOT the place to make a living.

My image of the true Olympic Athlete has grown to be this - A person who competes for the true love and joy of the sport and competition. If you want money and glory, get into pro sports; and good luck to you.

So, How Do They Do It?

So, even if you have the talent, how do Olympic Athletes reach the highest level? Here are the things I've consistently seen in the elite athletes.

1. Focus.
When training, these guys aren't watching TV or reading a book while on the treadmill. If you're running you're running. No distractions.  Weight training isn't a time to catch up on gossip or talk about what happened last night. Do your reps, and focus on technique and getting stronger.

2. Train Hard. No. Correction. Train Harder.
These are the guys out running, rowing, swimming at 5 in the morning while you're still sleeping. These are the guys doing wind sprints and hill repeats in the pouring rain and howling wind. This is the guy on the stationary bike beside you that gets up and goes harder after you think they can't possibly last any longer.

3. Learning Something From Every Competition.
Whether the athlete won or lost their event, the best of the best learn something from the competition. From learning something about themselves, about their competitors, their technique, whatever, they are always striving to get better. For many of us, we are satisfied with just completing something. These guys feed off the competition and want more. Constantly.

What Can I Take Away From All This?
We may never be Olympic Athletes ourselves, but some of their methods are worth applying to everyday life.

Focus on your task at hand. Be it at work, play, with the kids, whatever; we all are too distracted with "other stuff". Stop texting, watching TV, surfing the web, and focus on what you're really supposed to be doing. Enjoy it.

If you're doing something, go hard. Be it at the gym, at work, playing an instrument. Put everything you've got into it, and when you think you've done all you can, do just a little more. That's satisfaction.

Take a minute after you're done, and try to reflect on how to make it better.

Have a great day, and keep up the comments!

Tuesday, July 3, 2012

GoodLife Fitness and Childhood Obesity

Full Disclosure: I do NOT belong to GoodLife Fitness. (I might switch if they continue with programming like this!)

Today, I took my 12 year old son to GoodLife Fitness to register him in their Summer Teen Program.(Link Here.) In Canada, GoodLife Fitness is a national chain of gyms along the lines of a Bally's, Gold's Gym etc.
I take a small amount of pride that they had their beginnings in the town I live in; London, Ontario.
For the last several years, they have been running a program for youth ages 12-17 that gives them a free summer membership.

I was hesitant at first that there would be catches or severe restrictions on the program, but surprisingly not.
My son was required to attend an initial group orientation session to get acquainted with the club, use of equipment and machines. He was guided through a 1/2 hour weight session, and a 1/2 hour cardio session, and then given a membership card for future visits. That's it.

There was NO hard sell to me, the parent, to join. There was NO requirement for my son to join following the summer. His hours are minimally restricted,  from 08:00 am to 04:00 pm, but beyond that, he has essentially full access to the club. I was pleasantly surprised.

Childhood Obesity Stats

  • 1 in 3 kids are obese or overweight prior to their 5th birthday (2009 Pediatric Nutrition Surveillance System)
  • 17% of kids aged 2-19 are classified as obese (2009 U.S. Data). That's 12.5 million kids!
  • Obesity rates have TRIPLED since 1980

What to do?
Great question - with no good answer. As parents, we can certainly try our best to set healthy, active examples. 
Companies like GoodLife Fitness and Disney (Cutting Junk Food Ads) are setting a good example that others should take note of.

What suggestions do you have for helping the youth of today?