An Introduction To The U.S Health Care System

Danny Green, a star basketball player for the University of North Carolina, had a tough week in the middle of March this year just as March Madness was getting started.  He's known for his exceptional shooting skill yet Green was 3 for 25 in two games and even missed three layups. I mean, come on, I can make a lay up. The media was all over him.

It would be easy to slip into a serious funk. It would be easy for his coach, Roy Williams, to tell him to shape up, pay attention, be a stud, whatever. It would easy for Green to think it's over. He's finished. He's lost his mojo.

Instead, what was did Roy Williams tell Green?

Keep shooting.

Green took his advice and within a couple of games, found his mojo and UNC won the National Championship.

You can think things are too hard, or why bother, or it's not worth it. You can quit. You can go hide somewhere and sulk. Injuries tend to do that to you.

Or, you can keep shooting.

DK

From About.com:

"A home exercise program is essential to doing well in your rehabilitation program. If your physical therapist has not reviewed several exercises for you to do at home, you should ask to do so. A home exercise regimen should be performed two to three times per day. Being active in your own rehab will greatly pay off!"

Ok, so this pushes a button. I admit it. Global, one-size fits all, you-should statements are useless.

I agree with the first sentence - sort of. I think a better word is "independent" or "unsupervised". You may not be doing the exercises at home. The term is a hold over from a hospital based practice environment. The patient is about to be discharged and they need "home instruction" which turned into "home program". It's not in sync with reality. It is essential, at some point, for you, as the client, to be able to execute a plan on your own that will maintain your improvements. Agreed.

The second sentence seems reasonable. Any client would likely want to know the answer to, "What can I do at home or on my own?" Now, depending on the case, all that the person might really be able to do is to change sitting positions, sleeping positions, duration of sitting, etc., to relieve symptoms, for example, of back pain. None of these things are "exercises" but all of them are part of an overall plan. And, why is it so important that you, the patient or client, get "several" exercises? What's wrong with one or maybe two that really work?

Third sentence. Wait a minute. Just exactly what should you be doing two to three times per day? Quad sets? Ok. I'll buy that. Jogging intervals? Don't think so.

Exercise is controlled trauma. Used wisely, exercise can heal injured tendons, ligaments, and bones; strengthen muscle; improve posture. In fact, mechanical load via exercise is the most important thing in your life. Without it, you die. Through exercise, you stress tissue. Through rest and recovery, that tissue adapts; grows stronger. Too much exercise with too little recovery leads to progressive weakness.

Part of the problem is that some clinicians use passive techniques (massage, mobilization, physical agents like ultrasound, etc) as their primary intervention and leave the "exercise" up to the patient or client to do on their own. So, if the patient has not been instructed in a "home program", then, well no exercise happens. The decision to use manual therapy or a physical agent or exercise is a clinical decision making issue and one that cannot be solved by a blanket statement that everyone should be on a "home program" and should be doing that program two or three times per day. That's just stupid.

To suggest that somehow a physical therapist has missed something because he or she did not prescribe an exercise to be performed two to three times a day is like saying a physician goofed by suggesting you should take a medication only once a day. It depends on the problem and the "medicine" you've chosen.

"Being active in your rehab will greatly payoff!" Only if you're doing the right things the right way.

More is not always better. And more at home could be a disaster.
DK

52

Do you know me now?

What does “age” tell us?

What if my blood pressure is too high, my cholesterol is out of control, I can do 2 push ups, cannot stand on one leg for more than 2 seconds, cannot walk around the block or up a flight of stairs without being winded?

And what if now I told you I was 32?

Age is not a number. Age is a collection of numbers.

Focus on the collection.

At the end of April, I hoped that I would be off the Coney Island Cyclone. Not so lucky. The first fourteen days of May were just as bumpy, one day feeling good and the next like someone had jammed on hot iron poker in my  spine. What I wanted was control. I wanted to know that I could control my symptoms, that I could determine what, when, and how I wanted to do something and know whether or not I would hurt or my leg feel numb, or whatever. But, my body had other ideas. It would let me know what was going on when it felt like it. I felt sort of like I was sculpting jello. Working really hard at making something good happen but ending up with a whole lot of nothing. I have come to the conclusion that the body and mind have minds of their own. And, somewhere in between is me. It's like there are three beings: body, mind, self.

I finally figured out the the culprit, the engine for all of this emotional and physical upheaval was sitting. I started sitting again at the very end of April. I felt like I was being very conservative: starting with just 1 hour; 1 total hour of sitting a day. And, 1 hour seemed ok. So, the next day I went to 1.5 hours. That night, my sleep tumbled to 5 hours and I felt awful the next day.

When I tell people that the hardest thing for me to do right now is sit, I see a quizzical look crawl across their face. "Really? I would think things like bending and lifting would be really bad for your back." Well, that's true - it just depends on how you bend, how much you bend, how you lift and how much you lift. But, sitting is worse.

Why is sitting so hard on the spine? Well, two reasons. First, your spine was built for movement; not sitting. Wherever you find a joint in the body, you can assume it's there to provide motion. You have 117 joints in the spine (if you count from the head all the way to the pelvis and include the joints for the ribs that attach).  When joints don't move enough, they deteriorate. In a sense, they get weaker the more stationary you are; the less you move. Weak joints lead to symptoms like aching, stiffness, swelling, and pain in and around the joint. As far as I'm concerned, sitting is one of the worst things you can do for your back. But, you have to be able to sit - at least some. You can't go to a restaurant and eat standing up (I've tried). And, going to the movies, well, yes, technically you can stand up but who wants to do that? Sitting is a necessary function but you should move frequently if you have to sit a lot during the day.

The second reason sitting is so hard on spine is that the pressures produced in the spine from sitting are quite high. In fact, sitting slightly slumped creates more pressure on the spine than standing in a stooped or slightly bent over position. You can think of the pressure as squeezing the disc and discs really don't like to be squeezed for very long. A lot like the rest of the body for that matter. The sustained pressure interferes with the energy delivery and waste removal systems of the disc and this gradually erodes it.

May 1-7, 2008
The really good news this week is that my overall pain levels went through the floor averaging 1.2 out of 10. Wow. I had a few days where I felt normal; completely fine. Zero. Null set. Nada. Like I had never even been injured. That's a problem though - at least for me. Without the pain acting as a governor, I just start doing stuff. Naturally. I'm not thinking to myself, "Oh, boy, let's run the vacuum cleaner!" I just do more bending, twisting, sitting without really being aware of it. And, that leads to a system crash usually at night. I hurt and wake up hurting and am immediately ticked off and then have to focus on not being ticked off but I don't really have the energy to focus and it goes on and on until I sleep again.

My sleeping also improved overall. I had two nights of 8 hours and three nights of at least 7 hours. I also had a couple of really bad nights too but, still, five out of seven, 71%, that's at least a "C".

I also turned 52 this week (I'm not sure what 52 should feel like but whatever it is, I don't feel that way). And, my brother called me to say happy birthday. In speaking with him, I learned that he had tried a technique using meaningless sound (things like ocean waves, thunderstorms, etc.) to help him sleep and he thought that it worked really well. (Oh, and I don't mean that the sound of ocean waves is meaningless it's just that we don't immediately attach meaning to them as we do, for example, with music.) So, I created a few sound files and dropped them on my iPod to try out the night before my birthday. I wanted to be really rested and feel good the next day.

Disaster. The ear pieces were annoying and I couldn't sleep on my side because it felt as if there was a penny stuck in my ear. And, the wires kept getting caught on my pillow or something else. So, I had to sleep or try to anyway on my back. I never have liked that posture so I couldn't relax. And as far as the meaningless sounds of the ocean crashing on the beach, well, all I could think of was going to Maui and then my mind was off flip-flopping down memory lane. I slept all of 3.5 hours.

On the sixth, I started some upper body exercise and added some lower body strength training at Sports Center - all spine friendly of course. It felt really good to use some muscles again and without worrying about whether I might be injuring my spine.

May 8-14, 2008
I thought my pain was low the previous week but this week, it dropped even more to an average of  .4 out of 10. I had four days in a row with no symptoms. I started sitting more during meetings and noticed that I had very few problems if any during or after. Life was really starting to feel more normal. But, an old nuisance dropped in for a visit in the middle of the night on the 8th and hung around all week: stiff, sore, tight thoracic and lumbar spine. I had these symptoms several years ago and they come around every now and then but I was really surprised to find them now. So, sleeping wasn't as good as I would have liked but not due to my injury. I averaged right at 6.5 hours.

The weekend of the 10th and 11th, I actually ventured out into the social world. I went to a party on Saturday and on Sunday went to dinner. It was the first time I had been out to dinner since my injury. We sat at the bar, which I actually preferred for the energy and activity plus I could get up and move around and even eat standing up and no one seemed to notice or care. It's a bar. I was very tuned into time though. I set a timer on my watch, got up when it went off, moved around a little. I didn't want to end up in the hurt locker over a dinner.

I was anxious about the weekend. Would I make it through without making my self worse? And, if I felt worse, how long would it last? It felt like I was standing on the edge of a canyon knowing I was probably going to fall off and wondering just how far down it was to the bottom. I never fell off the edge. I made it through the whole weekend and felt great.

Here's what I wrote in my journal on the 13th: " What an awesome day. Did my rehab at Ross' and felt great. Like I could run; felt really, really good. Great energy. No symptoms. Felt strong again."

At the end of this period, I felt mostly normal, slept most nights fairly well, and noticed an increasing sense of optimism. That was, until I started something new; an experiment.