Tuesday, December 10, 2013

Winter Fitness, Part 2: Let it snow, let it snow, let it snow!

Running with frozen toes!

In honor of the lovely coating of white wonderland that New York has gotten this morning, and in honor of my first snow run since early November when we had beautiful snowflakes that didn't stick, I thought it's about time for a blog on outdoor training during the winter months. So read on for tips on how to keep training outdoors and fighting your SAD with some fresh air and exercise despite the elements :)

LAYER, Layer, Layer, layer, layer...LAYER!

The best thing to do to stay warm while being active in the winter months is to layer your clothing and choose wisely. Everyone is different in the amount of clothing they prefer. Keep in mind that you are going to warm up., but also keep in mind that the longer your workout, the more sweating you will do, and the more important it is to have fabrics that absorb moisture away from your body to keep you dry. By the end of a long endurance workout, you will get even colder, if you don't layer properly. This is really a lot of trial and error about what works for you, but some general guidelines are:

1. Your first layer should be tight-fitting tech-wear that absorbs moisture. Often, some folks will choose warmer weather compression clothing for this layer, or some use colder weather compression clothing for this layer.

2. A middle  layer can be added that is a little more loose-fitting but still wicks away moisture (still tech wear).

3. One to two outer layers, depending on how warm you like being --
    *A bulkier insulating layer
    *And then the outer-most layer should be something loose that blocks wind. A very thin wind-breaker does a WORLD of difference for keeping you warm, since 80% of the heat loss your body experiences is due to wind. Just try it. You may find you don't need as many of the other layers if you have this. They make some nice fitted ones for cycling. This one is even water-proof: http://www.pearlizumi.com/publish/content/pi_2010/us/en/index/products/men/ride/apparel/6.-productCode-11131102.html

The best thing about layering? You can take things off if you get too hot! But don't go crazy with that, since you don't want to cool-down too quickly after your body has worked so hard to get all your muscles warm and firing in the cold weather.


Again, everyone is different in what they need. My husband and I have done a lot of trial and error on this stuff after training in a pretty intense New York winter during our prep for Ironman New Zealand. He wore crazy ski gloves when we did our endurance runs because his hands would always get so numb and cold, and I wore Under Armour Cold Gear shirts that I would pull over my hands because I couldn't stand wearing even the lightest gloves because my hands would get so hot after the first 30 minutes, and then I wouldn't want to have to hold onto them if I took them off. They make a lot of outer layers that are made to come over your hands, which are awesome for running. I prefer these to gloves, but everyone is different :) 

So, from head to toe, here are some examples of good accessories to keep you warm and keep you getting your fresh air and preventing SAD with consistent training during those winter months:

Head protection:
Headed out for a 2-degrees-Farenheit-feels-like-minus-17 winter
training run, and we are prepared! :-P
Always a good idea for everyone, since your head is where you lose most of your heat. Again, something tech-wear is a good idea to absorb sweat. Some people like full hats or hoodies and some like head-band-type adornments. 

Check out face masks – not just for robbing banks after all!
Your face can get a lot of exposure when you are bundling everything else up, and I have to say, I do have one of these! 

Try feet and hand warmers like these

For your running toes

For your cycling toes
These are uh-mAAAAAAzing! These are the key to training for races when you know you have to get in an outdoor ride even in the winter time :) They really make a difference.

For your soles

Get some traction:
I haven't used these, so I'd be psyched to know how everyone feels about them.


My husband is going to laugh if he reads this, since I am one of the least safe athletes out there, but, be smart about the days you choose to train. If the world is a solid sheet of ice, no one will judge you for running on the treadmill that day or watching a sports movie while you hop on your bike trainer. Gyms often have great deals this time of year for people wanting to get in shape during or after the holiday season, fitness classes will be in full swing, and winter is always a great time for the indoor pool! We all know that we enjoy outdoor workouts, but you don't have to put yourself at risk of injury. If you want to get out there even in the most dire climates, though, keep these remaining tips in mind...


Try warming up first inside before heading out for a run. Bike-runs aren’t just for triathletes anymore! Bike 10-15 minutes on an indoor bike and then start your run; you’ll be able to run faster right away and you’ll already have a little sweat and increased circulation to your extremities to keep you warm.

COOL DOWN (well, warm up again)

*Return to childhood--> drink hot coccoa!
Normally after a hot run, it’s no trick to find ways to replenish calories and fluids because an ice-cold smoothie or protein shake is just the ticket to cool you down. But, after your extremities are feeling cold and numb during a long winter run, it can be hard to come inside and properly re-hydrate. Welcome to my favorite winter recovery drink—hot chocolate! Chocolate milk has been a known great recovery drink to replenish carbs and protein after workouts, so why not try the winter version? It warms you up from the inside out, and you are drinking fluids without feeling even colder afterward.

*Take a hot shower. But not too hot.
A hot shower after a long cold run feels like such a nice present, but don’t go too hot on the water. Heat feels good after being cold for a long time, but hot and long showers can easily dry out the skin during a time of year where your skin is already fighting dryness. Especially if you have problems with eczema or dry skin, this is not the cure for you. Keep your shower down to a few minutes and make sure to lotion up afterward with a good emollient like Aquaphor or Eucerin while the skin is still moist to help hold in moisture. 

I hope these tips keep you training outdoors this winter and feeling healthy even with all those tempting treats at holiday parties :) I enjoy a snow run because it always makes me feel like a little kid playing in the snow, so I hope to see a few of you little-kids-at-heart out there on the road/trail, but stay safe and stay warm :)

Until next time folks!

Wednesday, November 27, 2013

Women’s Health Month: Why Female Athletes are More Prone to ACL Injury

Thanksgiving is coming a little later this year, and so are my blogs on the promised topic of Women’s Health Month. As the weather gets colder and most high schools are starting their basketball seasons around this time of year, I thought a great blog topic would be ACL injury with particular attention to why this injury has a female-athlete predominance.

In 1972, 1 in 27 Varsity sport athletes were female. In 1997, this number drastically increased to about 45%: 55% female: male participation, thanks to Title IX. With this increase, the number of ACL injuries also increased with a notable female predominance to ACL injury. This sex discrepancy in ACL injury begins at puberty and continues into adulthood. Even more so, the number of non-contact ACL injuries is higher in girls than boys, and this is a notable increase in incidence that is also seen from the onset of puberty, age 12 to 14 years in girls. The peak incidence for ACL tear is in the group of 16 to 18 year-old girls, and the highest numbers of ACL injury have shown to be in girls’ soccer: 14 per 100,000 female soccer players vs. 4 per 100,000 male soccer players at the high school level. The second highest incidence is in basketball with the ratio of female: male ACL injuries in this group of high school athletes being 2:1.

So what’s the deal? Why are ACL injuries more common in female athletes? To begin to answer this question, we first have to discuss the biomechanics involved and this boils down to what is an ACL and what does it do…

What is the ACL and what does it do?

The ACL is the anterior cruciate ligament of the knee joint, and it runs from deep within the distal femur (the long bone of the thigh that is above the knee) to the front of the tibia (the bigger bone that makes up the shin). The origin or beginning of the ACL is within the notch of the distal femur and the proximal (beginning) fibers of the ACL fan out along the medial wall of the lateral femoral condyle. The ACL attaches to the tibia on the intercondyloid eminence that is adjacent to the medial meniscus. All of these interactions allow the ACL, along with the PCL (the posterior cruciate ligament) to stabilize the knee joint.
The ACL resists anterior (forward) and medial (sideways toward the middle of the body) movement of the tibia across the femur. In short, it keeps your lower leg from moving forward and rotating inward toward your other leg.

Terrible Triad
Because of the interaction of the surrounding stabilizing structures of the knee joint, a common injury that can occur is called the “Terrible Triad.” You might hear someone say with reference to this injury that they “blew out” their knee. This occurs when there is a tear of the ACL, the MCL (medial cruciate ligament), and the medial meniscus.

So what’s with the ladies?
There are many theories about why ACL injuries are more common in the female athlete. The answers have ranged from differences in female vs. male training, issues with flexibility and ligament laxity, hamstring/quad strength discrepancy, bone structure, and even female hormones. So let’s analyze the data and separate fact from fiction, folks.


Like everything that affects women, they’ve tried to blame the female athlete ACL injury predominance on our hormones, ladies, and guess what? The studies are still inconclusive. The most convincing theory is that estrogen receptors on ligaments cause increase ligament laxity in female athletes causing increased risk of ACL tear as opposed to male athletes.

                What supports this theory:
Some studies have found that there are an increased number of ACL tears around the time of ovulation (in the pre-ovulatory and ovulatory phase where estrogen levels peak). Moreover, some studies have shown that oral contraceptive pills have decreased the risk of ACL tear in female athletes. The theory behind this would be that OCPs prevent ovulation, maintain steadier hormone levels, and prevent the changes that make women more susceptible to ACL tear around the time of ovulation. This theory has been supported by evidence showing that early on in puberty there is not as much of a female predominance to ACL tear. Folks have postulated that this is because estrogen does not vary much at this time, i.e. estrogen is not exerting its effects on the neuromuscular system.

                What goes against this theory:
Men have estrogen too. What? Well, they do. But they don’t get the increased joint laxity that is often seen in female athletes. It may be that their receptors respond differently, but the fact is that in both boys and girls after puberty, peripheral testosterone is converted to estrogen, so both sexes have this hormone, which could exert effects on the neuromuscular system. Other studies have also come about to debunk the idea of an ovulatory association with ACL tear. They have found a greater number of ACL tears on cycle days 1 and 2 of the menstrual cycle. These days are during the first part of menstruation or during the early follicular phase of the cycle when levels of estrogen and progesterone are low. So what gives? Maybe this one isn’t actually something we can blame on our hormones, ladies.

Athletic Training and Conditioning

This argument really used to be something to think about back in the day when women were just getting into competitive sports, but now look at us! Go ladies! So proud of where we have taken female sport!!! :) With female athletics taking off and with Title IX giving women the same resources to trainers, physical therapists, strength and conditioning coaches, etc. that male athletes have, we really can’t prove with evidence-based studies that there are specific differences in the type of training that male and female athletes are doing which predisposes women to ACL tears. However, it may be more about what we are NOT doing in our training of female athletes to compensate for the differences in male and female musculoskeletal structure and biomechanics. This idea has been linked to hormones in one study showing that changes in knee joint laxity during the menstrual cycle does affect knee joint loading during movements, which could be important in ACL injury prevention programs and how we are training our athletes. This is just one study done in 2009. So, we need more evidence to come up with better training programs. But up next, what it is about the female musculoskeletal  system that predisposes to ACL injury?

Musculoskeletal Biomechanics

Female athletes are more quad and leg dominant; they rely more on ligaments for stability, and they have increased ligament laxity, especially after puberty. The intercondylar notch of the femur is more A-shaped in the female femur vs. the male femur. Women also have a wider pelvis, which increases knee valgus and causes a greater Q angle.

Bone structure

So what the heck is knee valgus and Q angle? Knee valgus is when the knee deviates inward (knock-knees). In many female athletes, when they jump and land, when they do a deep squat, or when they make a cut to change direction, their feet are externally rotated, and the hip and knee are not very flexed. This posturing causes an increase in Q angle, the angle between the pelvis and the knee. The male Q angle is typically about 14 degrees. The normal female Q angle is about 17 degrees. In persons with patellofemoral pain syndrome (something we can talk about another time), that angle is increased to greater than 22 degrees.
As puberty increases, the female pelvis is becoming and wider and flatter, causing the change in Q angle that we see between male and female athletes. Knee valgus and increased Q angle place increased strain on the ACL because the ACL has to work harder to pull the knee back into normal position and stabilize the knee joint. Taking all of this into consideration, it really does make sense to teach our athletes proper squatting and jumping/landing techniques.


The female ACL may also have a lower percent surface area of collagen.


Another consideration is the difference in strength between genders. By age 15-16 years, girls have 75% of the strength that boys have, secondary to increase in lean body mass that is much greater in boys. During puberty, boys increase their hamstring strength by 179% and their quad strength by 148%. On the other hand, girls become more quad dominant than boys do with these changes in strength during puberty.
Moreover, when women experience stress on their ACL, they naturally compensate by activating their quads and lateral hamstrings, which causes increased Q angle. Yikes!
Boys/men seem to fire their semimembranosus (the medial hamstring) later than girls/women do, and this action is thought to be more beneficial in protecting the ACL from injury. It seems that because of these differences, pubescent girls are at greater risk for non-contact ACL injury compared to boys.

Immediate Assessment: Does my child need an MRI?

So we all know that this is my favorite question for athletes and for all pediatric issues. Parents always want to know if their children need cat scans, x-rays, and MRIs. With any injury, it is important to get an assessment from a doctor as close to the injury as possible. Often this does mean going to an Urgent Care Center or Emergency Room as most sporting events take place after regular pediatric or orthopedic office hours. The opportune time for assessment of ACL tear is actually immediately after the injury occurs, so if your team has a Sports Medicine doctor available at the game, this is your best bet. Even waiting until you get to the ER after the game can sometimes make assessing an ACL tear more difficult because the more swelling that occurs, the more difficult it is on physical exam to evaluate the ACL.
Anterior Drawer Test - one of the physical exam tests
to evaluate for ACL tear.
The most important thing is to be evaluated shortly after the injury has occurred. You will not be able to get an emergent MRI, and an MRI is not always necessary in the case of knee injury. Depending on the mechanism of injury and the physical exam, your doctor may think an x-ray is necessary to rule-out fracture. The next step may be an MRI to evaluate ligaments and other soft-tissue damage, depending on the physical exam. Your child does not need a CT or cat-scan. This test is emergently available, but it is not as definitive as MRI and has, as we have previously discussed, a large amount of radiation, and should not be done unless absolutely necessary. Listen to your doctor and ask questions if you do not understand the tests ordered or the plan for the care of your child.


Interestingly enough, these days, for an ACL tear, depending on the severity, and depending on the future goals of the athlete, you do not always need surgery! Isn’t that great news? It depends on how severe the tear is and how competitive and lengthy the athlete’s future career will be. It is often helpful to get the opinion of two different orthopedic surgeons before making your decision on surgery. This injury used to be a career-ending injury for many athletes, and now recovery times and strong commitments to rehab have athletes back to jogging in 6 weeks and back to their sport within the same season, depending on when the injury occurs.


I hope that what this short article has shown you is that we actually need more studies to show what we should be doing to protect our athletes, what strength and conditioning programs would best help prevent ACL tear. Studies have shown that the types of prevention programs that are in the mix currently have made no difference for kids age 9-12 years in preventing ACL tear; however, they have noted improved technique and better prevention with programs in the age range of 14- to 17-year-olds. These kids may be more susceptible to feedback and coaching at this age, but 9- to 12-year-olds are kids already learning sport-specific skills, and we need to find a program that can work for improving their techniques in order to prevent ACL tear and other injuries. One thing is for sure, our treatments and our rehab have come a long way in helping athletes recover from these injuries, but prevention is definitely the future for our athletes.


Bell DR, et al. The effect of menstrual-cycle phase on hamstring extensibility and muscle stiffness. J Sport Rehabil. 2009 Nov;18(4):553-63.

Bell DR, et al. The effects of oral contraceptive use on muscle stiffness across the menstrual cycle. Clin J Sport Med. 2011 Nov;21(6):467-73.

Dragoo JL, Castillo TN, et al. Serum Relaxin Concentrations and ACL Tears. Journal of Sports Medicine. 2011. 39:2175-2180.

Lefevre N, et al. Anterior cruciate ligament tear during the menstrual cycle in female recreational skiers. Orthop Traumatol Surg Res. 2013 Sep;99(5):571-5.

Park SK, et al. Alterations in knee joint laxity during the menstrual cycle in healthy women leads to increases in joint loads during selected athletic movements. Am J Sports Med. Jun;37(6):1169-77.
Slauterbeck, et al. The Menstrual Cycle, Sex Hormones, and Anterior Cruciate Ligament Injury. Journal of Athletic Training 2002;37(3):275–280.

Wild CY, Steele JR, Munro BJ. Why do girls sustain more anterior cruciate ligament injuries than boys?: a review of the changes in estrogen and musculoskeletal structure and function in puberty. Sports Med. 2012 Sep 1;42(9):733-49.

Tuesday, November 5, 2013

26.2 miles and 1611 patients

"There's a place deep within yourself you must go to finish a marathon. I run because I can't get enough of that amazing place."

-Running Thoughts (twitter.com/RunningTH)

So this past Sunday was not only the first day with an earlier sunrise and sunset, but also it was the 43rd Annual New York Marathon. I have never run this marathon myself, since after 3 times attempting to get in via the lottery, I got addicted to Ironman instead, but this year, I wanted to try my hand at being a medical volunteer for endurance racing. I have been on the sidelines cheering for friends the last 8 years, and I have to say that there is nothing like the magic of this race and how all of New York comes together to welcome elite and amateur runners from across the globe. 

Last year, many runners were devastated that all of their training seemed like a waste as the race was cancelled due to resources needed to help our tri-state area recover from Hurricane Sandy. I know what it's like to train for 15 months, travel half-way across the world, and then have your race cancelled because I was in New Zealand for the Ironman in 2012. But, as much sympathy as I had for last year's runners, I have to say that the city made the right decision in cancelling the race. Since then, our endurance community has had to recover from even more tragedy, after the bombing at the Boston Marathon last April. 

I think that's why this year's New York Marathon seemed even more triumphant. I didn't cheer on the sidelines this year, but I was working in the P5 medical tent, the most acute tent that sees the most runners each year and handles the race's ambulance transports. We saw 1611 patients on Sunday in P5, including 6 runners who were very ill requiring ambulance transport and acute medical care in our tent. We are so proud of you runners and what you have accomplished and were happy to help make the hobbling home through NYC streets a bit easier...be it with crutches, with warm chicken broth, salt packets, bandages, Zofran, fluids, or other medical care. Thanks to all the volunteers and their support of this great event. 

There are so many great marathon stories each year, but I wanted to share a brief bit from a runner's story included in this week's JackRabbit Newsletter.

"This Sunday, I became a marathoner. Alongside tens of thousands of runners, I traveled 26.2 miles through the streets of New York from the Verrazano Bridge, through Brooklyn, Queens, the Bronx and Manhattan, to the storied New York City Marathon finish line in Central Park. After crossing the finish line, a runner next to me started sobbing and, not knowing what else to do, I hugged him. We didn’t speak to each other, I don’t know his name and odds are we will never see each other again but in that moment I knew we were both feeling the same rush of emotions: shock, disbelief, gratitude and finally a deep sense of calm: it was over, we’d done it, we were marathoners.
I don’t know what brought that runner to the starting line Sunday morning. Maybe he was raising money to cure a disease that had struck a family member, maybe he was a survivor of the Boston bombings, maybe his journey to the marathon was cut short last year by Hurricane Sandy, or maybe he was just in it, like myself, to prove that he could do it. While we all have our own reasons to toe the starting line—or to buy our first pair of running shoes or sign up for our first training program—we can only get to the finish through a combination of dedication, faith in ourselves, and a supportive community."
~Karen's marathon story, from JackRabbit Newsletter, 11/5/13

[As an aside, if you're in the NYC area and are not a JackRabbit member, this might be something to consider, especially to get going this winter. They send out email newsletters with upcoming local races, group workout events, options for training schedules, and so on. It could be a great way to stay motivated this winter! Also check out their stores for triathlon, running, and yoga apparel. Check them out: http://jackrabbitsports.com/]

I completed my first marathon 3 ½ years ago in San Diego, and I can't quite remember what my thoughts were crossing that finish line. All races blend together after a while, but I remember that I had a sense that I had gone to battle and that I had survived and done something that I never thought I could do before that moment of accomplishment. I think I likened it to graduating from medical school, although at that point I had not yet graduated, and medical school felt like the longest endurance race of my life. It seems to me that every time you take your training to the next level, you experience that kind of sentiment and philosophy where you feel you have gone to battle, survived, and come out stronger than you thought you were when you started.

I have to say that in the P5 medical tent on Sunday, with stretchers lined up everywhere, volunteers wheeling and transporting patients on wheelchairs and stretchers, and runners coming in sometimes too weak to stand, teeth chattering, pale or blue, screaming in cramp agony or looking pre-syncopal and woozy, it looked like an endurance battle field to me. 
This was during set-up. Things got too busy for pictures as the day worn on.
It was like the New York Marathon version of MASH. Our soldiers didn't have open bullet wounds or amputated appendages, but they were bleeding from gutsy abrasions won from falling and getting up to complete their 26.2-mile journey; some had broken bones in the form of stress fractures; and others had hobbled along on injuries earned during months of training. These were our soldiers who had come to race for their respective countries, and we were proud to care for them and get them safely home.

What a great day! If that doesn't make you want to do an endurance race, folks, I don’t know what will ;) Set a goal for yourself that is reachable but requires work this winter, and see how far your journey can take you, what character you build, and how many wonderful people you have in your life who will support and encourage you along the way and be so very proud of your accomplishment at the finish.

Monday, November 4, 2013

Winter Fitness, Part 1: Feeling SAD? exercise away winter blues!

It's becoming that time of year folks. We wonder if we are really working that much longer, or is it just that the days are getting that much shorter and we are leaving and returning home in darkness? The leaves are still beautiful, but as the ghouls and goblins come out for the tricks and treats, you can't help but notice that the time change is upon us, the end of daylight savings time has arrived, and so has the beginning of winter. :(

For the record, that used to not give me a frowny face. But the more time you spend in colder climates with longer nights and less daylight, the more your childish whimsical love of snowflakes and snow angels just turns into-- "Oh, great, another Nor'easter, time to shovel and see if I can get to work in this mess." This is so unfortunate because winter can be a fun time—hot cocoa, snuggling, fire places, caroling, holiday celebrations, baked goods… The problem is that some of us gain ten pounds just reading that list and the rest of us just think about how cold we are going to be and that going for a run is going to be the LAST thing on our to-do list this holiday season.

So while last week was particularly gray on most days, and I was very thankful for how bright and colorful our autumn leaves were since they felt like the only sunshine my serotonin-deprived brain was getting, it occurred to me that a very nice topic for this week’s blog would be seasonal affective disorder and how great a treatment exercise is!

But first a bit about SAD.

Is it real?
As a dear friend would say, “YOU BETCHA!” This is a real thing. SAD is a type of depression that occurs seasonally. Usually people with SAD get depressive symptoms that begin each year around fall and continue through the winter months. You may feel tired, moody, or have difficulty getting out of bed or getting going in the morning. My resident friends are reading this and thinking, “Wait, isn’t that just residency?” It may be partly SAD!

People who do shift work, night shifts, or are used to brighter and warmer climates may have more depressive symptoms in the winter time and have more difficulty coping with these issues. People who live in areas with long winter nights are also at greater risk of SAD.

Increased appetite or weight gain
Increased sleep
Less energy
Inability to concentrate
Loss of interest in work or other activities
Social withdrawal
Unhappiness and irritability

SAD can also become long-term depression or even develop into bipolar disorder. If severe, people can experience suicidal thoughts.

What’s going on in the brain?
The pathophysiology of seasonal affective disorder is still somewhat unclear and may be a biologically heterogeneous entity that results from a combination of factors including difference in genetics, altered neurotransmitters (serotonin, norepinephrine, and dopamine), and changes in circadian rhythm.

Several studies have linked SAD to changes in serotonin and even genes that influence levels of serotonin in the brain. One study of female participants even linked these changes to a possible hypothesis of why some people with SAD have increased eating behavior. Many studies have shown that natural light is a helpful treatment for SAD, and so it has been hypothesized that SAD results from circadian rhythm changes that occur when the brain is not stimulated as much by natural light during the winter months, making people sleepier and more sluggish.

There is also an association between SAD and adults who have residual ADHD symptoms. Dopamine and low central arousal in both ADHD and SAD are the linking factors to establish a connection between the association found in these patients. Neuroimaging studies have even shown a decrease in global cerebral metabolism of dopamine in both persons with ADHD and with SAD.

So, you betcha, folks, no matter what factors are leading to this disease, it is a real issue and something that many of us have to somehow cope with. I never knew how important sunshine was to me until I moved to New York, and after 11 New York winters, I can tell you one thing—I’m ready to move! ...and I love New York! But, apparently, my brain loves serotonin more. So, since most of us New Yorkers are stubborn and don’t want to leave, and since there are folks living in climates way colder and with way less daylight, I thought maybe we could go over some ways to deal with this thing called SAD.

What's the cure?

Obviously I'm very happy to say that getting 30 minutes of fresh-air exercise or just getting 30 minutes of exercise if you can't do the fresh air is what helps treat SAD because I think exercise pretty much cures everything...but you guys, it's true! Get some fresh air, get your body moving, get some adrenaline going, and watch that frown turn upside down :) It's hard to be sad and feel sorry for yourself when you're trying to run a certain speed or when you're listening to great music on the elliptical machine or feeling the relaxing buoyancy of an indoor pool. Find what works for you and go for it!

Buy an SAD light
I mentioned before the studies supporting this as a treatment for SAD. There are lots of options out there. I kind of refused to spend the money on this for a long time, and my wonderful friend who also struggles with SAD bought me one as a present last year. That SAD light during my weeks of night shifts and during the winter of intern year was my salvation. It may be partially placebo, but it really makes me feel more awake than regular indoor lighting fixtures do. Try what I found helpful and couple turning on your SAD light with the indoor workout of your choice. I always turn on my SAD light on rainy/snowy days when I am doing an indoor biking workout on the trainer. :)

Be a the-glass-is-half-full kind of person
At least you’re not living in one of these 25 coldest cities: http://www.thedailybeast.com/galleries/2010/12/10/america-s-25-coldest-cities.html#slide25
That doesn’t always work, since sometimes cold pictures make you more depressed. 

Subliminal advertising
Bora Bora, French Polynesia
Plan a warm vacation. Evidence shows that just planning a trip makes you happy.
No time? Pull out pics from your last beach trip and think about how nice that sunshine was—take 5-10 minutes and do a little Zen time where you imagine yourself back there each day or whenever you need it. Make a slideshow for your computer, set yourself up with a beach desktop background--it's the little things that count.

Not working? Better yet, try TAKING a warm vacation! :-P

Throw a party!
Planning a mid-winter party is the best way to catch up with friends and have a good time without even having to venture out into the cold yourself. Make a theme, do a potluck, eat wine and cheese, play board games together. One of my co-residents had a great idea to crank up the heat in his apartment and have a beach-themed party with frozen umbrella drinks. It's five o'clock somewhere, and maybe it can even be Margaritaville in your apartment. So what if you don’t have the money or the time for that Bahamas vacation—you have one weekend, and that’s all you need!

winter running can be fun! especially
when your running buddy thinks you're nuts!
Start a winter workout club!
Grab a group of friends and instead of getting hammered after work (we all know that is sometimes helpful, but it can get old and can add to your winter wobbliness), meet up for boxing class (Shout out to Leah Nelson for doing this!!!!) or spinning class or group polar-bear runs (Snow runs can be fun! Especially since they give you an excuse for hot chocolate afterward--the perfect winter recovery drink!) instead.

Set your sights on a spring or early summer race!
My SAD was never better than when I was Ironman training. Snowing outside? No problem. 5 hours on the bike trainer and a Rocky movie marathon it is! It doesn't have to be an Ironman; it can be a 5k, a 10k, a half-marathon, a tough mudder, a zombie race—anything that’s going to make you go get on the treadmill when it’s cold and you would rather stay under those covers.

What to do when your comforter says: “I’m warm and comfy too, baby.”
Just do exactly what this girl does and get out and run! Or go flip on your SAD light, eat some breakfast, and then go run, but the sooner you are in fresh air, the more awake and ready for the day you will feel. Make gym dates with friends to make sure you don't ignore your alarm and succumb to the warm comforter trap.

You knew I was going to give you like 3 tips that didn’t involve exercise and then a slew of tips that do because this is a Sports Medicine blog, but if you are feeling a little gray as the days get shorter, just try a workout program and bring along a friend if you want, and you will be surprised how much it helps, trust me.

Now is the perfect time to make this positive change in your life because we just had the time change and our bodies haven’t caught up yet! You are primed to go to bed early and to wake up early because you have already been doing it for the last several months! Stay on the same schedule, trick your brain, and get up early before work and start your day right—with exercise J You will thank yourself for the rest of the day with more energy, more smiles, and more excitement about having your evening free from the dread of needing to go to the gym. Just remember to hydrate :-P

A few more tips on ways to add happiness to your life:
(exercise is of course the first one!)

Remember to be thankful for sunshine in all its forms and to keep those exercise-endorphins pumping to fight SAD this winter.

Talk to your doctor.
So, I pretty much recommend exercise for every ailment, but I also recommend talking with your doctor. Obviously, this blog has a lot of tips that can help most people with depressive symptoms, but for some folks, daily exercise, planning trips, and SAD lights are not enough. Sometimes you need a little help to get going and get started with some of these fixes, and it can really help to see your primary care provider and ask about other treatments. Anti-depressive medications and psychotherapy are used together to treat SAD and other forms of depression. Especially if you have had trouble with depression in the past or are thinking about harming yourself, please tell your doctor. If you are having thoughts of suicide, call one of the following helplines or go to your nearest emergency room.

References/More Info:

National Hopeline Network: 1-800-SUICIDE

National Suicide Hotlines and Info: http://suicidehotlines.com/national.html

Suicide Hotlines for NY: http://suicidehotlines.net/newyork.html

RW Lam and RD Levitan. Pathophysiology of seasonal affective disorder: a review. J Psychiatry Neurosci v.25(5); Nov 2000.

Thursday, October 31, 2013

Traumatic Brain Injury: Concussions, Recovery, and Return to Learn/Play

So, high school football season is coming to a close and professional football season is just gearing up, and I love sports and sports safety (obviously), so I thought a great topic for discussion this time of year would be the topic of concussion. It's not just a football injury, folks! I'm currently doing an elective in Sports Medicine, and I have to tell you, we are seeing 6-8 of these injuries a day! Anyone who experiences head trauma can end up with a concussion. This means everyone is at risk, but the athletes playing football, hockey, lacrosse, and soccer are particularly at risk because they get their heads hit (by other players and by the ball) often. Even horseback riders are at risk because they can fall and hit their heads.

What is a concussion?

To explain what a concussion is, I think we first have to start with the brain. And you
know how much I love the brain and what it can do, which is why I recommend helmets for preventing Traumatic Brain Injury. The brain is special. It is a magical organ that contains neurons and blood vessels and is in charge of our entire body and what it can do. Some have likened it to the soul because so much depends on the brain: emotion, personality, intelligence, learning, memory. It's amazing, right? But what happens when it gets damaged? 

Injury to the brain can be present in 3 main forms:  1. hemorrhage, 2. fracture, 3. concussion. Those are a bunch of fancy medical words, but basically, when you have injury to your brain, you can have an intracranial bleed or hemorrhage, you can break part of your skull bone (fracture), or you can have a good old-fashioned bruise (concussion).

What's the mechanism?

A concussion is in fact a form of Traumatic Brain Injury. It’s an injury to the brain that changes a person’s behavior, thinking, or physical functioning. This injury can be caused by forceful blow to the head or body that causes rapid movement of the head. The brain is encased by a skull, the bones of your head, and when quick movement of the head occurs, the brain moves around within the skull and can get bruised, resulting in a concussion.

Does a helmet protect you? 

No, it actually doesn’t. Not even the new fancy ones that they hoped would help to protect better against concussion. Helmets can protect you against fracture and hemorrhage, but they won’t protect you against a concussion because the mechanism for concussion depends on whether the brain gets knocked around inside the skull, and a helmet does not keep that from happening. Slowing players down or lightening them up so they do not hit each other with as much force (That guy Newton said Force = mass x acceleration, remember? He was a smart guy.) would help lessen the risk concussion. But until we can get our athletes to weigh less, or until we can get them to slow down (Probably unlikely, right?), then we need to know how to handle concussions.

Does my child need a CT or a cat scan?  An MRI?

This is an important question, and it is one that depends on clinical judgment and your child’s symptoms. If there is prolonged loss of consciousness after head trauma, if your child is not acting normally, if he or she is vomiting, if there is something concerning on his or her neurological exam, these are all things that the physician evaluating your child will consider when deciding if a CT or MRI is necessary. Please keep in mind that a CT is a lot of radiation, way more radiation than a simple x-ray, and in pediatrics, we try very hard not to perform a CT or cat scan unless it is absolutely necessary. Most emergency room departments will observe the child for 6-8 hours following the head trauma if there are no focal abnormalities on the neurological exam. An MRI has less radiation than a CT, but it is not a test that can be done emergently. Once your child is out of the first window of danger after concussion, those first 6-8 hours of observation and into the next 24 hours, if he or she is still having the symptoms that we will discuss later in this blog, it does not mean that he or she needs a CT or an MRI. It means that your child has a concussion and needs to be followed clinically by pediatrician or concussion specialist to manage his or her symptoms. An imaging test at that point is not what is needed because the diagnosis can be made clinically based on symptoms.

Do I need to wake my child up to make sure he is not confused after head trauma?

Pediatricians actually recommend that you do NOT do this. This used to be what was recommended, waking the athlete up every few hours and asking them questions to see if they knew where they were, who they were, what day it was, etc. But some confusion after a concussion is possible, and let’s be honest, if someone wakes you up at 3am, do you really know what day it is and where you are, even if you haven’t had head trauma? Some of us are heavier sleepers than others. However, if your child is vomiting, if your child’s pain is worsening, or if she is not acting like herself, then you need to bring her back to the emergency room for additional evaluation, and your ER physician should review these important signs with you before you leave the ER after your first evaluation.

Symptoms of Concussion:

Neck pain
Sensitivity to Light
Sensitivity to Sound
Feeling “in a fog”
Fatigue – needing 12-13 hours of sleep per night, needing naps throughout the day
Difficulty concentrating 
Difficulty remembering
Changes in behavior

Your doctor should be evaluating these symptoms at each visit and whether or not they are getting worse. This is sometimes part of something called Impact Testing which evaluates overall how well you are recovering from concussion; it can help determine when you are ready to start gradually reincorporating some of these activities that use your brain.

What's the treatment for concussion?

The AAP just released a statement on concussion and has based its report primarily on expert opinion as well as adaptation from a concussion management program developed at the Rocky Mountain Hospital for Children, Center for Concussion in Denver, Colorado. 

Most kids recover from concussion in 3 weeks. However, some athletes may take 3 months to recover, depending on history of previous concussion, how severe their symptoms were immediately following concussion, and the progression thereafter. If symptoms are severe, some students may need to stay home from school after a concussion.

The hardest part about having enough symptoms that your child needs to stay home from school is that the reason your child is home is because he or she needs cognitive rest. Cognitive rest is rest for your brain, and resting for your brain is a lot of nothing! This is really hard for most people, but especially for kids. What does rest mean for concussion recoverers? No brain stimulation of any kind. Remember that even while you are sleeping, your brain is still active.
When awake, your brain is constantly working to process the world around you and perform whatever tasks you are doing. So, when you have a concussion, even eating, talking on the phone, texting, watching TV--all things we swear kids do without any thought being used--are activities that work your brain. For this reason, some kids cannot go back to school immediately following a concussion. Depending on symptoms, you may need to stay home and not even play video games (!) which we know to any school-aged kid or teenager seems to defeat the purpose of being home from school, but your brain really does need to rest and avoid stimulation.

So, rest for a concussion is different than rest for your femur fracture or your wrist fracture where you can just not use that appendage. Your brain is an appendage that you use for everything. When your doctor tells you to rest your brain, they really mean:

-no TV
-no video games
-no reading
-no school
-no homework
-no physical activities
-no social activities, i.e. no trick-or-treating for some folks if they are having too many symptoms, no sleepovers because concussion sufferers really need actual sleep

 (Man, concussions really suck!)

This can be so hard for teachers, parents, and coaches to understand, which is why, if you or your child suffers from a concussion, you really need to be followed closely by your doctor, preferably by a Sports Medicine doctor who has experience helping kids recover from concussions. This is a step-wise process, and every concussion, just like every child and every athlete, is different. Some kids who are having few symptoms can return to school on a modified schedule right away, and some need to stay home from school and avoid reading, TV, video games, etc. because all of these things, whether you realize it or not, are actually using a lot of your brain and can be very taxing for someone recovering from brain trauma. Remember, you have a bruise in your brain, and all bruises take time to heal. Healing requires a step-wise progression to returning to all of the activities you did prior to your concussion, not just playing your sport, and it depends on your symptoms and the recommendations of your doctor.

Return to brain-stimulating activities

Your doctor will recommend a schedule for you to return to some of these activities after the first few days of rest, and how fast you return depends again on your symptoms. I guess this goes without saying, but during your REST, you also need to SLEEP. A lot. 12 hours a night is not unreasonable to recover, and a nap after any sort of return to cognitive activity is also recommended. Some kids are even sensitive to light and sound and have to be in a dark quiet room even while awake during the day. If your child is better, and your doctor recommends trying 20 minutes of reading or video games, a nap in the afternoon to recover from that new brain stimulation is warranted. If these activities are going well with no worsening of symptoms, then tutoring at home can be set up in 30-minute to 1-hour intervals, again with naps and rest in between. And once returning to school, partial days and coming home to take a nap is also necessary for recovery.

Return to School or "Return to Learn"

Coaches, parents, and athletes are all often very focused on what they feel is the most important part of recovery from a concussion-Return to Play. However, we are focusing more now on something that is equally if not more important because it is essential to a child's development and also an important step towards Return to Play, and that is cognitive rest and Return to School or "Return to Learn" as it is now being called by some specialists in the field.

When recovering from a concussion, the brain has trouble with tasks that are very important for school and learning. For example, thinking, concentrating, remembering, and processing and retaining new information can be halted to various degrees depending on the severity of the brain trauma. If symptoms are mild or tolerable, the student/athlete may return to school on a half-days schedule with special accommodation. No non-core classes and no activities with the potential for loud noises or for getting hit again – so no gym, no band, no recess. Your child should eat lunch in the nurse’s office or in a quiet place like the library to avoid loud noises and stimulation during the first part of return to school.

Return to Play 
Troy Aikman of the Dallas Cowboys had
10 concussions in 12 NFL seasons.

Most schools now have their own protocols for return to playing sports after concussion. Your doctor will be able to tell you when you are ready for return to play protocol. You should be going to school for full days without symptoms and maybe doing some walks or slight aerobic activity of short duration also without symptoms before you progress to Return to Play. Most of these protocols involve a gradual return to physical activity with close monitoring of symptoms. A plan might be something like: Day 1: bike 20 minutes; Day 2: bike and run; Day 3: non-contact practice with team; Day 4: contact practice with team; Day 5: if no symptoms, ready to return to play. If at any point, the athlete is experiencing symptoms such as headache, dizziness, etc., he or she needs to rest and re-start the protocol when no longer having symptoms.

When to see a specialist:
Your general pediatrician should be able to follow most athletes with first concussions. However, if symptoms are very severe, or if it is taking longer than 3 weeks to recover, seeing a concussion specialist (This usually falls under the category of Primary Care Sports Medicine) is warranted. Also see a specialist if the athlete has had multiple concussions, particularly within a few months or less of each other. IMPACT testing is now done at many schools, which is a baseline test to determine cognitive abilities prior to concussion and then also to follow athletes during recovery from concussion. A specialist will also do these tests to evaluate your child and can send he or she for vestibular therapy (a subset of physical therapy) and/or occupational therapy if these are needed to recover.

Resources for Parents:
From the AAP on slow return to school: http://aapnews.aappublications.org/content/34/11/24.6.full

For Schools/Teachers:
Fact sheet by the CDC for Return to Learn strategies: http://www.cdc.gov/concussion/pdf/TBI_Returning_to_School-a.pdf

For pediatricians:
School daze. Students recovering from a concussion often need academic, environmental adjustments. Jessica Pupillo. AAP News 2013; 34:4; doi:10.1542/aapnews.20133411-4. http://aapnews.aappublications.org/content/34/11/4.full

For the college athlete:
The NCAA, as do pediatricians and the medical community, recognizes concussion as traumatic brain injury. More on concussions from the NCAA: http://www.ncaa.org/wps/wcm/connect/public/NCAA/Health+and+Safety/Concussion+homepage/

The AAP is putting out a policy statement in the November issue of Pediatrics regarding Sports Medicine  practices for secondary schools and colleges, so stay tuned.