Category Archives: wellness

Find Your Balance to Prevent Falls and Boost Confidence

About a third of people 65 years and older fall at least one time each year.1-3  Falls account for over half of all injury-related hospitalizations for the elderly.2

As a community, we can help  our friends and family members by assisting them with the exercises and helping them address any external factors noted below.  As individuals, we can boost motivation by exercising with a friend or taking a class.  Additionally, a common message that is conveyed to older folks is that they are frail and that inactivity and falls are an inevitable part of aging.6 As with many other things in life, its easy to take an aspect of truth and swing our pendulum in an extreme direction.  Its true that sarcopenia, the term given to the loss of muscle mass related to age, occurs.3,6  About two percent of muscle mass is lost per year after the age of 50.6 This loss in muscle mass is one of the main contributors to decreased function, such as rising from a chair, walking, making turns, and balance at rest and while performing activities.3,6,7  However, strength training has been shown to greatly mitigate this decline.5,6  Perhaps even more exciting is that exercises and educational programs have been shown to significantly improve balance and decrease the risk of falls as well as injuries caused by falls.1-13

Aside from the exercises mentioned below, Tai Chi2,14, Pilates21, and Yoga22 have been shown to improve balance and decrease the risk of falls.  If you live in the Bishop area, we’re blessed to have Tai Chi classes taught by Andy Selters and Deo Santos, Pilates at Bishop Yoga and Pilates Center and FlowMotion Pilates, and yoga at Bishop Yoga and Pilates Center, FlowMotion Pilates, Sabine Elia at Inyo Council for the Arts, and Sierra Shanti.

There are many exercise programs geared towards improving balance and decreasing fall risk.  They all tend to have the common themes of addressing strength, flexibility, and balance.  The general consensus recommends one hour sessions three times per week.  The bulk of the program below is taken from the Otego Exercise Program.  This program has been studied extensively and has been shown to decrease falls and the injuries caused by falls by over a third.5,10-12  In addition to the exercises, a discussion of the internal and external factors related to falls will be addressed first as many of these can be modified to greatly decrease a person’s risk of falling.1,4 

 

Internal Factors Affecting Balance:

  1. Vision – Make sure you have the correct prescription for eye wear.
  2. Vestibular system – This is the sensory system in your inner ear that communicates with your brain to tell it where your body is in space.  BPPV and Meniere’s Disease are examples of vestibular system disorders.
  3. Proprioception – These are the sensors in your joints that tell your body where it is in space.
  4. Strength – Weakness in the ankles, knees, hips, and low back/core region have been shown to affect balance and will be addressed below.5,8
  5. Flexibility – Decreased flexibility in the ankles, hips, and spine have been shown to affect flexibility and will be addressed below.5,8
  6. Dual tasking – Walking while adding another task, such as talking, turning your head to look at objects, or reacting to hearing or seeing something that is happening in your environment, is considered dual tasking.  This is a fascinating and overlooked topic that I did my grad school thesis on.  Older folks tend to have a decreased ability to dual task while walking which can increase the risk of falls.  One easy way of determining if you should be working on balance is if you stop walking when you begin talking.15-18
  7. Medical Conditions – Some examples are poor general health, diabetes, arthritis, osteoporosis, stroke, incontinence, medication use, and cognitive/mental health issues (memory, inattention, dementia, depression). Many of these issues can by improved greatly by exercise, nutrition, and lifestyle changes.
  8. Lifestyle Choices – Some examples are exercise, footwear, alcohol use, nutrition, hydration, and fear of falling.4

External Factors Affecting Balance:

  1. Throw rugs and cords or other obstacles
  2. Lack of nightlights for bathrooms/hallways
  3. Lack of handrails
  4. Objects that are out of reach
  5. Uneven ground
  6. Alcohol
  7. Decreased activity level
  8. Fear of falling
  9. Dehydration – The recommendation is about twelve eight ounce glasses of water per day for men and nine for women.19,20
  10. Lack of sleep – See my evidenced-based handout for sleep hygiene tips.
  11. Medication issues
    – Did your balance issues begin around the same time as a medication change?  Talk with your doctor.
    – Lightheadedness/dizziness with a change of position (lying to sitting or sitting to standing) can indicate a blood pressure issue.  Talk with your doctor.
  12. Pets – high energy dogs, for example

Exercises

I. General Guidelines – click on the underlined areas for video demonstrations

  1. A person should be evaluated by a healthcare practitioner familiar with balance disorders and training before performing the exercise program below.  All of the exercises can be modified to be made easier or more challenging and every person’s deficits will be somewhat different.  The best exercise program is one specifically tailored to the individual.  Safety is the most important aspect of any exercise program.
  2. Performing any of these exercises is better than none.  If the program is taking too much time or effort, have your physical therapist remove the exercises that are not as necessary for you.  It is much better to start off doing less than you are capable of and add to that program rather than starting with too much and hurting yourself or hating the program and throwing it in the garbage.
  3. Do not push through pain with any of the exercises, even if it feels like you are “not doing anything”.  Try to avoid having expectations about being able to perform a certain number of repetitions or move in a certain range.  Progress will come with consistent practice.
  4. Notify your physician if you experience dizziness, chest pain, or shortness of breath (ie., you are unable to speak because you are short of breath).
  5. Do not hold onto an object for support that may move (use your kitchen sink rather than a chair for example).
  6. Look ahead when walking on even surfaces or performing the exercises instead of looking down.
  7. Try to add walking into your daily activities as much as possible. For example, park farther away from the entrance when going to the store. Use the stairs when possible instead of an elevator.

II. Warm Up

  1. Walk for 20-30 minutes if time permits (stationary cycling is a good alternative if walking is too unsteady)
  2. Neck rotation – stand tall and turn your head to the side until you feel a stretch, repeat on the other side 5-10X each
  3. Chin tucks – stand tall and tuck your chin as if you are creating a double chin while imagining your spine stretching towards the ceiling, repeat 5-10X
  4. Trunk extension – place your hands on your low back and bend backwards until you feel a stretch, repeat 5-10X
  5. Trunk rotation – keeping your hips and pelvis stationary, rotate your trunk until you feel a stretch, repeat on the other side 5-10X each
  6. Seated ankle range of motion – bring your toes towards your nose, then push your toes down towards the floor, repeat 10X in each direction

III. Strengthening
use a kitchen counter for support for safety and to focus on your technique, as needed

  1. Seated knee extension – straighten your knee and pull your toes towards your nose, feel free to add ankle weights to make more challenging, repeat 10X for 2-3 sets
  2. Standing knee flexion – bend your knee by bringing your heel towards your buttocks, feel free to add ankle weights to make more challenging, repeat 10X for 2-3 sets
  3. Toe/heel raises (double or single leg) – raise up onto the balls of your feet, lower back down and raise up onto your heels, repeat 10X for 2-3 sets
  4. Hip abduction – stand tall and raise your leg out sideways away from your other leg, repeat 10X for 2-3 sets on each side
  5. Marching – stand tall and raise a knee towards your chest, repeat 10X for 2-3 sets on each side
  6. Squatting – keeping a neutral spine position with your chest pointing forwards and your eyes looking straight ahead, squat down until you feel pain or unstable and return to standing (you may want to use a chair to simulate standing up from a seated position and squatting back down until your buttocks barely touches the chair before returning to stand), repeat 10X for 2-3 sets
  7. Lunges (more advanced)
  8. Single leg quarter squats (more advanced)

IV. Static (not moving) Standing Balance
*use kitchen counter for support for safety as needed
*there are 4 progressively more challenging foot positions (1. feet as wide as your hips 2. feet together 3. tandem stance 4. single leg stance) and 4 progressively more challenging variables for each foot position (1. eyes open on an even surface 2. eyes closed on an even surface 3. eyes open on an uneven surface, such as a balance board, dyna disc, or pillow 4. eyes closed on an uneven surface)
*hold all positions for 30-60 seconds and repeat 2-3X

  1. Feet hip width with eyes open (close eyes or stand on an uneven surface to make more challenging)
    feet hip width
  2. Feet together with eyes open (close eyes or stand on an uneven surface to make more challenging)

    feet together
  3. Tandem stance (tightrope) with eyes open (close eyes or stand on an uneven surface to make more challenging) – both sides
    semi tandem stance (easier)

    tandem stance (harder)
  4. Single leg stance with eyes open (close eyes or stand on an uneven surface to make more challenging) – both sides

V. Dynamic (moving) Standing Balance
*
use a wall or counter (hallways can be helpful) for support for safety as needed
*perform each activity for 10 steps (or better yet, measure out 10-15 feet so the dual task of counting while you are walking is not added, at least initially) and repeat 5X

  1. Tandem walking (tightrope) – walk forwards placing one foot directly in front of the other as if walking on a tightrope
  2. Walking with head turns – turn your head side to side as if you are checking out the food on either side of you in the grocery store aisle
  3. Walking backwards
  4. Sideways walking
  5. Figure 8 walking – walk in a figure of 8 pattern
  6. Heel walking – walk on your heels
  7. Toe walking – walk on the balls of your feet
  8. Backwards tandem walking – walk backwards placing one foot directly in front of the other as if walking on a tightrope
  9. Stairs – use one or two rails for support until you feel comfortable walking with no support

VI. Stretching
*
hold stretches for 30 seconds and repeat 2-3X on each side daily

  1. Calf stretches (standing) – a stretch should be felt in the calf of the back leg
  2. Hip flexor stretches (standing) – a stretch should be felt in the front of the hip in the back leg
  3. Single knee to chest (lying on back) – a stretch may be felt in the knee, hip, or back

    single knee to chest
  4. Trunk rotation (lying on back)

    low trunk rotation
  5. Child’s pose (start on your hands and knees and sit back on your heels while bringing your head to the floor)
    Childs Pose

     

Check out Beyond Tape: The Guide to Climbing Injury Prevention and Treatment for more information about warming up, stretching, and other climbing (and non-climbing) injury related topics.  Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

References:

1Schwenk M, Jordan ED, et al. Effectiveness of foot and ankle exercise programs on reducing the risk of falling in older adults: a systematic review and meta-analysis of randomized controlled trials. J Am Podiatr Med Assoc. 2013 Nov-Dec;103(6):534-47.
2Sherrington C, Whitney JC, et al. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc. 2008 Dec;56(12):2234-43.
3Hamed A, Bohm S, et al. Follow-up efficacy of physical exercise interventions on fall incidence and fall risk in healthy older adults: a systematic review and meta-analysis. Sports Med Open. 2018 Dec 13;4(1):56.
4Florida Injury Prevention Program for Seniors (FLIPS) – https://slideplayer.com/slide/8680174/
5McMahon SK, Wyman JF, et al. Combining Motivational and Physical Intervention Components to Promote Fall-Reducing Physical Activity Among Community-Dwelling Older Adults: A Feasibility Study. Am J Health Promot. 2016 Nov;30(8):638-644.
6Papa EV1, Dong X2, et al. Resistance training for activity limitations in older adults with skeletal muscle function deficits: a systematic review. Clin Interv Aging. 2017 Jun 13;12:955-961.
7Gardner MM1, Buchner DM, et al. Practical implementation of an exercise-based falls prevention programme. Age Ageing. 2001 Jan;30(1):77-83.
8Emilio EJ1, Hita-Contreras F2, et al. The association of flexibility, balance, and lumbar strength with balance ability: risk of falls in older adults. J Sports Sci Med. 2014 May 1;13(2):349-57.
9El-Kashlan HK1, Shepard NT, et al. Evaluation of clinical measures of equilibrium. Laryngoscope. 1998 Mar;108(3):311-9.
10Shubert TE, Smith ML, Otago Exercise Program in the United States: Comparison of 2 Implementation Models. Phys Ther. 2017 Feb 1;97(2):187-197.
11Otego Exercise Program PDF – file:///C:/Users/Mike%20Gable/Documents/Originals/Articles/Balance/Not%20Read/Otago%20program%20PDF.pdf.
12Robertson MC1, Campbell AJ, et al. Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data. J Am Geriatr Soc. 2002 May;50(5):905-11.
13Sherrington C1, Fairhall NJ, et al. Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2019 Jan 31.
14Taylor-Piliae RE1, Haskell WL, et al. Improvement in balance, strength, and flexibility after 12 weeks of Tai chi exercise in ethnic Chinese adults with cardiovascular disease risk factors. Altern Ther Health Med. 2006 Mar-Apr;12(2):50-8.
15Lajoie Y1, Teasdale N, et al. Attentional demands for static and dynamic equilibrium. Exp Brain Res. 1993;97(1):139-44.
16Wright DL1, Kemp TL. The dual-task methodology and assessing the attentional demands of ambulation with walking devices. Phys Ther. 1992 Apr;72(4):306-12; discussion 313-5.
17Chen HC1, Schultz AB, et al. Stepping over obstacles: dividing attention impairs performance of old more than young adults. J Gerontol A Biol Sci Med Sci. 1996 May;51(3):M116-22.
18Lundin-Olsson L, Nyberg L, et al. “Stops walking when talking” as a predictor of falls in elderly people. Lancet. 1997 Mar 1;349(9052):617.
19Sawka MN1, Cheuvront SN, Carter R 3rd. Human water needs. Nutr Rev. 2005 Jun;63(6 Pt 2):S30-9.
20http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=10925
21Pata RW1, Lord K2, et al. The effect of Pilates based exercise on mobility, postural stability, and balance in order to decrease fall risk in older adults. J Bodyw Mov Ther. 2014 Jul;18(3):361-7.
22Nick N1, Petramfar P2, et al. The Effect of Yoga on Balance and Fear of Falling in Older Adults. PM R. 2016 Feb;8(2):145-51.

Sleep And Healing

Having 2 and 4-year-old kids has me thinking a lot about sleep lately.  I’ve been interested in how sleep loss affects the healing process though for a long time since I became fascinated with chronic pain conditions early on in my career.  There’s research going back to before I was born linking sleep deprivation and what we know today as fribromyalgia.1,2  Since then, there has been an incredible amount of research linking sleep deprivation with a myriad of health issues.  At the end of this article, I break down each of the many aspects of health that are affected by sleep and some of the research that has been done on each topic.  Many of the references are mentioned in the fascinating book Why We Sleep by Matthew Walker while many are additional articles I found through my review of the current literature.  This post is a greatly expanded version of the information I wrote about in Beyond Tape.

The potential causes of sleep loss are vast but seem to be able to be broken down into 2 categories , behavioral and medical, which can be linked in many cases.  Medical causes including obstructive sleep apnea, hormone imbalances, medication-related, and psychological disorders, which should be ruled out first by a qualified health care professional.3,6,9  Behavioral causes can be changed by modifying a person’s behavior, such as avoiding screens before bedtime.  Oftentimes, the causes are more on the behavioral end, which is where treatments like cognitive behavioral training and sleep hygiene techniques come into play.  Cognitive behavioral training (CBT), when performed by an expert in this field, has been found to be the most effective (even more so than sleep medications in some studies).  Sleep hygiene tips, one aspect of CBT, have been shown to be helpful as well.4-11  Check out my evidenced-based handout for sleep hygiene tips if you or someone you know suffers from sleep problems.

As a physical therapist, I’m mostly fascinated with the effects of sleep on injuries and the healing process.  Growth hormone is produced during stage 3, a deeper stage which is considered slow-wave non REM sleep, of the sleep cycle.12-14  This hormone helps to facilitate the healing process.  It takes roughly 90 minutes to get into this stage of the sleep cycle.15  Inadequate sleep has been shown to decrease growth hormone production.  Sleep disturbance can also contribute to myofascial trigger point formation, another contributor to chronic pain.  Psychological stress is a major cause of sleep loss.  This is a double-whammy, as stress causes an increase in production of the hormone cortisol (as does sleep deprivation), which has a negative impact on healing.  Laughter, meditation, and yogic breathing each have been shown to decrease the negative effects of stress.13,14

Aside from the affects on the healing process, sleep loss is linked to all kinds of problems which are described in the summary below.  Some big ones that are being talked about in the research are the link with metabolic syndrome (increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels — that occur together, increasing your risk of heart disease, stroke and diabetes), obesity and type 2 diabetes, both in adults and kids.16  This is thought to be due to the effects on hormones that play a major role in control of appetite and energy expenditure.  Hunger increases with poor sleep.  

Here is a summary of the health issues associated with poor sleep quality and quantity:

      • Cancer – Night shift work is associated with breast, prostate, and endometrial Cancers.17-19
      • Cognitive impairments – Cognitive functioning has been found to be impaired in all age groups, from children to the elderly, when restricting sleep by as little as 1 hour over 5 nights or 1 night of sleep deprivation.20-22
      • Alzheimer’s – Sleep fragmentation (repetitive short interruptions of sleep) and insomnia are found to be associated with Alzheimer’s and an increased rate of cognitive decline.23,24  Treating obstructive sleep apnea has been shown to improve cognitive function in Alzheimer’s patients.25
      • Cardiovascular disease and blood pressure – Poor sleep quality and insomnia are associated with increased blood pressure and vascular inflammation (C-reactive protein, a stable marker of inflammation that has been shown to be predictive of cardiovascular morbidity, has been shown to be elevated in subjects with total and partial sleep deprivation).26,27  People who get more sleep have been shown to have lower coronary artery (blood supply to the heart) calcification incidence.28  All these problems increase the risk of heart attacks and strokes.
      • Common cold and upper respiratory illness – Sleeping for less than 7 hours of sleep per night has been shown to be associated with an increased incidence of developing the common cold.29-31
      • Chronic pain and fibromyalgia – Sleep deprivation, especially of stage 3 in non REM sleep, has been shown to produce fibromyalgia-like symptoms of muscle tenderness and central sensitization.  This is where the nervous system becomes overly reactive, requiring less and less of a stimulus to create the sensation of pain and the pain is maintained even after the initial injury has healed.32-34  And as I mentioned above, stage 3 is when growth hormone is released which helps to facilitate the healing process.  Sleep hygiene education has been shown to decrease pain and fatigue in patients with fibromyalgia.35  Sleeping less than 6 hours has been associated with increased cortisol release and increased sympathetic nervous system activity, which contribute to central sensitization.36  Sleep disturbance is also thought to be a factor in the perpetuation of myofascial trigger points.37
      • Low back pain – Improvements in sleep quality are associated with improvements in low back pain and disability. 38 
      • Obesity – Sleep deprivation in both the short and long term is associated with increased obesity, body mass index, and weight gain in adults and children (including infants).  This is due to several factors including decreased glucose tolerance and carbohydrate metabolism, decreased insulin sensitivity, increased evening concentrations of cortisol, increased levels of ghrelin, decreased levels of leptin and increased hunger and appetite.  Ghrelin and leptin sound like Lord of the Rings’ characters, but they’re actually crucial hormones for regulating appetite.  Grehlin is an appetite stimulant and leptin an appetite suppressant.39-45  
      • Type 2 Diabetes – Sleep deprivation and poor sleep quality are associated with an increased prevalence of type 2 diabetes.  This is due to decreased carbohydrate metabolism and glucose tolerance, leading to insulin resistance and diabetes.46-49  
      • Sports injuries and performance – Decreased sleep is associated with a significantly increased prevalence of injury.  In one study, the likelihood of having an injury was 75% for 6 hours of sleep versus 18% for 9 hours in high school kids and 65% of kids were injured who slept less than 8 hours versus 31%  who slept longer than 8 hours.  This is thought to be due to the findings in other studies showing an association between sleep loss and impairment of psychomotor performance,  motor function, mood, and cognitive functions.50  Exciting research regarding performance shows that  basketball players who increased their sleep to at least 10 hours sprinted faster, shot more accurately, and noted improved physical and mental well-being.51  Decreased sleep is also associated with decreased performance, especially with “sports-specific skill execution and submaximal sustained exercise bouts”.  Increasing sleep showed an increase in “sports-specific skill execution and cognitive related tasks, such as reaction time and shooting accuracy”.52
      • Bone loss – Bone loss has been shown to occur after 3 weeks of sleep disruption, due to bone formation being decreased while bone resorption stays the same.53
      • Sleep medications – As a physical therapist, its beyond my scope of practice to give recommendations on medications.  That being said, sleep medications such as Restoril and Ambien have been shown to significantly reduce slow wave activity during non REM sleep.  Again, this is also called deep sleep and is the phase when growth hormone is released for healing of damaged tissues, glial cells in the brain are restored with sugar to provide energy for the brain, and synapses in the brain which are formed from learning and memory during wakefulness are regulated.54 Other factors that you may want to consider are that in some studies, sleep medications were no more effective than behavioral treatments55 and sleep medications have common, and often significant, side effects.54,56,57

It may seem strange for your physical therapist to be concerned about your sleep patterns, but I find (as does the research) that addressing all aspects of a person’s health leads to better and longer-lasting outcomes.  This is the purpose of my handouts for evidence-based sleep hygiene tips and evidence-based wellness topics.  Poor sleep quality and quantity is not just a normal part of the aging process and there are things you can do.  

Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.

1Moldofsky H, Scarisbrick P. Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation. Psychosom Med. 1976 Jan-Feb;38(1):35-44.
2Moldofsky H, Scarisbrick P, England R, Smythe H. Musculosketal symptoms and non-REM sleep disturbance in patients with “fibrositis syndrome” and healthy subjects. Psychosom Med. 1975 Jul-Aug;37(4):341-51.
3Bloom HG1, Ahmed I, et al. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. J Am Geriatr Soc. 2009 May;57(5):761-89.
4Sharma MP1, Andrade C. Behavioral interventions for insomnia: Theory and practice. Indian J Psychiatry. 2012 Oct;54(4):359-66.
5Orlandi AC1, Ventura C, et al. Improvement in pain, fatigue, and subjective sleep quality through sleep hygiene tips in patients with fibromyalgia. Rev Bras Reumatol. 2012 Oct;52(5):666-78.
6Zhou ES1, Gardiner P2, et al. Integrative Medicine for Insomnia. Med Clin North Am. 2017 Sep;101(5):865-879.
7Ye YY, Chen NK, et al. Internet-based cognitive-behavioural therapy for insomnia (ICBT-i): a meta-analysis of randomised controlled trials. BMJ Open. 2016 Nov 30;6(11):e010707.
8Kozasa EH1, Hachul H, et al. Mind-body interventions for the treatment of insomnia: a review. Braz J Psychiatr. 2010 Dec;32(4):437-43.
9Maness DL1, Khan M1. Nonpharmacologic Management of Chronic Insomnia. Am Fam Physician. 2015 Dec 15;92(12):1058-64.
10Siebern AT1, Suh S, et al. Non-pharmacological treatment of insomnia. Neurotherapeutics. 2012 Oct;9(4):717-27.
11MacLeod S1, Musich S2, et al. Practical non-pharmacological intervention approaches for sleep problems among older adults. Geriatr Nurs. 2018 Sep – Oct;39(5):506-512.
12Cauter E, Leproult R, et al. Age-related changes in slow wave sleep and REM sleep and relationship with growth hormone and cortisol levels in healthy men. JAMA. August 16, 2000 – Vol 284 No 7 pp. 861-868. 
13Robles TF1, Carroll JE.  Restorative biological processes and health. Soc Personal Psychol Compass. 2011 Aug;5(8):518-537. 
14Adam K, Oswald I.  Sleep Helps Healing. British Medical Journal. Volume 289, 24 November 1984. 
15Davidson J, Moldofsky H, et al.  Growth Hormone and Cortisol Secretion in Relation to Sleep and Wakefulness. J Psychiatr Neurosci, Vol. 16, No. 2, 1991. 
16Van Cauter E, Spiegel K, et al.  Metabolic consequences of sleep and sleep loss. Sleep Med. 2008 Sep;9 Suppl 1:S23-8.
17Pahwa M1, Labrèche F, et al.  Night shift work and breast cancer risk: what do the meta-analyses tell us? Scand J Work Environ Health. 2018 Jul 1;44(4):432-435.
18Viswanathan AN1, Hankinson SE, et al. Night shift work and the risk of endometrial cancer. Cancer Res. 2007 Nov 1;67(21):10618-22.
19Salamanca-Fernández E1, Rodríguez-Barranco M, et al.  Night-shift work and breast and prostate cancer risk: updating the evidence from epidemiological studies. An Sist Sanit Navar. 2018 Aug 29;41(2):211-226.
20Volkow ND1, Tomasi D, et al.  Hyperstimulation of striatal D2 receptors with sleep deprivation: Implications for cognitive impairment. Neuroimage. 2009 May 1;45(4):1232-40.
21Yaffe K1, Laffan AM, et al.  Sleep-disordered breathing, hypoxia, and risk of mild cognitive impairment and dementia in older women. JAMA. 2011 Aug 10;306(6):613-9.
22Sadeh A1, Gruber R, et al.  The effects of sleep restriction and extension on school-age children: what a difference an hour makes. Child Dev. 2003 Mar-Apr;74(2):444-55.
23Osorio RS, Pirraglia E, et al.  Greater risk of Alzheimer’s disease in older adults with insomnia. J Am Geriatr Soc. 2011 Mar;59(3):559-62.  
24Lim AS1, Kowgier M, et al.  Sleep Fragmentation and the Risk of Incident Alzheimer’s Disease and Cognitive Decline in Older Persons. Sleep. 2013 Jul 1;36(7):1027-1032.
25Ancoli-Israel S1, Palmer BW, et al.  Cognitive effects of treating obstructive sleep apnea in Alzheimer’s disease: a randomized controlled study. J Am Geriatr Soc. 2008 Nov;56(11):2076-81.
26Aggarwal B1, Makarem N2, et al.  Effects of Inadequate Sleep on Blood Pressure and Endothelial Inflammation in Women: Findings From the American Heart Association Go Red for Women Strategically Focused Research Network. J Am Heart Assoc. 2018 Jun 9;7(12).  
27Meier-Ewert HK1, Ridker PM, et al.  Effect of sleep loss on C-reactive protein, an inflammatory marker of cardiovascular risk. J Am Coll Cardiol. 2004 Feb 18;43(4):678-83.
28King CR1, Knutson KL, et al.  Short sleep duration and incident coronary artery calcification. JAMA. 2008 Dec 24;300(24):2859-66.
29Prather AA1, Janicki-Deverts D2, et al.  Behaviorally Assessed Sleep and Susceptibility to the Common Cold. Sleep. 2015 Sep 1;38(9):1353-9.
30Cohen S1, Doyle WJ, et al.  Sleep habits and susceptibility to the common cold. Arch Intern Med. 2009 Jan 12;169(1):62-7.
31Prather AA, Janicki-Deverts D, et al.  Sleep Habits and Susceptibility to Upper Respiratory Illness: the Moderating Role of Subjective Socioeconomic Status. Ann Behav Med. 2017 Feb;51(1):137-146.
32Moldofsky H, Scarisbrick P.  Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation. Psychosom Med. 1976 Jan-Feb;38(1):35-44.
33Moldofsky H, Scarisbrick P, et al.  Musculosketal symptoms and non-REM sleep disturbance in patients with “fibrositis syndrome” and healthy subjects. Psychosom Med. 1975 Jul-Aug;37(4):341-51.
34Simpson NS, Scott-Sutherland J, et al.  Chronic exposure to insufficient sleep alters processes of pain habituation and sensitization. Pain. 2018 Jan;159(1):33-40.
35Orlandi AC1, Ventura C, et al.  Improvement in pain, fatigue, and subjective sleep quality through sleep hygiene tips in patients with fibromyalgia. Rev Bras Reumatol. 2012 Oct;52(5):666-78.
36Spiegel K1, Leproult R, et al.  Impact of sleep debt on metabolic and endocrine function. Lancet. 1999 Oct 23;354(9188):1435-9.
37Dommerholt J, Bron C, et al.  Myofascial Trigger points: an evidence-informed review. Journal of manual and manipulative therapy. Vol. 14 No. 4 (2006), 203 – 221.
38Kovacs FM, Seco J, et al.  The association between sleep quality, low back pain and disability: A prospective study in routine practice. Eur J Pain. 2018 Jan;22(1):114-126.
39Chen X1, Beydoun MA, Wang Y.  Is sleep duration associated with childhood obesity? A systematic review and meta-analysis. Obesity (Silver Spring). 2008 Feb;16(2):265-74.
40Van Cauter E, Spiegel K, et al.  Metabolic consequences of sleep and sleep loss. Sleep Med. 2008 Sep;9 Suppl 1:S23-8.
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42http://teacher.sduhsd.net/mrall/ap%20bio/AP%20Bio%20classwork/sleep.pdf
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Evidenced-Based Wellness Recommendations

Healing is a multifaceted process.  When someone comes to me with back pain, for example, there are often other topics that come up.   “How does it feel to be injured?  How are you sleeping?  How does the injury affect your job, family, recreation?  How’s your diet and hydration?”  I’ve often wondered about the evidence behind some of the recommendations that are suggested from various experts or we see in articles or on the internet.  I’ve put together a handout, with citations included, for my patients about some common topics that come up in my clinic.  Below, I’ll briefly discuss my reasoning for adding each topic but here is the handout if you want to just skip to the business.

The Healing Process:  I think its crucial to have a basic understanding of what happens in our bodies when we have an injury.  This knowledge helps us understand that healing is a process, not an event.  It also helps us make decisions when trying to decide if and how a given intervention (exercise, manual therapy, surgery, medication, injections, anti-inflammatory modalities, etc.) will meet our goals both in the short and long term.

Sleep:  We spend roughly a third of our lives asleep.  Its easy to look at sleep as a waste of our waking lives and something we should try to fight (“Joe Shmoe is successful because he gets 4 hours of sleep a night”).  An overwhelming amount of research shows the incredible importance of sleep for all aspects of our lives.  A fascinating and in-depth read about this topic is Why We Sleep by  Matthew Walker (I hope Joe Shmoe checks this out).  Some people have been dealing with disrupted sleep for so long they think its normal or that nothing can be done.  Not so!  A psychotherapist with expertise in cognitive-behavioral therapy for insomnia can be of great help.  And here’s a list of evidence-based sleep hygiene tips.

Nutrition:  We’re learning more and more about how foods affect our beings and the healing process.  Recommendations change based off of new information and proper nutrition for each individual is often based on many factors that are unique to that person.  I frequently urge people to consult with an expert in nutrition.  Ask them questions about what you’ve heard or read about.  That’s what they’re there for.

Hydration:  Have you ever wondered if there’s evidence behind the recommendation to drink eight eight-ounce cups of water a day?  I have.  Turns out there’s not, but there has been research done regarding this topic.  I provide this information in the handout, and there are also lots of individualized caveats to consider.

Stress:  The fight or flight response is hugely important if you come face to face with a mountain lion while on a previously enjoyable jog in the mountains (that’s pretty extreme I know, but you get my point).  Many of us are living in a low-level fight or flight situation throughout each day, whether it be due to less-than-ideal relationships, work, or prior unresolved conflicts or traumatic events.  Hormones are released which are beneficial in short-term situations but wreak havoc on our bodies and lives when they’re constantly in our systems.

Volunteering:  I joined the Rotary Club (there are an infinite number of similar organizations who’s goal it is to serve their communities in meaningful ways) many years ago because I thought it would be a productive way to try to balance out the horrible things that we sometimes do to each other as human beings.  That’s why I continue to be a member.  The benefits I reaped (learning how to organize, speak publicly, work with people of differing views, gain the confidence to do things out of my comfort zone because I realize I’m a part of something bigger than myself, etc.) far outweigh my capacity to give back.  I was also pleased to see the solid evidence that volunteering benefits the helper in concrete physical ways as well.

Flexibility:  This topic got the ball rolling for me with the writing of Beyond Tape.  I was starting to see internet musings conveying the pointlessness of stretching and felt it would be beneficial for me to compile the actual evidence.  There are many benefits of stretching for both young and old.

Strength:   In my experience, many older folks are under the impression that strength training is a young person’s activity.  Not so!  This mindset tends to be a major player in the downward spiral that can, but doesn’t necessarily have to, happen as we age.  “If you don’t use it, you lose it” is for real.

Aerobic Activity:  It’s hard to make a lifestyle change and starting a walking, biking, or swimming program is nearly impossible without concrete goals.  We’re fortunate to have research that gives us solid guidelines to go by.  It’s important to see these guidelines as long term goals rather than something we should be doing right now.  I frequently suggest a person leave their front door, walk 5 minutes, and come back.  Add 5 minutes next week if it feels right to you.  Pat yourself on the back, you’ve made a start, and that’s the hardest part.

As always, let me know if you have questions or if you’d like to see additional topics added.  And please always feel free to let me know if I’ve missed anyone that you think should be on a list of practitioners I’ve provided (see the nutrition section of the handout).

Like my facebook page for updates and more information and rate/review Beyond Tape on my website or here My primary motivations for Beyond Tape and any of the posts are to:       1. Check out the most relevant and up-to-date research for each topic in order to dispel myths, sift out conflicting views, and help people to prevent or heal from injuries – letting me know about new research or opposing views is helpful and greatly appreciated       2. Contribute to the local and global communities by donating 100% of my net profits from Beyond Tape to service-based non-profit organizations, such as Rotary International, Doctor’s Without Borders, Access Fund, etc.