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Evidence-Based Practice in Medicine Part 3: Evaluate the Evidence

In our last installment we looked at the validity of medical claims based on the source of the claim, whether there is cited research, whether the research was published in a peer-reviewed journal, and whether the authors had any conflicts of interest.  Let’s assume you are researching the effectiveness of drinking beet juice to improve your running. A friend shares a link to an article on Facebook.  The article quotes and references some research studies one of which was published in the peer-reviewed journal Applied Physiology, Nutrition, and Metabolism . You search for and find the original research article on pubmed.gov.  So far you are doing good, the article’s author referenced a research study to back up their claims, the research was published in a peer-reviewed journal, and you can read the abstract online. Now, how do you know if this study is any goodYou need to determine what type of study was done and how much evidence that type of study imparts to the research question posed.  

Levels of evidence (sometimes called hierarchy of evidence) are assigned to studies based on the methodological design qualityvalidity, and applicability to patient care. Here’s a chart describing the basic types:  

You should always search for studies with the highest level of evidence, i.e. meta-analyses or systemic reviews that analyze many, many randomized, controlled trials (RCTs) to look for consistent results across large numbers of subjects and conditions.   A randomized, controlled trial (RCT) is, according to Wikipedia: “a type of scientific (often medical) experiment that aims to reduce certain sources of bias when testing the effectiveness of new treatments; this is accomplished by randomly allocating subjects to two or more groups, treating them differently, and then comparing them with respect to a measured response. One group—the experimental group—receives the intervention being assessed, while the other—usually called the control group—receives an alternative treatment, such as a placebo or no intervention.

Level 1 evidence would be the “gold standard” upon which we can make some good medical conclusions regarding our research question. Level 2 evidence is also very persuasive in our decisions to implement new medical treatments based on research findings.  Level 3 and below may provide useful information on trends and indications for future research.  Our beet juice study appears to be level 3 – placebo controlled, but not randomized because there were only 14 subjects who performed with both beet juice and without beet juice (i.e. a crossover study.)  Therefore, you may not want to rush out and buy a huge jug of beet juice to chug before your runs just yet – but the research is intriguing. 

They key words you want to look for when reading about scientific research in the mainstream media or on social media are the words “meta-analysis of randomized controlled trials.”  This means that a number of RCTs have been pooled together and analyzed to provide Level 1 evidence.  Lower levels of evidence may be good starting points for new directions in research. For example, if a coach writes an article about how she has noticed her runners performing better with beet juice supplements that may qualify as an expert’s opinion (Level VII.) It could be an accurate description of her experiences but may also be biased by the coach’s desire to sell beet root supplements. She may want to help athletes avoid the temptation of illegal sports-enhancing drugs or she may just want to improve her notoriety in the running communityA RCT on the use of beet juice designed to avoid these biases would help us see if  beets really do have a physiological effect on running.

No research study methodology is perfect. That’s why research is published, so it can be carefully reviewed by experts and the general public for any flaws, mistakes, or biases that could impact the author’s conclusions. When flaws are identified, new research studies aim to fix those problems and glean further information on the question. Thus, the scientific method is an iterative process where we gradually gather more and more information on a subject to clarify our understanding and produce better and better medical treatments. Yes, sometimes we get it wrong. It’s always important to challenge established conventions when new evidence comes to light. But it’s equally important to understand that new and unusual claims demand a high degree of scrutiny. Learn as much as you can about science and its methods, and you will be able to make better, more informed decisions on your own.  

If you don’t have the time or interest to become adept at evaluating research, you may want to search out expert opinions you can trust. How do you know if an “expert” is trustworthy?  How can you avoid getting scammed by disreputable fakes? That will be the topic of the next installment in this series.  

If you’d like to experience the difference evidence-based, hour-long, physical therapy sessions can make resolving your pain or healing from injury, call OrthoSport Hawaii at 808.373.3555 for more information on scheduling a free online or in-person consult.

 

 

 

 

 

 

Returning to Exercise after a Layoff – What You Need to Know

There will always be times when you must take a break from your exercise routine. For many, the closure of gyms and cancellation of exercise classes during the COVID-19 pandemic has meant little ability to exercise in their normal routine.  Some of you may have started walking or cycling outdoors recently and are interested in continuing and building on that. Here are some tips to gradually return to or start an exercise program – post Stay At Home orders. 

  1. As always, if you have any injuries or health conditions, are new to exercise, or haven’t seen your primary healthcare provider in recent years, a quick check-up and go-ahead from a medical professional is always a good idea.  Many people ignore this step, but it’s extremely important. I’ve seen runners collapsed in cardiac arrest, joggers overcome by heat exhaustion nearly unconscious, and cyclists or swimmers blacking out during their workout.  These people all thought they were healthy but were in very real danger of losing their lives.
  2. START SLOWLY, START SLOWLY, START SLOWLY! You won’t be at the same fitness and ability level anymore.  It doesn’t matter what you used to do; your body is different now.  What does start slowly mean?  If you normally spent an hour exercising (even in a class) cut that time in half. Don’t push yourself to your limit.  In weightlifting, decrease your resistance and reps by half and work yourself back up gradually.  For endurance exercise, decrease your distance and intensity adding only 10% each workout.  During a fitness class, slack off for the second half of the hour or even step out to rest and stretch.
  3. Overuse injuries are your enemy. Avoid them! Your tendons and ligaments are no longer adapted to the forces you used to put on them. Whether it’s playing tennis or getting back to martial arts, your connective tissue needs a couple of weeks to re-build and return to its previous level of elasticity and load tolerance. Now is not the time to snap your achilles.
  4. Respect the messages from your body. If you feel overly fatigued or sick, don’t exercise or cut your workout short.  Especially during the pandemic, pay attention to feelings of fever, cough, and unusual shortness of breath.
  5. Now may be a good time to seek instruction or coaching in your favorite sport or activity.  Certified trainers and sports physical therapists can help you improve your weightlifting form, analyze your running gait, and teach you how to stretch correctly.
  6. If you wear a mask while exercising, rest if you feel light-headed. Don’t forget to stay hydrated. Signs of overheating include headache, dizziness, nausea, faintness, cramps, or palpitations.
  7. If you notice an ache or pain that doesn’t go away with rest for a day or two, seek medical attention from your MD or Physical Therapist.  Treating an injury in the earliest stages results in the best outcomes and less time required for full healing. 

At OrthoSport Hawaii, we offer a variety of services to help you return to your favorite sport or start a new exercise program.  Our certified personal trainers and PTs are available to help you avoid or recover from injury and optimize your performance.  Check out our RunFit running analysis program and our SportFit package for athletes looking to stay active in their favorite sport into their older years.  For information on our personal training, physical therapy, and massage therapy services, call 808.373.3555. 

Pre-diabetic and not sure what to do now? Read on…

According to the World Health Organization, diabetes is a major cause of blindness, kidney failure, heart attack, stroke, and lower limb amputation. Have you had your blood sugar checked? 

Apple recently announced that select Apple Stores will now sell One Drop, a blood glucose monitor that closely integrates with the iPhone and the Apple Watch. Although this may be of great benefit to those who struggle to keep tabs on their blood sugar, the interesting thing is that Apple wouldn’t be selling this product if there weren’t a large enough market to make it profitable.  All forms of diabetes can benefit from close blood sugar monitoring and lifestyle choices that promote overall health. Type II diabetes and pre-diabetes are on the rise and Apple knows this as well as anyone.  A healthy bodyweight, appropriate diet, and the correct amount of exercise can go a long way in preventing, improving, and in some cases even curing Type II diabetes.  We know this, and yet diabetes continues to increase in both adults and youth.  

The American Diabetes Association states that “A healthy meal plan for people with diabetes is generally the same as healthy eating for anyone – low in saturated fat, moderate in salt and sugar, with meals based on lean protein, non-starchy vegetables, whole grains, healthy fats, and fruit. Foods that say they are healthier for people with diabetes generally offer no special benefit.”  

In addition, they recommend at least 150 min of aerobic exercise per week as well as guidelines for resistance and flexibility training. 

If your physician has told you that you are “pre-diabetic” what does this mean in terms of your current diet and exercise plan (or lack therof?)  Should you follow a “fad” diet to lose weight in hopes that general weight loss will lower your blood sugar? Should you cut out all carbs and try to get your body into ketosis? Is saturated fat a good or a bad thing to eat? Both refined sugars and high quantities of fat can trigger spikes in blood sugar as can overeating in general. Is your doctor prescribing the correct lifestyle changes needed to improve your health? 

Why Treating Chronic Disease is so Difficult

One of the reasons modern western medicine struggles with chronic diseases such as Type II diabetes, heart disease, hypertension, asthma, cancer, and so on is because our single cure model of treating illness worked so well in the past. Acute illnesses such as polio, TB, cholera, and smallpox which were once the scourge of humanity responded immediately once a single treatment or preventative vaccine was discovered. Medical/pharmaceutical research is still looking for that single magic bullet that will eliminate chronic illnesses because our health care system is focused on cures, not prevention. 

Also, if the cure or preventative treatment isn’t patent-able (for example, broccoli ) it isn’t profitable. Who will fund such research? Prevention requires knowledge, motivation, lifestyle changes (sleep, exercise, stress, etc.), dietary changes, and commitment. Fortunately, even if you already have issues with blood sugar, these same preventative measures may decrease your symptoms and need for further treatment.   

Where to Begin

So if you’ve found yourself in a situation where you know you need to make a change but aren’t quite sure how to go about it, where can you turn? Your health insurance may not cover the dietary and exercise guidance you need to be healthy.  Do you give up?  Start taking medication but continue poor health habits?  Now is the time to take charge of your own health by investing in the knowledge and expertise you need to manage your blood sugar and prevent the debilitating effects of this serious disease.   

Here are three simple steps to begin your journey to a healthy lifestyle: 

  1. Consult with a registered dietitian regarding your diet and any changes you should implement. Find a meal plan you can stick with.
  2. Consult with a medically-focused personal trainer regarding an exercise program specifically designed for someone struggling with blood sugar.  You can work one on one with a trainer, join an appropriate group class, or learn a program to do at home.
  3. Inform your MD of your plans, and make sure to monitor any lab values they recommend as you make changes. Some people are able to reduce or eliminate medications as their health improves.

Yes, you may have to pay out of pocket for some or all of these interventions.  The choice is yours, pay now, or possibly pay with very serious consequences later.  To learn more about how the dietitians and personal trainers at OrthoSport Hawaii can help, call 808 373-1114 to set up a free, no obligation orientation in our Medical Fitness center. You literally have nothing to lose and everything to gain.

 

Exercise or Have Fun? Why Not Both?

One reason people give for not exercising is that they don’t “enjoy it.” Yes, sometimes we have to force ourselves to get off the couch or drive to the gym after a long day at work, but exercise CAN be enjoyable if you find the right “happiness mix.” Research has shown that happy people have common characteristics, and many are under our own control.  Here are some ideas on how to make an exercise program enjoyable and even fun! 

1. When you start a new exercise program, aim low.

In other words, most people try to do too much, too soon, too fast and for too long. They end up fatigued and sore which is definitely not fun. Eventually, they give up. If you joined a gym to start weight training, limit your first session to 30 min and use weights that seem extremely easy. You should be able to perform the exercise for 15 repetitions (reps) before muscle fatigue sets in. As you get stronger, you can increase the weight and lower the reps. If you’ve decided to begin jogging, start slowly! You shouldn’t hear yourself panting or feel seriously out of breath. Go easy and limit yourself to no more than 10 minutes if you haven’t jogged since, well, forever. Walk for another 10 minutes or so. Then add a couple more minutes of jogging every session or two and soon you will be jogging for 20 minutes or more. Make the initial workouts feel a little too easy and you’ll be back for more next time.

2. Make exercise a party!

Or at least make it a social activity.  Joining an exercise class, sports team, or training group means meeting new people and getting inspired by the instructor, coaches, and athletes more advanced than you. However, you still need to follow tip 1make sure the workout is a little too easy the first few days.  Don’t kill yourself to complete all the bootcamp exercises like the advanced students, and don’t try to keep up with those goat-footed hikers racing ahead of you on the trail.

3. Have fun with technology.

There are many different types of fitness trackers, GPS watches, phone apps, websites, etc. that provide more data than you will probably know what to do with. You can track your daily steps, your average heart rate, your max heart rate, your stress level, your sleep quality, calories burned, pace, distance, and more. You can generate maps of your runs, hikes, swims, bikes etc., to share with friends.  You can compare your workout efforts over the weeks and months to see how much you’ve improved. Be careful though, that you don’t become overly obsessed with collecting data and miss the actual experience of the workout.

4. Make it meaningful to yourself.  

Why are you exercising, to look good and improve your health? Those are great reasons, but they may not be enough to keep you motivated over the long run.  One way to stay focused is to have a larger goal.  Are you trying to overcome an injury? Don’t let where you are now, limit your potential, dream big!  Perhaps you’d like to complete a marathon, sky dive, or snorkel the great barrier reef?  Is there a mountain you always wanted to climb, a wave you wanted to surf, or a sport you always wanted to try? If you don’t know how to achieve your goal, consult with a personal trainer who can set up a customized plan to get you where you want to go and keep it fun along the way. When you’ve accomplished one goal, enjoy your success and then pick something new to work towards.  You will have achieved a fitness-based lifestyle!

5. Make it meaningful for others. 

Many charities sponsor awareness and fund-raising runs, walks, races, and so on. Staying fit while helping others can be very rewarding. Even without a charity, you can dedicate your efforts to someone or something you care about. Create your own team, design your own t-shirts, medals, events, and so on to proudly accomplish your goals in honor of a greater cause.

push button in car6. Use music.

It’s great to listen to your tunes while exercising on your own or feel the beat in a group class. But you can also use music to get yourself pumped prior to your workout. Listen to inspirational music when you first get up in the morning or in the car while you drive to your workout and you’ll be less likely to talk yourself out of exercising. Not a big music fan? Try listening to positive affirmations, freely available on YouTube and other sites to get your motivational juices flowing.

7. Get outdoors.

It may seem obvious but staring at the same four walls for every workout is not conducive to calling it “fun.” If you usually swim in a pool, learn how to swim in the ocean, it’s really quite different! Instead of an indoor rowing machine, try joining a recreational paddling club or rent a kayak.  Attend an outdoor Taichi or Yoga class.  Go for a full moon walk.  Play a new outdoor sport like Frisbee (Disc) golf or lawn bowling. Use your creativity and don’t let the weather keep you indoors. With the right attire, you can enjoy just about any sport in most conditions.

 

The key to achieving a lifestyle where exercise is consistent and productive is to make it fun.  After a year of fun, you may be surprised how fit and healthy you have become and possibly made new friends along the way. 

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