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The Grim Reaper Only Finds What It Can Catch!

I posted this video (or see below) after I came across one of my favorite articles. This study by de Britto et. al. looked at people (51–80 yo) who could perform this movement (sitting rising test) from the floor without losing balance or needing support. They found those who could complete this movement tended to live longer compared to those who could not! In the video below, I’m keeping my arms extended so that I do not use my hands to push off of my knees. This same study was also covered in a local news segment which does a nice job breaking down the movement and the scoring.

When I see patients I focus specifically on how they move in the clinic. I watch how they get on and off of the table, take their shoes on/off, etc. To me, these are the MOST essential survival skills and tells me the most about where my patient’s problems start. As an example, think about how babies learn to walk. On the surface it looks very straightforward. First they need to be able to roll on their stomach. Then they build up strength in their neck and back muscles to get to their hands and knees. As they build up hip and shoulder muscles they start to crawl. Eventually they can stand and start moving their legs in a walking motion. Voila! That’s it! But is it that simple?

As a clinician and parent, my experiences taught me there is more than meets the eye. It’s very easy to appreciate the learning process in young children but we fail to recognize how we lose these skills as we age. And when I say age, I mean starting from grade school! More on this topic for a different blog post.

Falls in an aging adult become very serious and in some cases deadly. It’s a known fact that mortality increases dramatically after an adult suffers a fall related hip fracture. There are several risk factors that contribute to a fall. Despite this knowledge, the risk of death within the first year of hip fracture ranges between 14–58%. The first question that comes to mind is why did the person fall. Maybe it was a pure accident or there were some modifiable risk factors involved. However, the better question is why could they not get up. When someone is discharged from the hospital after a hip fracture, the focus is primarily on important tasks such as dressing themselves, going to the bathroom, and climbing stairs. While this is crucial to the rehabilitation process, have we actually decreased their risk of falling? Are they more likely to get up if they fall again?

Seeing a fall is a very late manifestation of a degrading sense of play that occurs slowly but continuously over decades. To understand why people fall you must breakdown what you need to stand.

I believe these factors are the most important when it comes to movement and survival.

MOBILITY

Mobility or freedom of movement in all joints is important. I’m not talking just about your hips, knees, and spine. I’m talking even about your ankles, toes, wrist, and fingers. As young children, we are super flexible but as we age we get stiffer and it’s not because we are getting old. It’s mainly because we become less active and become more “confined.” What is one of the first things that happens once babies start to walk? We put shoes on them! Shoes are not evil. They provide much need protection in a modern world but they do change how we move our feet. What’s next? When they get into 1st grade they begin sitting a lot more! As we enter into high school, physical activity starts to become less and less. Once we enter into the work force we end up stuck in front of cubicles for 8 hours a day. This is when the process of freezing up the knees, hips, and spine begins in my opinion. Immobile joints are not just a structural problem but also a societal and cultural one.

MOVEMENT PLANNING

“man climbing cliff beside beach” by Chen Hu on Unsplash

I view the head, arms, and legs as tools your for your “core.” You use them to help you crawl, stand, walk, run, and climb. There is no “best” way to use these tools. Period. There are a multitude of ways to accomplish and create movement. Imagine crawling for the first time and using your arms mainly. It’s certainly possible to do this with just your arms. However, if you do it this way then your legs drag and increase resistance to your movement. Now if you flex your hips and knees to the side like frog when trying to advance your arms, you’ll notice that it’s not only easier but you are also moving faster. Watch carefully how the baby learns how to crawl and then walk. Similarly, if you are trying to stand for the first time and you put your feet too close together you will likely fall on your butt. The next time you look up, widen your stance, and put your hands in front of you to counter balance your weight. I think that you will learn that it’s easier to stand for a longer period of time! Tools when used with intention creates learning. A great example of this is rock climbing or parkour athletes. Watching these athletes is totally amazing! In order for them to scale these structures there is a lot of planning that goes into each step.

SENSE OF CENTER

I do not consider “sense of center” and balance as the same thing. Balance is a neurological balance of sensory input from the eyes, inner ear, and peripheral nerves to keep you from moving or falling. The center can be found in the middle of your torso if you stood straight up and drew a perpendicular line from the top of your head to your feet. Your center is moveable and can change locations. Knowing where your center is can help you immensely. It improves your efficiency of movement but it can also help you leverage and create force without using more muscle. There are a number of pictures on the Internet comparing how a child performs a squat compared to an adult. Children effortlessly get into this position and also get up without using their hands. Plus, they are built super top heavy. Imagine balancing a big head on a wobbly body. That’s your baby trying to walk! Babies have to learn this skill in order to stay upright. As adults, finding our sense of center requires more intentional practice. Let’s be honest, we tend to be sedentary people. We like small technology that makes us slouch. We are more likely to look for an app to do something instead of physically having to do it. However, there is not app for learning movement skills and there is no replacement for actually doing it.

COORDINATION

Coordination, like balance, is a complex interplay of the nervous system. It’s not about strength but control of movement. Imagine extending your arm and index finger in front of you and then touching your nose as fast as you can. A lot of neurological input and control is needed in order to complete this task without poking yourself in the eye or giving yourself a bloody nose. Now imagine trying to throw a baseball, run, or perform a squat. These movements are a summation of thousands of learned decisions which becomes “coordination.” These decisions have to be practiced and refined which is why it can take time for kids to learn how to stand. Now imagine trying to get off of the ground right now versus 20 years from now. What does it look like? Is it effortless? Are you using your tools? Knowing how to get off the ground is a matter of life and death when you are 80 versus than when you are 20.

CREATIVITY

Last but probably the most important. I define creativity as the ability to assess a situation, understand what you need, taking what you have, and completing the task in a variety of ways. This is really where we can learn from children. They are not born fast or strong. Children learn movement from experience and not purely their physical attributes. They do not carry preconceived notions of how they should move or what their physical abilities are or should be. They simply move, learn, and repeat. As I’ve said before, there is no perfect way to do things. Situations change in an athletic movement. You are running on a hard surface that becomes rocky. You jump in the air for a rebound when all of a sudden someone bumps you and now you have land only on one leg. What if you were walking along the sidewalk and caught your toe causing you to stumble. Would you be able to recover and not fall? Having a routine practice helps build skill but not creativity. Changing things up the environment or who you exercise can keep you challenged, thinking, and ready to react. Creativity I believe is the single most important movement skill to have hands down. Check out the video of parkour in the elderly. You are never too old to be creative!

So why do I think that people who can get off the ground live longer? If you think about some of the most common medical problems like diabetes, heart disease, obesity, and smoking. We do not traditionally look at how medical problems effect movement but they do. These diseases directly influence all of the factors I listed above by impairing sensation, endurance, flexibility, and strength. A person with heart disease or problems with their weight are less likely to be active because they get short of breath or it hurts their joints to move. As a result, they tend to sit because it’s more comfortable. As they sit more, muscles and joints get stiff and their mobility skills starts to decline. Conversely, immobility is like fertilizer for medical problems. When people stop moving, medical problems almost always get worse. Therefore when a patient tells me that they have a hard time getting off of the ground I become very concerned about their health in general. Getting off of the ground is one of the hardest but most important skills to learn as a human. So when they can’t do it anymore I know there has been a significant loss of their most basic skills. Pain is often the reasons people see me but it’s often a late manifestation of events not the start of their decline. Maintaining our movement skills takes time and practice and it becomes more difficult as we get older or if we have pre-existing medical problems. If you are having problems putting on your socks, getting out of a chair, or even the car it’s time to reassess your movement skills and maybe seek some help. Remember, the grim reaper only finds what it can catch!

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WORK HISTORY

April 2016 – Current

Director of Sports Medicine

EVMS MEDICAL GROUP, NORFOLK, VA

I currently work in the Department of Physical Medicine and Rehabilitation. I also serve as assistant professor at EVMS working with residents and medical students.


August 2012 – March 2016

CLinician and managing Partner

REBOUND ORTHOPEDICS & NEUROSURGERY, VANCOUVER, WA

I loved living in the Pacific Northwest! Aside from clinical care, I was involved in holding monthly spine conferences and helping develop a multidisciplinary spine center.


EDUCATION

2011 – 2012

Spine and Sports Medicine Fellowship

SPINE AND SPORTS PHYSIATRISTS, ELMHURST, IL

A year dedicated to diagnosing and managing a variety of musculoskeletal injuries. I also had the opportunity to give a variety of lectures to various residents in the Chicagoland area.


2008 – 2011

Physical Medicine & Rehabilitation Residency

NORTHWESTERN UNIVERSITY / REHABILITATION INSTITUTE OF CHICAGO, CHICAGO, IL

Outside of residency, I became very involved within the field at a national level serving as president of the Resident Physician Council for the American Academy of Physical Medicine & Rehabilitation. Helping develop the largest and longest running physiatric medical student programs in the country is one of my proudest achievements.


2003 – 2007

Doctor of Osteopathic Medicine

ARIZONA COLLEGE OF OSTEOPATHIC MEDICINE, GLENDALE, AZ

A challenging yet exciting part of my life. This is where I started to create my vision of musculoskeletal medicine. My skills as an osteopathic physician have truly complemented my sports medicine practice.


1997 – 2001

B.S. Biology

GEORGE MASON UNIVERSITY

Aside from studying, I became very involved in the Filipino-American community on campus. This is where I realized my passion for leadership and mentoring.

NAVIGATION