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Reflections on “The Alchemist” Part IX

“There is only one way to learn, it’s through action. Everything you need to know you have learned through your journey.”

Some people are frozen when having to make a decision. Whether it be what type of beer to drink at a brewery or what major to choose in college. I make decisions mischief easier now than when I was younger.

There is only one asset that has a limit and that is time. All other assets are potentially limitless.

I recently went to a brewery with friends. They had a ton of beers on tap. I could’ve spent my time deciding what beer to try while standing at the bar and my friends were at the table discussing life. Why bother?!

Time is more important than a few dollars at that point in the weekend. The amount of time that I would’ve been away from friends that I only get to see but a couple times per year wasn’t worth it for me to be standing at the bar.

I spent a few dollars more and bought a flight of beers. It cost only $3 more than buying one of the 50 beers that they serve. The $3 was a risk I was willing to lose. I only drank one of the 4, but at least tried them all for one sip. I was very satisfied with that decision even though I left 3 beers on the table (mind you I don’t really enjoy drinking to begin with so I would’ve had to ask a lot of questions just to order one beer).

I was able to enjoy conversing with old friends and make memories. That was worth the $3.

I think many people struggle to make decisions because they don’t look at what is lost in the time to make decisions. I recently started learning about decision fatigue and try to make fewer and fewer choices throughout the day. Essentially, my day is very structured (it’s both good and bad, but it’s a trade off). It saves me a lot of time and prevents any sort of stress in decision making by keeping a routine.

This same strategy of weighing cost to benefit works for me in all decisions. I discuss this with all students going into college and professional school. Is the decision to go to college worth it?

The student should have a pretty good stronghold on what they want out of college before signing up for school. Otherwise, that person is spending tens to hundreds of thousands of dollars on an education that they may not use or enjoy the benefits/wages.

There are plenty of trades that one can join at a low cost of entry. If a person is unsure of their life’s purpose, they should do something with a low cost of entry because there is little to keep one from walking away when the time comes. A high cost of entry, not paid for in cash on hand, causes a person to make different decisions and to feel stuck in a position because they will have to pay off the debt that accumulated prior to jumping into a different profession.

I wish this stuff was talked about in college preparatory courses. Unfortunately, many learn the lesson the hard way through decisions that they would not have made if they were 20-30 years older.

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Reflections on “The Alchemist” Part VIII

“The secret is here in the present. If you pay attention to the present, you can improve upon it. And, if you improve on the present, what comes later will also be better.”

This was hard for me for so long, until Natalia was born. She really put life into perspective. I loved life for big goals. I would be so focused on the future, that the present was just something that I had to get through in order to reach my goals.

Lenna is our oldest, but it was different. Anita, my wife, is amazing at what she does. She can juggle so many balls in the air at the same time and still manage and take care of Lenna. I never had to worry about that one.

Natalia was different, and not just because she has Down Syndrome. It’s a radical change going from one child to two. Ania needed more help. I spent a lot more time with Natalia, when she was a baby, than with Lenna. It’s the same with our third now, Adam. I spend maybe more time with Adam than Natalia when she was a baby.

That’s only because Ania usually takes care of the other two and I only have to take care of one at a time!

Having Natalia made me slow down a little. I appreciate the cartoons, coloring with Lenna, helping Lenna with her “sight words” (if you don’t have young kids then this is a foreign concept), and working on homework with her. It’s because of the youngest two that I spend more time with the oldest.

Enjoying the present makes me realize the WHY for the future.

PT and tendons: where are we at?

“Complicating matters further is the mismatch between reported pain (and disability) and imaging (and pathology), as well as evidence of widespread sensory nervous system sensitization in some tendonopathies.”

A little background. Pain is not always viewable. This is a large debate even among the highest level of pain organizations. The IASP (Thanks to Colin Windhu for catching a mistake) is looking to change the definition of pain to include tissue based problems, or at least perceived problems.

Not all pain has a tissue based component, as some have a cognitive and emotional based component. For instance, I treated a person that was so afraid of performing activities that this person developed a pain from the thought of movement. After establishing that movement was safe, this person more than 10X increased the ability on a functional test…in less than 6 weeks.

This person, and others that I’ve worked with, have a “stinking thinking” type of pain. This may not be the fault of the patient, but instead it may be the fault of the faulty medical system. One that drives fear.

How many people have heard a physician say

“This is the worst spine I have seen”

“You shouldn’t squat/run because it’s bad for your knees”

“You shouldn’t work with heavy weights because it’s bad for your back”

“Your knees/hips are bone on bone and you will need a new knee/hip in the future”

Your pain is because you have a rotator cuff tear/disc herniation/arthritis etc”

These types of interactions do more to hurt the patient than help the patient and can start the cycle of inactivity out of fear of breaking oneself.

Don’t buy into the hype. A little stat, when a physician diagnoses your back pain as a herniated disc, arthritis, muscle strain, stenosis, etc do you know that the diagnosis is only right about 10% of the time?!

People are hanging their health habits in a guess that has a worse chance of being right than flipping a coin. You would have better odds of getting 4 of a kind in Texas Holdem.

Let’s start by not placing too much weight into the diagnosis because it’s a best guess at best.

Here’s what we think may happen. Some pain can cause more pain. Nerves can communicate with each other.

It’s similar to an infection. Any nerve that comes in contact with the nerve that is irritated can then become infected (irritated). Hmm?

I’ve seen many patients that experience widespread pain even though “everything is healthy”.

Yet another reason not to hang your hat on one specific tissue problem.

“… A diagnosis of tendinopathy is reasonably easy to make clinically, on the basis localized pain over the tendon that is associated with loading of the tendon.”

If you hurt your biceps and you ask your biceps to work, it makes sense that it may not like that.

If you hurt/injured your biceps and it hurts when you make your ankle muscles work, we wouldn’t expect that to create a problem in the biceps if the problem is localized to the biceps.

Make sense?

In other words, when a tendon is injured, we expect specific behaviors like

1. Pain with contraction under load that may increase with increasing loads

2. Pain with compression of that area

3. Pain with stretching that specific area

4. No issues when that area is not moving.

If the symptoms operate outside of this narrow set of parameters, it may not be only a tendon issue. This is not to say there isn’t a tendon issue, but instead is meant to say that the tendon may only be a part of the problem and we have no idea how much of a part it is until more assessment is done.

“…management of tendinopathy should optimally involve addressing loading of the tendon”

A tendon connects a muscle to a bone. It doesn’t have a ton of blood flow and can be slow to heal.

It needs to work in order to get back to its normal function.

This is what it means to load the tendon. Make it work, but don’t irritate/create harm. As long as the tendon/pain is not worse following an activity…awesomesauce…no harm done.

“Management of load…usually commenced with complete removal of offending activities and the introduction of appropriate and graduated loading activities”

If you break your leg, you will expect to be on crutches. This is to allow the bone time to heal. This stage lasts anywhere from 4-6 weeks. Loading before then one is ready to accept load can result in worsening the injury. You would know this because the pain worsened or you would break it further.

Loading a tendon before it is ready to be loaded OR more than it is ready to accept will lead to increased pain in that area, pain that is lasting and worsening function over time.

These are the clues a patient needs to give their attention towards.

Sometimes you need to remove all load from a tendon to allow it to rest and others you can perform your normals daily activities, but any more would result in increased pain that lingers.

When the pain no longer lingers after an activity, it is time to do more activities and create a new norm.

It doesn’t have to be any more complicated than this. Some research shows that 1200 repetitions of calf raises should be performed weekly, but it doesn’t have to be this structured.

“…requires patient buy-in…involves the clinician educating the patient about the nature of the tendinopathy, its relationship to loading, and a likely recovery trajectory.”

This is by far and away the most important detail.

If the patient is not educated on how the body should respond AFTER performing the activity, then the patient may be reluctant to continue anything that creates transient (short-lived) pain.

This is one of those issues that only gets better with direct loading. It doesn’t “fix” with time because it needs to be strong enough to handle the loads that you would throw at it on a daily basis.

“This exercise program should be adequately supervised, reviewed, and progressed to ensure adherence and resolution of the tendinopathy.”

SOAPBOX: ADEQUATELY SUPERVISED DOES NOT MEAN THREE TIMES PER WEEK FOR SIX TO EIGHT WEEKS. THE PATIENT SHOULD BE PERFORMING THE HOME PROGRAM AND THE THERAPIST IS IDEALLY ONLY A PHONE CALL AWAY. THE PATIENT SHOULD RETURN IF SOMETHING U EXPECTED HAS OCCURRED OR THE PATIENT NO LONGER IS ABLE TO REPRODUCE THE SYMPTOMS WITH THE LOAD THEY ARE USING AT HOME.

“(a) symptom-guides management, (b) symptom-modification management (c) compressive versus tensile load (d) stages of loading through the rehabilitation process (isometric and isotonic strengthening, energy storage and release, return to play), and (e) what I will refer to as movement competency…in a way that does not provoke pain.”

This doesn’t need to be summarized and is great advice for most soft tissue disorders.

“In the lower limb (Achilles tendon, patellar tendon), it appears that pain up to 5/10 on a numeric pain rating scale during and after training is not harmful and may be desirable”

This is a little more aggressive than I go initially, but the patient’s response gets to dictate how hard we push.

If there is a 3 point change and the patient is no worse after repeatedly creating a 3-point change, the. They have earned the right to go to a 4-point change. At some point, we would predict that too much of an increase would lead to an inflammatory effect, but we just don’t know what that number is for that specific patient.

The only way we will ever know is to test it.

“The fad of giving all patients with tendinopathy an eccentric exercise program from the onset has largely abated; however, after adequate strength of the muscle has been achieved, it is necessary to use eccentric exercises to reinstitute the energy storage/return capacity of the musculotendinous complex”

Not sure if this is any different than just load the tissue. The tissue needs to be able to contract under load and stretch under load. That’s normal mechanics for a muscle.

“Movement competency…is mainly about the form and shape (posture and alignment) with which physical activity is performed.”

This is consistent with what Dr. Kelly Starrett has been preaching for years through his books, videos and interviews.

A squat should look like a certain shape and many things look similar, such as a lunge (squat with one leg), clean start position, deadlift start position, standing up from the toilet etc.

Of course I know there are nuances between the squat and deadlift regarding hip height and back angle, the clean and lunge regarding shin angle etc, but in the end the basic shape still applies (knee bent and hip bent with shoulders forward and back fairly flat with head looking straight ahead). The similarities are where most people need to function and the nuances are what make the exceptional athletes different.

Link to article

Reflections on “The Alchemist” Part VII

“My heart is a traitor… It doesn’t want me to go on.

Naturally it’s afraid that in pursuing your dream, you might lose everything you’ve won.

Well then, why should I listen to my heart?

Because you will never again be able to keep it quiet.”

I have a couple of big picture drivers in my life.

1. Have no regrets

2. Don’t do anything that would bring shame to my dad.

In 2008, my brother died. He died from an overdose of Benedryl…(I hear it all the time, I didn’t know it was possible…me neither).

He had his demons…we all do. He was a great guy, but again, he had his problems. He had been imprisoned for DUI and just got out. He started joining me at the gym and he was making great progress in the gym. He couldn’t squat more than me, but that bastard deadlifted 405 on his first attempt. (I say that out of love because it took me years to lift 405).

Anyway, we would have conversations about serious things every once in a while (we shared a room growing up. I worked overnights and was going to school and at the time he wasn’t working, so the bed was his at night and mine during the day).

Aside: those that know me, know that I am like a tornado. Wherever I go, I organize things so that they make sense to me. This usually means a bunch of separate piles with very clear distinctions between the piles. (It works for me!) Mike, on the other hand, was just a slob! He loved candy. It wasn’t uncommon for me to come home after working overnights and going to school in the morning, only to find a ton of wrappers in the bed and a full cup of coke on the floor. It was like living with a big kid at times (usually that’s one of the ways I get described, but Mike took it to an extreme). I used to think that if I just pushed it all on the floor that he would clean it up…Nope. Just a new pile of wrappers the next day! I miss my brother. He was a good person and was very good to me growing up. I’m going to keep reminiscing a little because…why not?

I used to love to sing Karaoke and was actually a DJ for a while. It paid good money, but I’m glad I stayed in school because: who goes out to sing Karaoke anymore? Mike had a problem with alcohol. I’m not saying anything bad about him, it was just true. It didn’t make him a bad person, but like I said, he had demons. We went out to the bar (mind you, I didn’t drink at the time), after working out (the bar was right next door to the gym). I sang some songs, bought him a Long Island iced tea (I had no clue what this drink was prior to that night) and he listened to me sing a couple of songs. The car ride home (I’m the little brother, obviously not by size). He said, bro I’m proud of you. You grew up in the same house we all did. You can go out to the bar and drink orange juice and have a good time. You work full time and go to school. You’re going to be great at anything you do. (This memory always brings tears).

I was a new grad physical therapist. Not even practicing for a year when my mom called me in the middle of the night to scream through the phone that “I lost my baby!” Those words and that conversation is burned in my brain. That whole night at the hospital was like a haze. Hard to believe.

What’s harder to deal with is that 10+ plus years have passed and how much he’s missed out on. He was great with kids. He would’ve loved my kids. I think of all that he could’ve done and seen. He always wanted to go to Alaska. I made a copy of one of his pictures and carried it with me while we honeymooned in Alaska. I miss my brother.

I learned one thing…life is very short and don’t have any regrets.

The second big picture ideology that I try to live by is to not bring shame to my dad.

You’ll hear me say it frequently that my dad is my Superman. He knows that, which was very important for me to make sure that he knows I’m proud of him and the life he lived and continues to live.

He served as a medic for the 101st Airborne, the Screaming Eagles, in Vietnam. He stated in Vietnam longer than he had to in order to ensure that his younger brother didn’t have to go to Nam. He came home and worked in the family business (construction) for 30+ years. He divorced my birth mom (whom I have no contact with, which is why I say birth mom) and took care of all the kids as best he could. He and Aida worked hard to move us to a quieter area with less shootings. They made the decision to send me to Providence. Essentially, all of the good things I have came from that man.

I disappointed my dad one time. I was 13 and was a shoplifter. I would steal anything just to see if I could.

I got caught at the old Cub Foods on Larkin Ave. I was stealing magazines and baseball cards. I was with my cousin at the time (and I still believe that he got caught, but water under a bridge). I was fined $2,000 and was out in handcuffs, but wasn’t arrested.

I got home that night (understand that my dad typically would wake up at 3 AM to prepare for work) and it was about 11 PM. My mom told him what happened. I was never really punished (aside from paying back $2000, which at the age of 13 wasn’t easy to make…thanks to Norm Fanning for getting me a job shoveling manure). He said that “I’m disappointed in you son”.

I worked my tail off to pay back the fine by the end of summer.

It’s been 25 years and I’d like to believe that I haven’t done anything since that day to bring shame to my dad.

The moral of this story is twofold.

1. Have no regrets.

2. Have a role model in which to look up to and live up to.

Thanks for reading.

I got to go see a man about a horse.

Reflections on “The Alchemist” Part VI

“Tell your heart that the fear of suffering is worse than the suffering itself. And that no heart has ever suffered when it goes in search of its dreams, because every second of the search is a second encounter with God and with eternity.”

This rings true in my life. I thank my wife for supporting me in my decision to do more as a PT.

I had fear of jumping out of the position I had and jumping into a new position in a different city with a new company.

We played out worst case scenarios and you know what?…

Worst case scenario played out.

The clinic loses due to issues outside of my control and I was without a job.

The work that I put into trying to make the first clinic a success is what landed me the second job. The second job came with a substantial raise, but no time off of work. Those that know me, also know that this is not an issue. I enjoy my profession so much that I give back to the profession free of charge most nights. Working more hours is not an issue, at this point in time.

When I speak to students or those looking for their life’s meaning, I typically spend some time playing Devil’s advocate. I will use my best logic and knowledge to dissuade someone from following their dream. If I can convince someone that they should not do something within a 30 minute conversation, the reason FOR doing that something was not very strong.

Usually, the argument that dissuades people FROM making a decision is MONEY! I’ve found that when money is the driver, it’s easy to help that person discover what they really want.

1. Why does salary matter?

Because I want to make enough to support myself

2. What experience have you had that led you to believe that life is harder without money?

Xyz from childhood

3. Could you live on $60K/year?

Usually the answer is yes.

4. How many professions pay at least $30/hr?

They do a little research and then things start to open up a little more regarding what they would like to do or other options.

When money is the driver, it clouds our judgement.

If you believe that money buys happiness, I’m sure you’ve made decisions based on finances.

Sometimes it’s as simple as living on a few dollars less than you make. That becomes a lot easier to manage.

I’m reminded of stories from the Dave Ramsey Millionaire hour. Many people making less than $75k per year go on to have millions because they followed that one simple concept: spend a little less than you make.

Follow your passion! Follow your purpose!

Money is easy to get, but happiness and satisfaction in life…not so much. Too many other aspects cloud our judgement.

Love your life or change it!

No regrets!