THE CLINIC

Eat Right and Exercise, But Then What?

I'm a 55-year-old female. I mainly eat fish, vegetables, pasta, yogurt and fruit. I run daily and also bike and kayak. Yet I can’t seem to lose a few extra pounds from my body weight unless I starve myself, which I know is not the right way to go and ultimately leads to a pendulum swing of weight gain later. The extra pounds contribute to mediocre race results and are very frustrating. I doubt that I can exercise any more than I already do, and I don’t think I can eat less. Any advice?

Courtney Strong
Rapid City, SD

I agree that it's counterproductive to starve yourself. You may be able to make some changes that will enable you to eat fewer calories without feeling as if you are starving. One concept that is important to keep in mind is the idea of energy balance. As you probably are aware, your body expends energy every day whether you sit at a desk, walk, run, bike, or swim. Every time you eat, you take in energy. If weight loss is your goal, you either need to increase your activity so that you expend more energy, take in fewer calories, or do both.

If you have a few extra pounds to lose, it may be helpful to write down everything that you eat (food or beverage and amount) for at least three days. Then, evaluate your eating habits. Were there "empty calorie" foods that made little contribution to your diet other than providing calories? Eliminating these or cutting down on them can help with weight loss. Pay special attention to portion sizes. If you eat out often, it's very easy to eat more than you realize.

As you embark on a weight loss plan, it's important to clearly establish your weight goals. See http://www.nhlbi.nih.gov/health/ for a BMI calculator to determine what an appropriate goal weight would be for you. A safe weight loss rate is one to three pounds of weight per week. By looking at your weight goals and a reasonable weight loss rate, you can see about how long it will take to lose the amount of weight that you want to lose.

Here are a few other food-related suggestions:

  • Be sure to eat generous amounts of higher fiber foods like fresh fruits and salads. Eaten before a meal, these foods can make you feel full so that you're less tempted to overeat.
  • Try not to skip meals. Sometimes when people skip meals, they end up eating more at their one large meal than they would have eaten at three smaller meals
  • Practice mindful eating. Ask yourself if you're hungry or if you're eating for another reason like fatigue or boredom.
  • Activity is the other side of the energy balance equation. You mentioned that you didn't think that you could exercise any more than you already do. It's great that you are running, biking, and kayaking! While it may not be possible to exercise any more than you do, you may be able to find ways to increase your activity in general. As you go about your daily routine, think about times where you could walk instead of drive, take the stairs instead of the elevator, and/or get up and move around for five minutes every hour if you have a sedentary job. These small increases in activity, along with a moderate reduction in energy intake, should lead to the weight loss you'd like to see.

Reed Mangels, PhD, RD
Amherst, MA

Non-Surgical Solutions for Spine Trouble

I have been diagnosed with Diffuse Idiopathic Skeletal Hyperostosis (DISH), a skeletal problem caused by build-up of excess bone in the spinal canal. In addition, I also am trying to manage a narrowing of the cervical canal (stenosis) and a decrease in the space between vertebrae (spondylosis).

Can I avoid surgery? Also, is my spine necessarily getting weaker, because although I have some neck pain, my spine doesn’t actually feel appreciably weaker to me. Would swimming be a good idea and/or a reasonable therapy as opposed to surgery? I intend to stretch a lot as well, hoping to stave off the inevitable surgical intervention, but am I kidding myself?

Frank Blainey
Corinth, NY

My field's specialty is involved with providing non-surgical care to a variety of orthopedic conditions. A significant number of my patients are spine sufferers.

In your case, you have neck pain which seems only tolerably better with regular swimming, meds, activity modification, and therapy. If you have DISH, I would be surprised, since it is defined by an abnormally accelerated process of spur formation all along the spine at multiple levels, and commonly semi-fuses the spine gradually all along its length. These patients are very stiff from neck to bottom. I would suspect that the spur formation in your neck is more probably just at the levels of disc injury/degeneration, and in time these spurs can and often do fuse together.

If you can't stand the pain, then surgeons can speed this process along by stimulating your body to fuse the painful neck joint levels quicker, and can implant a plate and screw system to reduce the joint motion significantly. I would ask your doctors about Prednisone pill trials (one or two), and keep up the swimming. Take an occasional aspirin, Motrin, or Tylenol.

It may be helpful to discuss certain aspects of how, more generally, the musculoskeletal system works. When we are born, all of our bones are strong and the ligaments (straps) that hold these bones together are both strong and elastic. In the spine, we have discs, which lie between the vertebrae of our spine, to cushion the blows of everyday life. At birth, these discs have strong walls, and are filled with a gelatinous type fluid, which provides shock absorption to the adjacent bones in upright postures.

Traveling within the vertebrae, through continuous tunnel systems, are nerves, which connect the brain with the body. Our bone-to-bone connections (joints) have a continuous production of internal joint fluid, to lubricate the joints. Periodic movements relieve the internal pressures on our joints, releasing some of this fluid.

As we age, gravity and lifting demands on our spine squeeze out the fluid in the discs, and cause the bones to progressively lie closer to one another. There is less space between the bones for movement, "stenosis," and the rubbing of bones together produces spinal pain. The hyper-mobile walls of the discs or in the ligaments are another cause of local pain (spinal pain). In the end, as a result of the natural aging process, gravity's influence, or of the physical demands of our lives, our ligaments are loose, the
discs are deflated, the bones are experiencing high frictional rubbing against one another, and in severe cases the crowding of structures around the nerve channels becomes stenotic and strictured. The bone/disc/ligament abnormalities are associated with neck pain and stiffness. Nerve irritation yields arm pains/numbness/weakness. Nerve injuries are often irreversible.

Surgery is at the end of the treatment chain, and attempts to change the anatomical relationships of the above structures in patients with chronic unremitting pain levels, or in individuals who are experiencing nerve function loss. And generally, surgery can only be performed if the injury/arthritis is confined to a small area. In a sense, all surgeries mimic real-life biologic activities. If no surgery were performed on individuals with disc degeneration, where bones are rubbing painfully against one another, the constant
biologic drive within our body is to grow bone spurs from one bone to another, bridging the gap. In time, years typically, the adjacent bones will fuse together, thereby eliminating altogether the painful joint.

Before reaching surgery as an option, keep generally active or swim, to "pump" out the joint fluid in our spine in a natural way. Repetitive low-impact exercise pushes out the joint fluid, and makes other activities that follow more tolerable. I can't emphasize this point enough, since swimming is at the core of all arthritis interventions. The process of simply moving your joints relieves joint fluid build-ups and related pain levels.

So swim away or pursue simple walking on soft surfaces. Any low-impact repetitive activity is fine. And on the other end of the scale, avoid high impact, torsional loading to your spine. Activities which knock bone ends together, or which have high inherent shear forces will cause an increase and more rapid production of joint fluid, and redness.

Try and maintain a straight or reasonable neck posture while at work, or while performing static tasks. If we maintain a flexed neck posture, we are essentially placing all of the weight of the head and neck on just the front portion of our discs. This in turn will cause increased neck pain.

John Schnell, MD
Cleveland, OH

Muscle Cramps Could Mean Many Different Things

I am a female runner approaching menopause. I’ve got nine marathons and five half-marathons under my belt. I run 25 to 30 miles per week, and have done so without incident until recently. I’ve started to suffer calf cramping to the point where I must walk to finish the race.

The cramps usually hit somewhere between miles 17 and 20, although I have had one instance where the cramps hit me at the finish of a half-marathon (so this means they could start arriving earlier).

The races tend to be very warm, in the 80- to 90-degree range. I was well-hydrated,
However. Should I have blood tests for minerals or electrolytes? I’ve never cramped up like this before the age of 47 (I am 48).

Laura Pembrook
Santa Fe, NM

I feel there are several things that may be causing your cramps. Perhaps you are having electrolyte difficulties but I am not so sure that this is the real issue. Being perimenopausal could be contributing to this but I am not familiar with a specific link between the two.

More likely, the cause is muscle fatigue for one of two reasons, or even both. First, in slower runners there is a tendency to overload the calf muscles eccentrically (while the foot is
planted and you are moving your body over it). This causes the fatigue, and cramp. Second, if you have any compression of nerve roots from your back you may be reducing the available power supply to your legs and causing the fatigue to happen sooner than it normally would.

Compression would happen in people with a disc protrusion (new or old), spinal arthritis, or both. Do you have any history of back problems? Even if not, sometimes this phenomenon can be silent as far as the back is concerned. Because running is a high demand activity, the problem may be mild enough that it only shows up when there is high demand placed on the nerve.

So, what I would suggest is that you see a sports medicine physician who is capable with the problem I outlined above. You might also check with physicians in your area familiar with athletes who cramp due to excessive sweating and electrolyte loss.

John Cianca, MD
Houston, TX

Cramps can happen for a number of reasons, including dehydration, over-hydration, electrolyte
abnormalities, and muscle fatigue. You didn't mention any problems on long training runs so we need to look at what is different on race day. If you are running at a faster pace than on training runs, fatigue is a problem. Try performing some runs at your planned marathon pace during training; too often, training pace is faster than race pace on short runs and slower on long runs.

Gradually increase runs at marathon pace from 8 miles to 15 miles. Sweat rates are variable from person to person and will change with acclimatization and weather conditions. Weigh yourself nude prior to a long run and again following the run. Each pound that you lost is a 16 ounce fluid deficit; you should add the amount of fluid that you consumed during your run to this to estimate your sweat rate.

Repeating this in various weather conditions can reveal a significant fluctuation in sweat rate. A runner who is a little under- or over-hydrated should not experience problems. Keep in mind that it is possible to consume too much fluid while running, causing blood sodium levels to drop. This can cause swelling, cramping, nausea, vomiting, seizures, and worse. Salty snacks or supplements may help prevent this, but avoiding over-hydration is the key factor.

The fact that you can continue to walk without a problem leads me to believe that fatigue may be the more significant factor. Incorporating strength training may also be helpful. To work on calf strength, raises should be performed at the edge of a step, dropping the heels
down below the step and then rising onto your toes.

Cathy Fieseler, MD
Tyler, TX

Finding the Right PT Could Be a Challenge

After a severe hamstring tear several years ago, I have wanted lately to return to road racing, but not if I cannnot be competitive. After three years I took up racewalking, and have done reasonably well. The problem is that I have a large collagen lump in the hamstring—it's about the size of a handball—and the sports medicine doc I originally went to said I should not expect the hamstring to regain more than 80% of its prior function. Have there been any techniques developed that might help reduce the size of the lump and make room for muscle regrowth?

Wayne Kemp, Jr.
Eureka Springs, AR

This is a difficult problem to treat. The lump that you feel in your hamstring is probably the remnant of a partial tear that you incurred. It is probably made up of dense, fibrous scar tissue. It is unlikely to be affected much by massage, injection, or even surgery, and unfortunately at this point there will not be any muscle regrowth.

I would suggest exercising to your pain tolerance. Of course you should commence with a gentle warm up that includes stretching. Doing some light massage on your own after workouts will also be beneficial. I would try non-impact activity as well, such as pool running with an aqua jogger, or using an elliptical trainer in the gym. You may be able to run again, but as you said, it may not be at a very fast pace!

Jon Halperin, MD
La Mesa, CA

The lump in your leg is quite likely the remnants of your hamstring that have balled up in your leg. It is not going to heal and there is not going to be any muscle regeneration at this point. If you want to confirm my suspicions, an MRI or diagnostic ultrasound exam would be helpful. It is probably likely that you won’t have full strength in your hamstring but you still might be able to run/race—albeit not at your previous capacity.

John Cianca, MD
Houston, TX

The bad news is that there are no new techniques to reduce the scar tissue. The good news is that there are techniques that have been around for quite a while that will do you a world of good. Unfortunately, the PTs that actually practice them are a bit few and far between.

By using a combo of ultrasound, soft tissue manipulation, and very specific therapeutic stretching and strengthening, the adhesions can be broken. The scar tissue will then be remodeled in such a way as to minimize the negative effects on muscle tissue. By manipulating the fibers as they redeposit, the scar will be stronger and will act and feel more like "normal" tissue.

The challenge will be to find an orthopedic manual physical therapist who will do the work—and it does take work. Passive modalities without the manipulation will yield little in the way of results.

Maribeth Salge, PT, CSCS
Rockledge, FL

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