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Director of Stanford Runner’s Injury Clinic discusses treating and preventing common injuries

Director of Stanford Runner's Injury Clinic discusses treating and preventing common injuries

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It may surprise you to learn that past studies show that runners have a 50 percent chance of sustaining an injury that disrupts their training, and those that compete in marathons have an incidence rate as high as 90 percent. But don’t hang up your sneakers just yet. Many common aches and pains that nag runners can easily be treated or avoided.

On Thursday, Michael Fredericson, MD, who is director of the Stanford Runner’s Injury Clinic and has been head team physician with the Stanford Sports Medicine Program since 1992, will talk about the latest running prevention and treatment methods during a Stanford Health Library lecture. (For those unable to attend the event in person, you can watch the live webcast starting at 7 PM Pacifiic time.) To kick off the conversation, I reached out to Fredericson to discuss some of the topics of his upcoming talk, including the harms of overstriding, the benefits of cross-training, and remedies for prevalent joint problems. He and Adam Tenforde, MD, a sports medicine fellow at Stanford, responded to my questions.

How can overstriding lead to injury?

The term “overstriding” refers to running with the foot striking the ground too far forward from normal stride length. This results in heel strike pattern that may increase stress in the hip and knee joints. Research has shown that forefoot strike patterns tend to reduce stress on the knees and hips, although this may lead to greater stress on the foot and ankle. We conduct a clinic called RunSafe, where we evaluate gait of runners using video and markers. More efficient stride frequency is 90 strides per leg per minute. When a runner overstrides, this may result in a lower stride rate and an inefficient gait. We evaluate for the causes of overstriding, including poor hip extensor strength (weak gluteal muscles), decreased flexibility and technique and encourage correction of these biomechanical contributors. Also, we may suggest shoes with reduced weight, such as ‘minimalist shoes’ as these tend to encourage a runner to run with a more mid-foot strike pattern. However, we caution any changes in shoe type or technique be introduced gradually to decrease risk of developing an injury from changes in gait pattern that stress the body in a new way.

Why is it important for runners to cross-train?

Cross-training refers to forms of aerobic exercise that do not involve running. Doing exercises that do not involve the repetitive ground-impact experienced during running help to rest tired muscles and decrease stress on bones, assisting in recovery while building aerobic capacity. There are no established forms of cross-training to prevent injuries, but performing exercises that do not involve impact loading through the legs, such as elliptical trainer, cycling or deep water running may be helpful.

Many runners select shoes that compensate for how their foot pronates. But recent research shows that pronating too much or too little may not actually increase a runner’s risk of injury. How important is pronation and foot type in preventing injuries?

We evaluate foot type and pronation during our RunSafe clinics. Pronation is a normal motion that helps to distribute forces while landing through the foot and ankle, reducing stresses through the lower extremities. If the foot abruptly stops moving from too much or too little pronation, the other joints and lower limbs may absorb these forces and can become injured. Foot type (having too high an arch or too flat a foot) may also result in higher forces in the legs and joints through associated biomechanics. Foot type and concerns of pronation need to be put into context of prior injury history, as recent research has suggested that foot type and pronation do not necessarily predict future injury risk.

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Cancer, Events, Patient Care, Public Health

“Stop skipping dessert:” A Stanford neurosurgeon and cancer patient discusses facing terminal illness

"Stop skipping dessert:" A Stanford neurosurgeon and cancer patient discusses facing terminal illness

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Updated 10-23-14: Dr. Kalanithi spoke about this topic on campus earlier this week; more on the event, and his insights, can be found here.

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10-20-14: When Paul Kalanithi, MD, a chief resident in neurological surgery at Stanford, was diagnosed at age 36 with stage IV lung cancer he struggled to learn how to live with conviction despite a prognosis of uncertainty. He found comfort in seven words from writer Samuel Beckett, “I can’t go on. I’ll go on.”

That mantra has given Kalanithi the strength to face his own mortality and have tough conversations with his wife and loved ones about the future. Tomorrow evening, he’ll join palliative-care specialist Timothy Quill, MD, for a discussion about end-of-life decision-making. The campus event is free and open to the public; no registration is required.

As a preview to the talk, Kalanithi talked with me about his experience as a patient and about the importance of end-of-life decisions.

How has your prognoses changed the way you talk to patients and their loved ones about grim news?

In large part, the way I talk to patients and their families hasn’t changed, because I had excellent role models in training. I remember witnessing a pediatric neurosurgeon talk parents through the diagnosis of their daughter’s brain tumor. He delivered not just the medical facts, but laid out the emotional terrain as well: the confusion, the fear, the anger and – above all – the need for support from and for each other. I always strove to emulate that model: to educate patients on the medical facts isn’t enough. You have to also find a way to gesture towards the emotional and existential landmarks.

Seeing it from the other side, it’s really hard, as a patient, to ask the tough questions. It’s important for the doctor to help initiate these conversations. I think it’s worth addressing prognosis and quality of life with patients, asking them what they think. My own assumptions about my prognosis were way off base. As a doctor, you can’t provide definite answers, but you can remove misconceptions and refocus patients’ energy.

Finally, I think, if you are the oncologist, it’s important to establish yourself as a go-to for any questions. Patients are bombarded with well-meaning advice, from dietary recommendations to holistic therapy to cutting-edge research. It can easily occupy all a patient’s time, when you ought to also spend time thinking about the priorities in your life. Physicians can also advise patients, as my dad would insist, that they can stop skipping dessert.

What is your advice to patients who are struggling with the certainty of death and the uncertainty of life?

I’ve written a little bit about facing terminal illness in The New York Times and The Paris Review. I found the experience difficult. I still find it difficult. It is a struggle. The problem is not simply learning to accept death. Because even if you do come to terms with finitude, you still wake up each morning and have a whole day to face. Your life keeps going on, whether you are ready for it to or not.

In some ways, having a terminal illness makes you no different from anyone else: Everyone dies. You have to find the balance – neither being overwhelmed by impending death nor completely ignoring it.

You have to find the things that matter to you, in two categories. The first is of ‘the bucket list’ sort. My wife and I always imagined revisiting our honeymoon spot on, say, our 20th wedding anniversary. But I didn’t realize how important to me that was until we decided to go back earlier (on our 7th anniversary, instead, about four months after I was diagnosed).

The second is, as all people should be doing, figuring out how to live true to your values. The tricky part is that, as you go through illness, your values may be constantly changing. So you have to figure out what matters to you, and keep figuring it out. It’s like someone just took away your credit card, and now you really have to budget. You may decide that you want to spend your time working. But two months later, you might feel differently, and say, you really want to learn saxophone, or devote yourself to the church. I think that’s okay – death may be a one-time event, but living with a terminal illness is a process.

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Cardiovascular Medicine, Men's Health, Mental Health, Research, Women's Health

Examining how mental stress on the heart affects men and women differently

Examining how mental stress on the heart affects men and women differently

stress_womanPast research has shown that stress, anger and depression can increase a person’s risk for stroke and heart attacks. Now new findings published in the Journal of the American College of Cardiology show that cardiovascular and psychological reactions to mental stress vary based on gender.

In the study (subscription required), participants with heart disease completed three mentally stressful tasks. Researchers monitored changes in their heart using echocardiography, measured blood pressure and heart rate, and took blood samples during the test and rest periods. According to a journal release:

Researchers from the Duke Heart Center found that while men had more changes in blood pressure and heart rate in response to the mental stress, more women experienced myocardial ischemia, decreased blood flow to the heart. Women also experienced increased platelet aggregation, which is the start of the formation of blood clots, more than men. The women compared with men also expressed a greater increase in negative emotions and a greater decrease in positive emotions during the mental stress tests.

“The relationship between mental stress and cardiovascular disease is well known,” said the study lead author Zainab Samad, M.D., M.H.S., assistant professor of medicine at Duke University Medical Center, Durham, North Carolina. “This study revealed that mental stress affects the cardiovascular health of men and women differently. We need to recognize this difference when evaluating and treating patients for cardiovascular disease.”

Previously: Study shows link between traffic noise, heart attack, Ask Stanford Med: Cardiologist Jennifer Tremmel responds to questions on women’s heart health and Study offers insights into how depression may harm the heart
Photo by anna gutermuth

Neuroscience, Research, Sleep, Videos

How sleep acts as a cleaning system for the brain

How sleep acts as a cleaning system for the brain

Here’s one more reason why getting a good night’s sleep is critical to your health. As neuroscientist Jeff Iliff, PhD, explains in this just released TEDMED video, the brain has a specialized waste-disposal system that’s only active when we’re slumbering. Watch the talk above to learn how this system clears the brain of toxic metabolic byproducts that could lead to Alzheimer’s disease and other neurological disorders.

Previously: Why sleeping in on the weekends may not be beneficial to your health, The high price of interrupted sleep on your health and Examining how sleep quality and duration affect cognitive function as we age

Mental Health, Research, Technology

How social media can affect your mood

How social media can affect your mood

Facebook_10314A close friend engages in a yearly media detox, where for a period of time he limits his time and activity spent on the Internet. He only answers e-mails requiring an immediate response, spends few minutes reading current news and avoids engaging in social media, shopping online or perusing gossip and entertainment sites. Another friend goes on annual eight-day meditation retreats and turns off her phone for her entire stay. Both report that these periodic breaks significantly improve their moods.

Past research supports their personal experience and shows that while many of use social media to feel connected to others, it can also leave us feeling frustrated, lonely and depressed.

A study (subscription required) recently published online in the journal Computers in Human Behavior offers context to these earlier findings and suggests that when we are feeling blue we use social media sites, such as Facebook, to find friends that are also having a bad day, suffered a setback or going through a tough time in their lives.

During the experiment, researchers gave participants a facial emotion recognition test and randomly told them their performance was “terrible” or “excellent” to put them in positive or negative moods. The individuals were than asked to review profiles on a new social networking site. The profiles used dollar sign or heart icons to make users appear successful and attractive or unattractive and unsuccessful. All profile photos were blurred and the status updates were relatively mundane and similar in tone. PsychCentral reports:

Overall, the researchers found that people tended to spend more time on the profiles of people who were rated as successful and attractive.

But participants who had been put in a negative mood spent significantly more time than others browsing the profiles of people who had been rated as unsuccessful and unattractive.

“If you need a self-esteem boost, you’re going to look at people worse off than you,” [Silvia Knobloch-Westerwick, PhD, co-author of the study] said.

“You’re probably not going to be looking at the people who just got a great new job or just got married.

“One of the great appeals of social network sites is that they allow people to manage their moods by choosing who they want to compare themselves to.”

Previously: Ask Stanford Med: Answers to your questions on the psychological effects of Internet use and Elderly adults turn to social media to stay connected, stave off loneliness
Photo by Paul Walsh

Big data, In the News, Patient Care, Pediatrics, Stanford News

Examining the potential of big data to transform health care

Examining the potential of big data to transform health care

Back in 2011, rheumatologist Jennifer Frankovich, MD, and colleagues at Lucile Packard Children’s Hospital Stanford used aggregate patient data from electronic medical records in making a difficult and quick decision in the care of a 13-year-old girl with a rare disease.

Today on San Francisco’s KQED, Frankovich discusses the unusual case and the potential of big data to transform the practice of medicine. Stanford systems-medicine chief Atul Butte, MD, PhD, also weighed in on the topic in the segment by saying, “The idea here is [that] the scientific method itself is growing obsolete.” More from the piece:

Big data is more than medical records and environmental data, Butte says. It could (or already does) include the results of every clinical trial that’s ever been done, every lab test, Google search, tweet. The data from your fitBit.

Eventually, the challenge won’t be finding the data, it’ll be figuring out how to organize it all. “I think the computational side of this is, let’s try to connect everything to everything,” Butte says.

Frankovich agrees with Butte, noting that developing systems to accurately interpret genetic, medical or other health metrics is key if such practices are going to become the standard model of care.

Previously: How efforts to mine electronic health records influence clinical care, NIH Director: “Big Data should inspire us”, Chief technology officer of the United States to speak at Big Data in Biomedicine conference and A new view of patient data: Using electronic medical records to guide treatment

Medical Education, Medical Schools, Stanford News

Free online Stanford course examines medical education in the new millennium

Free online Stanford course examines medical education in the new millennium

Prober_092314At this year’s Stanford Medicine X, executive director Larry Chu, MD, announced the launch of a new group of initiatives that would expand the conference and “quicken the pace of changing the culture of health care.” In addition to continuing to build community, the Medicine X Academy will aim to use technology, the principles of design thinking, and a model of inclusivity to redefine medical education.

“We’re moving from talking to doing,” said Chu. “We want to move the conversation earlier into the education system so students begin to think differently about health care and [so we can] improve medical education with the input of all stakeholders.”

As part of the academy, Chu, Kyle Harrison, MD, clinical assistant professor at the Palo Alto Veterans Affairs Hospital, and Nikita Joshi, MD, an academic fellow at Stanford, will begin teaching a massive open online course (MOOC) course titled “Medical Education in the New Millennium” this Thursday. Anyone can enroll in the class through Stanford OpenEdX. Additionally, it will be webcasted on the Medicine X website and live tweeted on the @StanfordMedX feed.

The eleven-week course will ask the fundamental question: What is the definition of medical education? Participants will explore a variety of topics including how to improve the educational experiences of today’s Millennial medical students and residents; how patients and caregivers can be active participants in their care teams; how MOOCs, social media, simulation and virtual reality change the face of medical education; and how to make learning continuous, engaging, and scalable in an age of increasing clinical demands and limited work hours.

Among the class guest lectures are Charles Prober, MD, senior associate dean for medical education at Stanford; Kirsten Ostherr, PhD, an English professor at Rice University and co-founder of the Medical Futures Lab; ePatient Britt Johnson; and medical and nursing students from Duke, Stanford and other universities.

As noted on the course website, the course is targeted not only towards medical students and educators but also patients, caregivers, and anyone who wants “to join a conversation about how to improve medical education.”

Previously: Medicine X aims to “fill the gaps” in medical educationRethinking the traditional four-year medical curriculum and A closer look at using the “flipped classroom” model at the School of Medicine
Photo of Charles Prober by EdTech Stanford University

Bioengineering, Imaging, Research, Stanford News, Videos

How CLARITY offers an unprecedented 3-D view of the brain’s neural structure

How CLARITY offers an unprecedented 3-D view of the brain's neural structure

Last year, Stanford bioengineer Karl Deisseroth, MD, PhD, and colleagues in his lab announced their development of CLARITY, a process that renders tissue transparent, sparking excitement among the scientific community. As explained in the above video, released yesterday by the National Science Foundation, researchers had been unable to directly study the human brain’s circuitry because much of the organ is covered in an opaque tissue. But using CLARITY researchers can “chemically dissolve the opaque tissue in a post-mortem brain, and in place of that tissue, they insert a transparent hydrogel that keeps the brain intact and provides a window into the brain’s neural structure and circuitry.” For this reason, the technique is “hailed as an important advance in whole-brain imaging.”

Previously: Process that creates transparent brain named one of year’s top scientific discoveries, An in-depth look at the career of Stanford’s Karl Deisseroth, “a major name in science”, Peering deeply – and quite literally – into the intact brain: A video fly-through and Lightning strikes twice: Optogenetics pioneer Karl Deisseroth’s newest technique renders tissues transparent, yet structurally intact

Cancer, Health and Fitness, Research

Exercise may boost effectiveness of chemotherapy

Exercise may boost effectiveness of chemotherapy

running_092214Staying physically active during chemotherapy treatment can benefit patients’ physical and mental health. But findings from an animal study show that exercising may also help reduce the size of tumors.

As reported by Futurity, University of Pennsylvania researcher Joseph Libonati, PhD, and colleagues originally set out to test whether adding a fitness regimen to chemotherapy would offset cardiac damage related to the drug doxorubicin. While the team failed to find any significant evidence that exercise provided protection against negative cardiac side-effects, they did find that mice that exercised while receiving chemotherapy had notably smaller tumors than those that had chemotherapy alone. From the article:

Further studies will investigate exactly how exercise enhances the effect of doxorubicin, but the researchers believe it could be in part because exercise increases blood flow to the tumor, bringing with it more of the drug in the bloodstream.

“If exercise helps in this way, you could potentially use a smaller dose of the drug and get fewer side effects,” Libonati says. Gaining a clearer understanding of the many ways that exercise affects various systems of the body could also pave the way for developing drugs that mimic the effects of exercise.

“People don’t take a drug and then sit down all day,” he says. “Something as simple as moving affects how drugs are metabolized. We’re only just beginning to understand the complexities.”

Previously: Stanford preventive-medicine expert: Lay off the meat, get out the sneaks, From leukemia survivor to top junior golfer, Examining exercise and cancer survivorship and Study shows benefits of exercise for patients with chronic health conditions
Photo by MilitaryHealth

Aging, Health and Fitness, Public Health, Research

Twenty-four percent of middle-aged and older Americans meet muscle-strengthening guidelines

Twenty-four percent of middle-aged and older Americans meet muscle-strengthening guidelines

free_weightsPast research has shown that strength training can benefit older adults’ health in numerous ways including arthritis relief, alleviating back pain, increasing bone density, improving sleep and boosting mental health. But despite these findings, a new study from Centers for Disease Control and Prevention (CDC) has found that few U.S. adults age 45 and older adhere to the Department of Health and Human Services’ muscle-strengthening recommendations.

The guidelines advise middle-aged and older adults to do moderate or high intensity muscle-strengthening activities that involve all major muscle group two or more days a week. Training can involve hand weights or weight machines, basic exercises such as sit-ups and push-ups or yoga and similar fitness practices.

In the latest study, researchers examined data from a telephone health survey conducted in 2011 by the CDC known as the U.S. Behavioral Risk Factor Surveillance System. For the survey, respondents provided information about the types of physical activities they engage in and frequency, as well as answered questions about if they specifically did exercises to strengthen their muscles. HealthDay reports:

Of all those who answered the questions on muscle strengthening, about 24 percent said they met the government’s recommendations.

Among those less likely than others to meet these guidelines were women, widows, those age 85 or older, people who were obese, and Hispanics. Participants who didn’t graduate from high school were also less likely to meet U.S. strength-training recommendations.

Jesse Vezina, of Arizona State University, and his fellow researchers concluded that interventions designed to encourage people to participate in strength training should target these high-risk groups.

Previously: Moderate exercise program for older adults reduces mobility disability, study shows, Help from a virtual friend goes a long way in boosting older adults’ physical activity and Do muscles retain memory of their former fitness?
Photo by Positively Fit

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