Stop Icing and Heal Faster

Stop Icing and Heal Faster

 

The use of ice to treat injuries has become controversial in sports medicine. Gabe Mirkin, MD coined the mnemonic R.I.C.E. (Rest, Ice, Compression, and Elevation), for sports injury first aid in 1978. But he recanted his opinion on ice in 2014. His reversal came after a review of the research which indicated no evidence that ice improves recovery time. Moreover, research suggests that cold therapy can suppress the body’s natural inflammatory stage of healing and reduce blood circulation to the injury.

Inflammation gets a bad rap in the medical community as it is associated with many disease states from cancer to arthritis – this association applies to chronic inflammation, NOT acute inflammation that follows trauma to the tissues. Acute inflammation is a normal healthy response.

The body’s response to ice is as follows: blood vessels constrict to reduce hemorrhage and swelling; nerve endings are numbed to provide pain relief; and, when applied intensely, the painful inflammatory response is suppressed. All three effects reduce pain which is why ice has been a popular home remedy. Giving up the ice does not mean you have to suffer in pain; there are other measures you can take that provide relief and support your natural healing response.

The reduction of hemorrhage, swelling and pain can be accomplished with compression, elevation, and gentle movement. Notice complete “Rest” of injuries (from the R.I.C.E. model) is also in question. Gentle movement helps the body pump dead cells away from the injury and reduce swelling. It also improves circulation of blood to the injured site, bringing healing factors released by your immune system.

Heat also improves circulation to the area but is not recommended the day of injury because increasing circulation to a fresh injury may increase the bleeding in the area. But within hours the bleeding stops, especially when compression is applied, so after that heat is okay and studies indicate it causes no harm.

Over-the-counter pain medicine can reduce the pain, but be wary of the one you choose. Ibuprofen (Advil) is an anti-inflammatory – is that what you want? Acetaminophen (Tylenol) offers pain relief without affecting inflammation. Pain medicines commonly prescribed in emergency rooms are also acetaminophen based.

If your goal is to be back in action as soon as possible, don’t freeze your injury. Instead, take other measures to help yourself heal: start with compression and elevation and after the first day include heat and gentle movement.

(A more thorough article on this topic titled Think twice before applying ice was posted earlier on my blog)

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The Healthy Kind of Happiness

The Healthy Kind of Happiness

You can take anti-inflammatory drugs and consume an anti-inflammatory diet, but how about experiencing a dose of volunteer work to lower your inflammation? Chronic inflammation is a topic of research because it is implicated in a wide range of diseases from cancer to heart disease  A study published in Proceedings of the National Academy of Science showed that people who experienced happiness primarily by working for the greater good had lower levels of inflammatory proteins circulating in their blood; in contrast, people who experienced happiness predominately from self-gratification had higher levels of inflammatory proteins – comparable to levels in people who are depressed or stressed.

TWO TYPES OF HAPPINESS

The authors differentiate between the following two types of well-being:

  • Hedonic: self-gratification experienced from positive transitory events such as purchasing a new car, smelling roses or enjoying ice cream
  • Eudemonic: happiness that results from striving toward meaning, a noble purpose beyond self-gratification, and working for the greater good

The emotional experience of these two kinds of happiness feels the same to you but the research shows your body knows the difference.

Perhaps when your source of happiness is primarily hedonic, there is an underlying stress after one source of gratification ends until the next one is attained. Self-gratification happiness is situational and temporary. Let’s say, for example, you go to the freezer for your private stash of chocolate ice cream — your source of hedonic happiness — but find that your carefully hidden stash has been uncovered and consumed down to the last teaspoon. If you were dependent on that chocolate ice cream for your happiness, then your biomarkers for inflammation just increased.

Eudemonic sources of happiness – volunteer work, spirituality, creative endeavors – are more stable and have deeper meaning than the “stuff” in your life. You can attain this type of happiness in a variety of ways: practicing your spirituality; volunteering your service to organizations that serve the disadvantaged; building trails and picking up litter to care for the environment; being involved in political activism for a cause that is compelling to you.

Hedonic and eudemonic forms of happiness are not mutually exclusive and this post is not about convincing you to give up your hedonic pleasures. The point is that participating in activities that benefit the common good and feeling a part of something greater than yourself create physiological changes in your body that positively impact your health.

 

Breathing Alignment into the Painful Shoulder

Breathing Alignment into the Painful Shoulder

Have you ever had a shoulder pain that seems to have crept up on you for no traumatic reason? Maybe it’s a too-much-sitting-not-enough-moving type of injury or the too-much-moving-in-poor-posture sort of injury. It could be a problem of alignment.

If you have been following this blog, you are already familiar with the link between diaphragm dysfunction and low back pain. Perhaps your shoulder pain could also benefit from the inclusion of respiration activities. The exercises described in this post are meant to provide you with a possible home remedy for non-traumatic shoulder pain; and to alert you to an important, but possibly missing, piece of your prescribed home exercise program following traumatic shoulder injury.

Most gym workouts targeting the upper body focus on the visible outer layer of muscles to develop shoulder strength. Lying deep to those is the rotator cuff, a more delicate group of muscles that stabilize and guide the bones to articulate properly within the primary shoulder joint.  If the shoulder muscles aren’t balanced in strength, or the shoulder is not aligned with good posture, these deeper muscles and their associated tissues cry out with pain.

Dysfunctional breathing patterns and poor position of the diaphragm leads to imbalanced inhalation and twisting in the rib cage. If your shoulder blades are sitting on a misaligned rib cage your shoulder is out of alignment. Exercises for stabilizing the shoulder blades are essential to every home exercise program for shoulder rehabilitation. Unfortunately, these exercise programs often lack respiratory activities to address the ribcage component; this may result in stabilizing yourself in poor position – a situation that leads to abnormal wear and tear on the shoulder complex.

Various postural bodywork disciplines, including the Rolf Method of Structural Integration, address alignment quite effectively. As a living, breathing, moving human being, your muscles also need to be trained to support your alignment.  The exercises described in this post train the muscles that influence the ribcage.

The diaphragm muscle has an elaborate array of connections and influences in the human body as described here. The Postural Restoration Institute and the therapists trained in their method have had excellent results treating chronic pain by incorporating diaphragm training into their home exercise routines; considering the proximity of the shoulder girdle to the rib cage it makes sense to include this training in shoulder rehabilitation.

The first exercise described below was previously included in my blog post  The Diaphragm is a Core Muscle. The second exercise – 90/90 Bridge with Ball and Balloon – was designed by the Postural Restoration Institute; a thorough rationalization for this exercise was published in the North American Journal of Sports Physical Therapy in 2010. Though I recommend it here for shoulder pain, it was originally developed as a remedy for low back pain, another condition often attributed to misalignment.

DIAPHRAGMATIC BREATHING EXERCISE

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  • Lie on the floor with your legs up on a chair or couch so that your hips and knees are at right angles. This passive position allows you to focus your attention on your breathing mechanics while allowing your body to settle into balance.
  • Place your hands on the sides of your ribcage and abdomen.
  • Expand your abdominal region and your chest as you breathe in. This expansion naturally occurs when the diaphragm descends and displaces the abdominal organs outward.
  • Allow the expansion of your ribs out to the sides to create space for the air filling up your lungs.
  • Your shoulders should not move toward your head as this indicates unnecessary contraction of the neck and upper chest muscles – a breathing pattern that can lead to fatigued and tender neck muscles.
  • Practice breathing into your abdomen in this position for 10 minutes a day to regulate your nervous system and to bring awareness to how it feels to breathe correctly.

90/90 BRIDGE WITH BALL AND BALLOON

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  • Lie on your back with your feet flat on a wall and knees and hips bent to a 90-90 degree angle
  • Place a 4-6 inch ball between your knees, squeezing with light pressure on the ball
  • Hold the balloon in one hand and place the other arm above the head in a relaxed position
  • Perform a posterior pelvic tilt (tailbone is slightly raised off floor, the back is flat against the floor). Make sure you are not pushing your feet into the wall, but rather slightly pulling your heels down, contracting your hamstrings. Maintain this position throughout the exercise!
  • Inhale through your nose (~75% of max) and slowly blow out into the balloon (3-4 seconds)
  • Pause for 3 seconds with your tongue on the roof of your mouth to prevent airflow out of the balloon and without pinching the neck of the balloon
  • Inhale through your nose again, and slowly blow back out into the balloon (Do not perform too forcefully, you should not be straining your neck or cheeks)
  • Repeat breathing technique a total of 4x
  • After the 4th breath in, pinch the neck of the balloon, remove it from your mouth, breath normally and let the air out of the balloon
  • Relax and repeat the entire process a total of 5 times!

(Credit for 90/90 Bridge with Ball and Ballon Exercise: “The Value of Blowing up a Balloon” by Kyndall L Boyle, PT, PhD, OCS, PRC; Josh Olinick, DPT, MS; and Cynthia Lewis, PT, PhD

 

 

 

 

Your Diaphragm is a Core Muscle

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BREATHE LIKE A BABY

The first thing you did when you were born was breathe air into your lungs — and you did it perfectly. A baby’s breathing pattern, expanding its little belly with every inhalation, is a beautiful demonstration of healthy breathing technique. As life goes on, stress, poor posture, injuries, trauma, vanity, and even well-intentioned exercise programs can result in a dysfunctional diaphragm that compromises your capacity to breathe air into your lungs and to stabilize your core.

Deep and controlled breathing techniques have long been prescribed for stress management and reduction of blood pressure. Some recent studies indicate that diaphragm training potentially has other benefits. A review article in the Journal of Multidisciplinary Healthcare 2013 explains anatomically how the diaphragm is intimately connected to multiple systems within your body and its dysfunction can be implicated as a component of neck and low back pain, headaches, incontinence, gastric reflux, and sluggish lymphatic and blood flow. A 2012 study published in the Journal of Orthopedic and Sports Physical Therapy indicated that there is a close association between chronic low back pain and a sub-optimally performing diaphragm. In a 2013 study, researchers used Magnetic Resonance Imaging to compare diaphragm performance of healthy subjects to those with low back injuries and found stability and respiratory functions were compromised in the subjects with low back injuries.

Faulty posture and altered breathing patterns diminish the capability of the diaphragm to perform core stabilization and inhalation of air. Postural training and focused breathing exercises described in this post are basic techniques you can practice at home. Disciplines such as yoga, sitting meditation, qigong, tai chi, and other forms of martial arts integrate healthy diaphragmatic breathing into their practices.

HOW THE DIAPHRAGM WORKS

When you are sitting up or standing the diaphragm muscle forms the floor of your breathing chamber spanning the circumference of the bottom of our rib cage. It is 5mm thick and shaped as an upward facing dome. Ideally, it is parallel to the pelvic floor so it can descend directly down like a piston drawing air into your lungs.

The diaphragm performs as a deep core muscle that provides stability from the inside out. It forms a lid over the top of your abdominal section connecting to a multitude of structures including the inner surfaces of the bottom five ribs, the top 3 lumbar vertebrae, and the psoas and quadratus lumborum muscles to create a complex unit that stabilizes the core. In my physical therapy practice, patients with low back pain often have tight and tender psoas muscles in the front and quadratus lumborum muscles in the back. Hip flexors tend to be shortened. The strain from these tight muscles along with abdominal weakness puts the diaphragm in a disadvantaged position; the result is shallow breathing, recruitment of neck and upper chest muscles that compensate by lifting the ribcage, and instability of the low back.

START WITH THE BASICS

The diaphragm exercises shown in this post are performed lying on the floor so that your posture is supported while you learn the basics. This is the first hurdle in training yourself in healthy diaphragmatic function. After practicing a while you may learn to adjust your breathing pattern at other times of the day. Good times to check in are when you are sitting at a stoplight, or standing in line at the grocery store. The goal is constant diaphragmatic breathing during all of your activities.

DIAPHRAGMATIC BREATHING EXERCISE

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  • Lie on the floor with your legs up on a chair or couch so that your hips and knees are at right angles. This passive position allows you to focus your attention on your breathing mechanics while allowing your body to settle into balance.
  • Place your hands on the sides of your ribcage and abdomen .
  • Expand your abdominal region and your chest as you breathe in. This expansion naturally occurs when the diaphragm descends and displaces the abdominal organs outward.
  • Allow the expansion of your ribs out to the sides to create space for the air filling up your lungs.
  • Your shoulders should not move toward your head as this indicates unnecessary contraction of the neck and upper chest muscles – a breathing pattern that can lead to fatigued and tender neck muscles.
  • Practice breathing into your abdomen in this position for 10 minutes a day to regulate your nervous system and to bring awareness to how it feels to breathe correctly.

The exercise below builds on the first exercise by adding the core stabilization component.

DIAPHRAGMATIC CORE STABILIZATION EXERCISE

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  • Lie in the same position as the first exercise, knees shoulder width apart
  • move your hands down to your lower abdominal area on either side of the rectus abdominis (aka your six-pack muscle).
  • Inhale deeply to expand your abdomen down into your lower abdominals so you feel pressure against your hands.
  • Maintain the lower abdominal pressure against your hands as you lift your legs off the couch
  • Hold that position for 5 breaths, expanding your chest on inhalation
  • Keep your neck relaxed.
  • Feel the stability coming from the inside out throughout your core*.

*If you find the abdominal pressure drop away from your hands, you have lost your stability from the inside. If this happens, start again but slowly take the weight off your legs to the extent that you can maintain the lower abdominal pressure against your hands. This is a skill that takes practice.

Awareness of how it feels to use the diaphragm for stabilization can go a long way, but when you get up on your feet things get a bit trickier as your upright postural alignment plays a role in how effectively your diaphragm can function.

THE IDEAL POSTURAL ALIGNMENT

The diaphragm is optimally positioned when it is level and parallel to the pelvic floor so it can easily descend during inhalation. If the rib cage is tipped backward, which often occurs with tight back muscles and weak abdominals, or tipped forward, which happens when sitting slouched, the diaphragm is not in an optimal position to contract normally. There are also torsional factors in the trunk from imbalanced posture left to right that can interfere with optimal diaphragm function.

Addressing all possible postural faults is beyond the scope of this post, but the fault most commonly seen in my practice is a forward tipped pelvis that results from too much sitting. Sitting allows adaptive shortening of the hip flexor muscles which in turn create a downward pull on the front of the pelvis when you are standing. A forward tipped pelvis creates stretched weakened abdominals and a relative backward tipped ribcage; this make the pelvic floor and diaphragm out of alignment – a situation that causes the diaphragm to be dysfunctional for both breathing and core stability. In our culture, just about everybody would benefit from lengthening their hip flexors.

My favorite hip flexor stretch involves a modified lunge position as shown in the picture below. This is an active stretch that demands effort when performed properly.

HIP FLEXOR STRETCH

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  • Place a cushion on the floor under the kneeling knee
  • Step forward with the opposite foot so your front knee is directly over your foot
  • Keep your body upright and tuck your pelvis so your tailbone points to the floor — this protects your low back and is accomplished by engaging your lower abdominals. Do not arch your back.
  • Shift your body forward (without bending over) until you feel a stretch in the front of your hip
  • Contract the buttock muscles in the hip of the back leg. Contraction of the buttock reflexively relaxes the hip flexors.
  • Reach with the arm on the same side as your kneeling knee up and toward your head
  • Side bend your trunk slightly away from your kneeling side
  • Hold this position for 3 minutes using diaphragmatic breathing the full duration

The diaphragm is intimately connected to your stability, respiration, nervous system, blood flow, digestion, and more. Hence, regular practice of these exercises has the potential to improve your well-being in a multitude of ways. Why not give it a try?

Think Twice Before Applying Ice

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DOES ICE OR HEAT HELP INJURIES HEAL FASTER?

Ice and heat are convenient home remedies used to reduce pain. When deciding which one to choose you should consider the potential effects of each one on the healing process. The conventional use of ice, particularly in the first 24-48 hours following injury, soothes the pain and slows the bleeding into the injured area, but some experts suggest that its effects on the circulation might slow the natural rate of the healing process.  Heat stimulates the area to respond in ways that seem to promote healing but the current research is lacking direct evidence that it influences recovery time.

THE CONTROVERSY AROUND ICING INJURIES

Sports Medicine physician, Gabe Mirkin, MD, coined the mnemonic RICE for Rest, Ice, Compression, and Elevation as the first aid approach to sports injuries in 1978. Ice has been the standard recommendation for treatment of injuries ever since. Ice seems to make sense because the body responds as follows: blood vessels constrict to effectively reduce hemorrhage and swelling; nerve endings are numbed to provide pain relief; and, if applied intensely enough, the painful inflammatory response is suppressed.

In 2014 Dr. Mirkin reversed his stance regarding the use of ice on injuries in his online article “Why Ice Delays Recovery”. His new theory is based on his sports medicine experience and a literature review published in The American Journal of Sports Medicine in 2004 that concluded that there was no definitive evidence that ice provides any healing benefit. He also cites studies that suggest the body’s response to cold of reducing blood flow to the area hampers the delivery of healing immune factors to the injured tissue and suppresses the inflammatory stage required for healing. A 2014 study on deep cold therapy methods cautions that deep methods of cold-induced blood vessel constriction risks cellular damage due to prolonged lack of oxygen in the tissue. In the field, our experience is that ice helps reduce pain, but since pain is measured by individual perception the evidence is anecdotal.

WHAT ABOUT HEAT?

Heat is also a convenient home remedy for pain. In the first few days following injury heat is generally discouraged as the belief is that it will increase painful inflammation; however, when applied at moderate intensity there is no evidence that heat causes any harm.  In fact, it is questionable whether it penetrates the tissue deep enough to influence the inflammatory process.

According to a literature review published in Postgraduate Medical Journal in 2015 , “The physiological effects of heat therapy include pain relief and increases in blood flow, metabolism, and elasticity of connective tissues.” These effects sound beneficial for healing, but currently there are no studies that conclude that heat improves recovery time.

The Chinese Medicine model, which is centuries old, prefers heat over cold when treating injuries. The theory is simple: heat encourages circulation and cold restricts it; circulation is required for tissue repair so cold is never recommended for injuries.

MY RECOMMENDATION

I recommend heat over ice for pain in most situations, except within the first day following injury when heat may exacerbate bleeding into the injured site. In that stage I would agree with Dr. Mirkin’s current advice of elevation and compression, adding gentle active motion as tolerated. Active motion by itself encourages circulation; active motion combined with elevation assists in the flow of lymphatic fluid carrying dead cells and debris away from the injury.  Notice that Dr. Mirkin has replaced total Rest in the RICE model with gentle motion.

In my clinical experience, I have found that heat eases muscle stiffness and pain, encourages mobility of arthritic joints, deactivates painful trigger points in the back and neck, soothes tendonitis and bursitis, and helps relax muscle spasms. I recommend heat because: there is no evidence that warming the tissue causes any harm; patients tend to find heat more agreeable than cold; and the increased circulation to actively healing tissue seems like a good idea.

USE CAUTION WHEN APPLYING HEAT OR COLD

Caution is advised when applying hot or cold, because extreme temperatures can damage the skin.  Our pain tolerance will protect us from this in most cases but burns and frostbite are a risk if one ignores those painful burning signals or has impaired sensation.  Warm baths, heating pads, and microwaveable rice bags are all soothing methods of home therapy.  The temperature should feel warm — not hot. The skin should be monitored regularly during application of either ice or heat. Never sleep on a heating pad.

The next time you consider applying ice to an injury, be wary of intensely chilling the tissue and remember that cold interferes with your body’s natural inflammatory response that is required for healing. If your intent is to limit the initial bleeding into the injured site, remember that compression and elevation are also effective means toward that goal.

Leaving the Insurance Nightmare Behind

Leaving the Insurance Nightmare Behind

It is time for me to dig out from under the frustrating quagmire of paperwork imposed on me by my insurance contracts so I can reclaim my sanity and love of my work. I am terminating all of my in-network contracts, firing my billing service, and focusing my clinic time and energy entirely on patient care.  Removing my practice from the control and limitations of healthcare insurance companies allows me to continue to offer extended one-on-one quality physical therapy sessions to my patients who are more to me than their injured parts.

I opened Harmony Physical Therapy in 1994 offering extended appointments for complicated patients. My patients were survivors of auto accidents who were thrown through the windshield in head on collisions or tossed around in their car as it rolled down a mountainside; they were victims of bike crashes, rock climbing falls and a variety of other serious accidents.  These patients were often dealing with brain trauma that rendered them moody, forgetful, and foggy. I laid my hands on and worked stuck damaged layers of tissue apart, coaxed closed joints to open naturally, and transformed strained postural patterns into better balance – and I listened.  I listened as my patients shared stories of travels, relationship struggles, traumas, job stress, personal victories, and grief. Emotional support became equally as valuable as physical support, and my extended appointments allowed time to provide it. This became my niche.

In the beginning, my time was fairly compensated by insurance companies. My husband was also self-employed so we had the flexibility to raise our family without the use of daycare services.  We weren’t wealthy, but we got by and life had balance.

In 2003, after massive lobbying efforts by auto insurance companies in Colorado, the no-fault coverage for injuries sustained in auto accidents was abolished. Payments for medical bills related to auto accidents are delayed, sometimes several years, until the determination of who was at fault is sorted out in court.  Injured parties, wary of navigating the legal system, often chose not to seek treatment and stuck it out with their pain. My niche was hit hard.

In a move to boost my patient volume I decided to join the managed care system and accepted provider contracts with major insurance companies in my area. As a solo practitioner, I had no negotiating power on these contracts; my choice was to either accept the low ball offers or to be left out of a stream of potential patients shopping for care within their benefit plans. The payments were per diem and priced to cover less than 30 minutes of direct-contact physical therapist treatment.  I compromised by offering 45 minute appointments, but stubbornly continued to treat the complicated patients for an hour or more. This was not a wise business strategy, but it allowed me to maintain a pace I needed to function optimally with my patients. By 2012, I was working twice as hard as I did in the 90’s and barely earning the same annual income.

The paperwork demands by insurance companies has steadily escalated every year.  The coding for Medicare claims is increasingly complicated. Time consuming data collection, patient surveys, pre-authorizations, and electronic medical record keeping are required to avoid payment rate penalties and flat out denials. I adapted by using an electronic health record service for an ongoing monthly fee. Electronic billing that streamlined from my records became necessary to save time on collections and chasing down lost claims; this service cost me a percentage my collections.  Business and cost of living expenses climb higher and insurance reimbursement rates remain flat or diminished. The games insurance companies play to delay or deny payments have become unbearably frustrating. Despite keeping my overhead as low as possible and working more hours, my business model has become nonviable within the system.

Ironically, even though some of my senior patients are happy to pay out-of-pocket to see me, it is not legal for me to accept direct payment from Medicare recipients for physical therapy services; how strange, given the financial strain already on the system, that this law results in both higher cost to tax payers and restriction of the rights of seniors.  This law can change only through an act of congress. Thankfully, my skill set can be classified as wellness and fitness care — services outside the realm of Medicare — my seniors who see me because they want to maintain their mobility can still be served at Harmony Physical Therapy. Those with rehabilitation needs, as in post-surgery, will be referred to one of my capable colleagues in the community.

In response to this news some patients say to me, “My deductible is so high I pay out of pocket anyway” or “I applaud you, your services are worth it” or, interestingly, “It seems simpler for everyone”. Others are gravely disappointed as their finances prevent them from paying out of pocket and they will have to seek care elsewhere.

My frustrations, within the complicated mess that is our healthcare system, are common among medical practitioners. The time demanded for paperwork is disproportionately large compared to the time allowed for meaningful interpersonal interaction. The insurance companies control the money and hold the power in the system. I am frustrated with both our government run system and the private health insurance industry so the solution is not clear. I feel compelled to point out, though, that as a consumer I pay more each year for my own health insurance while simultaneously receiving less as a provider within the system, and the CEO of United Healthcare is taking home upwards of $66 million annual income.

Welcome to Being Human

Balancing my life as a physical therapist, business owner, trail runner, meditator, world traveler, and Mom of three kids has been my practice in the art of being human.  My happiness and health are interdependent, and so I seek ways to experience peace of mind as much as I do physical health.

For nearly 30 years, my career has been to help people restore function and balance in their bodies in order to return to the activities they love whether it be hiking up a mountain, running a marathon, or as basic as maintaining an independent living situation.

As the cost of healthcare escalates each year, it is more important than ever to take responsibility for the health of our bodies and minds. This requires self-motivation to educate ourselves and to follow through with proper nutrition, exercise, and as much balance as we can achieve between family, work and play. Our mental health is intricately woven into our physical health; positive social interactions, time in nature, spiritual practice, appreciation of the arts, and any activity that reduces stress are all supportive to our mental health.

Being Human is about taking care of ourselves so that we can minimize our reliance on the overburdened healthcare system.  If you share this philosophy and want non-preachy guidance from a physio in the field, then you have come to the right place.

Photos posted on this blog are all mine taken on my trail runs and travels. Enjoy!