Jess Kehoe, DPT
I made it through the holidays! And like most of us, enter into January promising myself (as a rule I avoid resolutions!) to try to eat better. Really this means less sugar filled treats. As much as I love cookies, by the time January rolls around I’m ready to throw out the last few Christmas cookies and candy (don’t tell my kids!!). This recipe has been a favorite at my house for years, and always a go to when I feel I need to sneak some healthy eating in. It’s also easy to make a double batch and freeze for a crazy week day in the future, or share with your friends, these days with a less than satisfying, but likely still greatly appreciated drop off.
Also, a note about blended soups. All the recipes instruct you to transfer in parts to a blender for puréeing. But at the risk of sounding like an advertisement, I doubt I would ever make any blended soups with that method...so much mess! I have discovered that a stick blender was made just for this purpose Just use it in the pot when it’s all cooked. SO EASY.
1 onion, diced
2 cloves garlic, minced
1 large celery rib, diced
1 large carrot, diced
1 baking potato, peeled and cut into 1 inch pieces
1 rounded cup of red lentils
1 1/2 quarts stock (I’ve used vegetable and chicken here with equally yummy results)
1/2 teaspoon ground cumin
1/4 teaspoon cayenne
2 tablespoons fresh lemon juice
Salt and pepper to taste
In a large soup pot heat up 2 tablespoons olive oil over moderate heat. Add the onion and garlic and sauté until fragrant, about 2 minutes. Add the celery and carrot and continue to cook for about 5 more minutes. Add the potatoes, lentils and stick; bring to a boil. Cover and lower the heat to a simmer until veggies are tender, 40 minutes. Purée the soup (either in batches or with your stick blender). Add the cumin, cayenne, lemon juice, salt and pepper. Serve and enjoy! We like to have some good crusty bread to accompany this soup.
North Clinic Giving Tree
Please join Alpine in spreading the cheer this holiday season for one of the following charities. Take a tag that you wish to purchase and return items (unwrapped) under the tree (at the North Clinic) by no later than December 21st. If you choose a tag with a monetary donation, please visit this charity's webpage to make your contribution.
Soft Landings: https://softlandingmissoula.org/act
More than 68 million people worldwide have been uprooted by conflict and natural disaster. A group of concerned Missoulians came together to be a small part of alleviating the suffering for these families and provide a "soft landing" for them in their new community of Missoula, Montana. Soft Landing Missoula focuses on building a sustainable effort to engage the community in being a welcoming, supportive and informed place to help refugees and immigrants integrate and thrive.
United Way: https://missoulaunitedway.org/
United Way wants to celebrate this season of giving by sending a little extra hope to our community’s Healthcare Heroes. Join us in thanking all of Missoula’s healthcare workers on the front lines of the COVID-19 pandemic and letting them know that their hard work has not gone unnoticed.
We’re asking for a $30 donation, which will be matched by United Way and sent to our Healthcare Heroes in the form of a Visa gift card for dinner to-go, a tank of gas, a holiday treat or whatever else they may choose.
My Student In Need: https://www.mystudentinneed.org/Missoula-MT
My Student In Need is a nonprofit designed to fulfill teacher's requests for students in need. Currently in the Missoula area there are 4 students who are in need of instrument rental fees for the spring semester ($75.) If you can provide even part of this fee, it is helpful. Please remove a tag and go to MyStudentInNeed.org and click on fulfill a need at the top of the screen. Find Missoula County to find the students and fulfill a request.
South & Downtown Clinic Food Drive
Jess Kehoe, DPT
Are you a cook from scratch, geek like me? If so you roast a pie pumpkin around Halloween to have puree for Thanksgiving. You have also learned that usually you wind up with more puree than that pie calls for....in steps pumpkin bread to save the day. This is also completely unnecessary and a can of pumpkin puree sure does the trick also!
This recipe was easy to make and turned out pretty yummy. Of course I added chocolate chips (my kids insisted) but you could add pecans, walnuts, raisins or nothing. You can also substitute canola oil, olive oil or even apple sauce for the coconut oil. Often my coconut oil begins to solidify when I mix it with the eggs and other cold ingredients, but this recipe had a slick fix that I will remember to use in the future again. Simply warm up your mixing bowl, I put mine in the oven for a few minutes as it was pre-heating. Problem solved!
Made for a great toasted snack with peanut butter this week. Enjoy!
⅓ cup melted coconut oil
½ cup honey or maple syrup
1 cup pumpkin puree
¼ cup milk of your choice
1 ½ tsp of pumpkin spice blend (OR ½ tsp cinnamon, ½ tsp ground ginger, ¼ tsp ground nutmeg, ¼ tsp allspice or ground cloves)
1 tsp baking soda
1 tsp vanilla extract
½ tsp salt
1 ¾ cup whole wheat flour
As the percentage of the population affected by COVID-19 increases it becomes more important to understand some of the long term effects of this virus. There is building evidence that the novel coronavirus can cause cardiovascular damage during the course of the infection. Data is currently being collected about the prevalence of cardiac injury due to a bout with COVID-19. In reports earlier this year from hospitalized patients, it has been shown to be greater than 20% demonstrating cardiac injury. However there is much variety in symptoms and severity with COVID-19 and we are still learning much. For athletes and the general public frequently engaged in fitness pursuits, cardiovascular damage can be a cause of sudden cardiac arrest. Based on the ongoing uncertainty about the cardiovascular risk of returning to sport following a COVID-19 diagnosis there are some new recommendations being put forth for returning to sport activities.
In general, listen to your body! Take it slow, and if an athlete is reporting more fatigue than usual during their gradual return to sport, referral to MD for cardiovascular screening is recommended.
Reference: Jonathan H. Kim, MD, MSc; Benjamin D. Levine, MD; Dermot Phelan, MD, PhD; et al. “Coronavirus Disease 2019 and the Athletic Heart Emerging Perspectives on Pathology, Risks, and Return to Play” JAMA Cardiol. Published online October 26, 2020. doi:10.1001/jamacardio.2020.5890. Accessed November 23, 2020.
Research article link: https://jamanetwork.com/journals/jamacardiology/fullarticle/2772399
Jess Kehoe, DPT
My kids see the buttermilk container in the refrigerator and know that is the necessary ingredient for pancakes, so all last week they incessantly were asking for them on Saturday.
Whether it's just a regular weekend morning or you're celebrating the holidays with only your quaran"team", sometimes it's nice to have a good pancake recipe. I'm a huge fan of basic buttermilk pancakes, but when I think I need to sneak some more health into my morning meal this is my go-to.
These cakes still turn out fluffy, the key to this being separating the and beating the egg whites. This batter is a little thicker than the average pancake batter and the beaten egg whites injects a ton of air into the cakes. However, if this is too much, you can simply mix the whole egg in and they are still quite tasty.
I'm also not terribly strict with the different kinds of flours. You can use any combo, as long as the total amount is the same. This weekend I used Kamut and Oat flours instead of rye and barley and I have flax in a huge Costco bag, and have substituted this for the wheat germ.
I'm also reading "Cooked" by Michael Pollan and spending time with my daughter, aka "little mixer" in the kitchen, making something yummy seems like just the right kind of thing to be doing in late 2020.
Four-Grain Fitness Pancakes
1/2 cup all-purpose flour
1/2 cup whole-wheat flour
1/2 cup rye flour
1/2 cup barley flour
1/4 cup cornmeal
1/4 cup toasted wheat germ
2 tsp baking powder
1/2 tsp baking soda
1/4 tsp salt
2 large eggs, separated
1 1/2 cups buttermilk
1/2 cup milk
1/4 cup canola oil
2 tbsp honey or maple syrup
In a large bowl, whisk together the buttermilk, milk, oil, honey and egg yolks. Mix the dry ingredients into the buttermilk mixture until just combined. Beat the egg whites until soft glossy peaks form, then fold these into the batter, try not to over mix.
Heat a griddle over medium heat, grease lightly. Spoon batter on to the griddle. Let them cook until bubbles appear on the surface and the edges look dry, about 2 minutes, flip and cook about 1 more minute. Serve immediately with any pancake toppings you enjoy.
LEAH VERSTEEGEN, DPT
Sciatica is a term that is widely used to refer to pain that seems to be spreading or radiating into the back of the hip and sometimes down the leg. Where does this pain come from?
Technically the term 'sciatica' means that the sciatic nerve itself is the source or cause of the discomfort, but that is not always the case. The sciatic nerve is a thick nerve that courses through the buttock area and is formed from a combination of several nerve roots that originate in your low back and sacrum.
The nerve roots from the lumbar spine that are a part of the sciatic nerve are L4, which exits between the lowest two vertebrae in your back, and L5 which exits between the last vertebrae and the tailbone. Other nerve roots that make up the sciatic nerve are S1-S3 which all exit from the tailbone or sacrum.
What this anatomy tells us is that sciatica often stems from irritation of a nerve root at one of these levels and not necessarily from just the sciatic nerve itself. The pain that you are feeling in your buttocks or down your leg could be originating from inflammation or stiffness in your low back just above your tailbone. It could also be from inflammation of the sciatic nerve itself as it courses through stiff or thickened musculature in the buttock region, but this is less often the source of the symptoms.
To effectively treat sciatica, it is important to determine the underlying cause of your symptoms. Are they coming from the sciatic nerve in the hip, from the nerve roots in the low back, or from a combination of the two? Why is there inflammation, tension or stiffness in your hip or low back? Are there other structures, such as tight hip flexors or loss of mobility in the upper spine, that are contributing to the symptoms?
Once the true underlying cause of your sciatica is identified then you can choose the correct exercises, mobility work or stretches to help treat the cause of the symptoms and not just chase the symptoms themselves.
Don't let sciatica prevent you from having fun and definitely don't settle with the thought that you 'just have to live with it'. It can be treated with simple daily movement when done with the correct intention and aimed at the structures that are the true source of the problem.
Francisco Quinones, DPT
There is no doubt that we are living in strange times. Many things we used to take for granted as “normal” will no longer be the norm moving forward. Based on what infectious disease experts are saying we will all have to figure out a way to live with COVID-19 for the foreseeable future and that means adjusting to a new normal.
Virtual visits are not really new. Originally Virtual Visits were thought of as an answer to the difficulty of improving healthcare access to rural & underserved populations. Since the Coronavirus became a pandemic there has been a big push to increase the use of Virtual Visits for healthcare everywhere, as it maintains access for patients while eliminating risk of exposure for all parties. It looks to be the new normal, not just for PT but healthcare in general for the foreseeable future.
What can a PT offer in a Virtual Visit?
There is a false perception that the hallmark of our skill set lies in our ability to help people with our hands, what we call Manual Therapy. The reality is Manual Therapy is only a small part of the skills a physical therapist has at their disposal. On average a PT has between seven and nine years of college education with the last three years spent in intensive training to obtain a Doctorate of Physical Therapy (hence the DPT behind a PTs name).
Unlike Doctors and Surgeons (or even Chiropractors) PTs do not usually have imaging at our disposal so we have been extensively trained in pattern recognition. We are trained to identify and categorize injuries based on clusters of signs (what we test) and symptoms (what you tell us you feel). We have extensive knowledge of the musculoskeletal system and Anatomy and Physiology.
PTs know how the human body works. We know how particular joints are loaded based on the mechanics of a movement pattern. We know how to identify limitations in movement and where compensations are likely to occur as a response. We also have a thorough understanding of exercise and how to modify exercise to shift load away from painful tissues (joints, tendons, muscles, ligaments, ect) and toward tissue that is not compromised. We also know how and when to progress loads gradually back to those painful tissues to drive adaptation and get them back to doing what they were capable of doing pre-injury.
That is all a long winded way of saying we have a lot to offer people beyond what we can do with our hands.
What does a Virtual Visit look like?
What do I need to be ready?
What if I don’t have any exercise equipment at home?
This is one of the real benefits of Virtual Visits, we get to work with you in your home environment and brainstorm with you how to overcome obstacles in your way to recovery. Really it comes down to creativity, and it is hard to imagine a scenario where we can’t figure out things in your household that will work just fine for the movements you need to perform.
Will my insurance pay for it?
The short answer is it may... and it may not. The long answer is things are changing daily. There is a lot of political pressure currently to make insurance companies pay for telehealth services. On 4/22/20 Governor Bullock announced that he was declaring a state of emergency to dictate insurance companies have to pay for it. If you are not sure if your insurance company covers Virtual Visits let us help you figure it out.
Are Virtual Visits private & secure?
Any platform Alpine uses has to be HIPPA compliant meaning yes they are private and secure. Security on the internet however all comes down to the weakest link in the chain. With that in mind it is a good idea to look into how secure your internet is at home. Some basic recommendations are to ensure that your wifi is password protected with a good strong password (google tips to secure wifi). To really ensure you have a secure connection anywhere you go, having a VPN is a good idea (do I need a VPN).
Unfortunately our reliance on computers and home internet will only go up during this crisis so now is the time to make sure you are taking the steps to keep your internet as secure as possible .
Why are PTs pushing for Virtual Visits?
There is a big risk/reward calculation to be made about doing an in-clinic visit. Currently, no matter how valuable an in-clinic visit may be it also comes with an increased risk of exposure for all parties. Keep in mind the average transmission rate for COVID-19 is 2.5 (so every person, on average infects 2-3 other people). Virtual Visits are the best way to keep our patients safe while keeping up their care during this pandemic.
Aside from eliminating risk, the main benefit of Virtual Visits is creating independence. By working with a patient in their home, using what you have available we are helping to create the best path towards self-efficacy (empowering you to take control of your own journey towards recovery). Of course it would be easier to teach you how to use the equipment we have available in our clinic, or the equipment available at a gym but, if we can figure out a plan for you with what you have at home, you are more likely to do it.
The goal of any PT is to get the patient to become knowledgeable about their condition and learn how to recover from it. Research has shown the greatest predictor of a future injury is a prior injury, so it’s important we give you all of the tools you need to take ownership & agency of your recovery. We want to ensure you have the tools necessary to minimize the potential for recurrence, and manage recurrence if your symptoms do return. We want patients to be little versions of ourselves when it comes to taking care of their bodies. PT is not just about giving you exercises to get better, it’s about giving you the knowledge to take care of your body now and in the future, and Virtual Visits are a great platform for us to provide a patient with the education they need to get there.
What are other patients saying about it?
How do I schedule an appointment with Alpine for Telehealth?
This is the easiest part. You have three options:
Address Health Concerns with Telehealth.
Receiving Quality Care at Home.
FRANCISCO QUINONES, DPT
What is tendinopathy?
Good question and the truth we don’t know exactly what happens to the tendon that makes it painful. We used to think there was an accumulation of microtears in the tendon (from overuse) but we know now this is not the case. For some reason the cells that lay down tendon material seem to go a bit haywire and just start laying down proteins in a haphazard way which changes the tendon stiffness and structure in a part of the tendon.
What causes tendinopathy?
This one we do know, loading a tendon in a way that exceeds it’s normal capacity. Every tissue in our body has a certain capacity both from it’s inherent properties and from the ways we use it (i.e. the ways we have asked it to adapt in the past through exercise or work).
What is a tendon?
Right, let me back up. The tendon is what anchors our muscles to our bones. It is designed mainly to transmit tension (or pulling) loads to the bone and gives the muscle an anchor from which it can contract to perform work.
How do I know if the pain I have is a tendinopathy?
Well you can’t really. There is a reason why we (Physical Therapists) go to school for 7-9 yrs, but, in general if you have a tendinopathy, the pattern should be that your pain occurs when you use the aggravated tendon and is not painful when you don’t. So your pain shouldn’t be showing up when you're resting (although it may ache after exercise) and the more you use it the more it hurts.
So I should rest it right?
No. There is no benefit from long term rest because the tendon will adapt to this too. You can think of all the tissues in our body as constantly adapting, both up and down based on what we do with them. With a tendinopathy the capacity of the tendon has already taken a big hit and the last thing we want to do is have the tendon adapt (down) further toward having a lower capacity. In some (more painful cases) it may help to rest it up to 72 hrs after injury but after this it is time to start the hard work of changing the tendon back to it’s prior capacity.
So how do I get it to change back?
Right. First we need to identify just how much (load) the tendon currently tolerates and we can do this by using your pain as a guide. During exercise we think that pain between 0-3/10 is perfectly safe. pain between 3-5/10 as being on the upper end of ok and anything more than this as being too much. I know everyone hates the pain rating scale but people are actually pretty good at getting these numbers right. If this doesn’t work at all for you than just think of it as it’s ok if the pain is there with exercise whispering at you but you don’t want it yelling at you and you shouldn’t have to reach for Alieve when you are done. Think of that light pain as your tendon telling you this is my capacity right now. Every exercise session then is just a matter of meeting it there every time and doing this consistently (every other day or every third day). This means you may need to go slightly up or down with weight or reps with each exercise on a given day but overall, you should be gradually going up to meet it where it’s at. If this is happening, then you are on your way as it is already adapting to doing more. Pain overall will improve gradually too but it tends to trail behind how much the tendon tolerates.
So It should take a couple of weeks then?
No. Unfortunately the research is clear here to that the road to fixing a tendinopathy is a long one. 12-16 weeks is the current timeline we think it takes to make a permanent change in the tendon. The road to getting it pain-free may be up to six month or more. This doesn’t mean that the pain will still be the same six month later, it will be quite a bit better but may still occasionally show up (with exercise or work).
Can I speed this up if I do exercise every day instead of every other day?
No. There is some research that shows we need to give the tendon at least 24hrs between loading sessions to give it time to adapt for the better. But, you can certainly do other exercises that don’t overload & provoke the tendon like low impact cardio or exercises targeting the non-affected parts of your body.
How do I know if I need the help of a Physical Therapist?
Well if you are able to exercise and keep the pain below a 3/10 and it is gradually getting better than you are probably on your way. But, if you are struggling to figure out what to do and how to load it and getting mixed results or it is getting worse than it would probably be worth your time to have someone with training help you figure out how to navigate this injury. I like to use the analogy of bowling where I just act as the bumper guards for my patients so that they can be successful. Ultimately the work has to be done by you either way but the road back from a tendinopathy can be confusing and anxiety ridden so it may help to have a guide.
By Kristina Pattison, DPT, OCS, CSCS
Photo by Seth Orme: Jenna Lyons and Kristina Pattison at the 2020 Runners Edge Run Up For Air fundraiser for Climate Smart Missoula
With upcoming races on the calendar, it can be tempting to increase miles quickly this time of year. But gradually building a solid base of running volume is the best way to prevent the dreaded overuse injuries that often plague runners later in the year. When Planning a Race Season and developing Phases of a Running Program it is important to consider both the principles of overload and rest for a safe build up for the year.
It’s important to understand the physiological implications of increased volume over the course of a training season. Increased miles equates to increased forces absorbed by the body as you’re pounding around on the pavement or trails. With each step the body absorbs 2-3 times your body weight while running. These forces are attenuated mostly by soft tissues of the body--muscles, tendons, ligaments. But also cartilage and bone can take a beating as well as the body fatigues, so the goal is to keep your active shock absorbers--muscles--doing the work to offload less compliant tissues like cartilage that is susceptible to irreversible degeneration. This takes time and gradual adaptation. Remember that as you progress miles, it’s been found that increases of less than 10% per week is associated with decreased incidence of injury in runners.
Also, consider that the day you rest is the day your body heals and responds to overload by becoming stronger and more adept at absorbing shock. The soreness you feel when starting a program is considered to be due to healing associated with micro-tears in weaker muscle fibers. As these fibers heal they become stronger and better adapted to withstand that higher amount of stress during future bouts of exercise. When designing training a training program, most coaches will incorporate at least one full day of rest into the week, and vary the intensity of days so there is at least one easy run between each of your harder, longer, or more intense efforts.
Strategically incorporating increases in volume paired with appropriate rest days allows your body to naturally adapt to increased miles and speed so you can reach you race goals without setbacks associated with injuries.
By Kristina Pattison, DPT, OCS, CSCS
Keeping things interesting on a treadmill can be a feat in itself. The boredom of miles spent in one spot can derail the most well-intentioned training program. Here are several ideas to improve your chance of success for the runner who uses the belt:
One of the key measurements of work while running is cadence, or steps per minute. Historically, the rule of thumb for ideal cadence was identified by averaging the cadence of a handful elite Olympians at the 1980 Olympics in Los Angeles. What did they find? Across all distances most of these runners were running at approximately 180 steps per minute. Since then, research has determined that increased cadence results in decreased ground reaction forces through the lower extremity during impact, which can be useful for minimizing pain while running. But also, increased cadence has shown to improve the activation of stabilizer musculature just prior to impact which helps with force attenuation during landing. These improvements can occur at just a 5-15% increase in a runner’s natural cadence.
TREADMILL PLAN: Count your steps for 6 seconds while running at a normal speed, multiply by 10 and this is your steps per minute. Even better, have someone else do it or film you and count for a longer period. Your cadence will change at different speeds and inclines and all of us have a sweet spot where our form is the most efficient. It’s important then to practice keeping a higher cadence while running at the less natural speeds and grades. Try these ideas: shallow hill repeats at 6-8% grade for 3-5 minutes keeping your natural cadence. Or: short intervals at increased speed (1-3 minutes) when cadence naturally speeds up slightly, with the intention of trying to keep an increased cadence during your rest or slow period.
Power is defined as the rate of work performed, with work being the force transmitted multiplied by the displacement of an object. Power is traditionally a metric used in cycling due to ease of measurement of force applied with a meter attached to the bike. Running meters that attach to the shoe (e.g. Stryde) can calculate force development by the foot hitting the ground, multiplied by the distance traveled per unit of time. Ideally, power would provide a more precise interpretation of effort input to gauge the intensity of workouts, instead of using heart rate that has somewhat of a lag to catch up to effort. However, these running power devices can be relatively unreliable and the information they provide is sometimes confusing or easy to misinterpret. If you aren’t a tech connoisseur, you could consider using proprioceptive cues instead for improved force development during your training bouts.
TREADMILL PLAN: During an easy paced run, think of “running through the wall” a proprioceptive cue used by coach and author, Matt Fitzgerald to encourage the runner to exert increased force through the ground propelling the runner horizontally forward. The idea is to visualize a wall in front of you that you must break through to the other side. Importantly, this can result in you running into the front of the treadmill, so be prepared.
Historically, effort has been measured in terms of heart rate. Runners can use heart rate as an indicator of effort to ensure easy efforts are truly in an easy range, or to ensure they are staying in the correct intensity ranges during anaerobic efforts. However, clinical trials have found that rate of perceived effort is generally just as applicable for determining your effort zone. The Borg rating of perceived exertion is a scale of 6-20 and roughly correlates to heart rates. For example, 6 is sitting on the couch having a beer at halftime, and 20 is all out sprint to the end zone.
TREADMILL PLAN: Start your warm up at an easy pace where you can easily breathe through your nose and/or if you’re with a partner, carry on a conversation. Note your effort rating on the Borg scale. Then start to increase your speed until you feel you are running about as fast as you can for 10 minutes. Note your effort and speed. Return to easy for a couple minutes and complete the above at a shorter time frame until you’ve tried 10-8-6-4-2 minute reps with a 2 minute rest between. On subsequent reps you should be running faster and may note your effort rating change. With future trials of this workout you may notice your effort decrease at the same speed. Running at an increased step per minute and increasing your force per step will increase your running speed. As your body adapts, you will gradually feel these efforts become easier and easier until it's time to try some runs outside again!
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