Tag Archives: Medical

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Back it up: Let your death inform your life

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Death is the only wise adviser that we have.
— Carlos Castaneda

We’ve all heard about “bucket lists.” You’ve probably got your own. It may include ideas about what we want to see and do and where we want to go before we die. Some folks have thousands of items on their list and manage to get a bunch of them done; others not so much. Many simply dream.

These lists are great — I have a few of my own. At the top is returning to a particular hotel on the Big Island of Hawaii.

Let’s dive a bit deeper, though, and stretch even further. Go straight to your death now. How you wish to be remembered may change how you live your life.

Here are five strategies to get you started:

Write your own obituary

Considering your own death can be daunting. Several of my friends are convinced they will live to be at least 120 years old. I know some brilliant young minds who are opting for cryonics, wanting to be frozen and revived in the future when better technology and medicine exist.

At some point, we will die. By writing your own obituary while you are still alive, you retake ownership of your biography. Imagine reading about yourself in the newspaper after you’re gone. Narrating how you wish to be remembered reminds you how to live.

Write your own eulogy

Why not sing your own praises, recount fond memories and celebrate your life while you’re still here? And share it with your family and friends? While a eulogy is often the speech given at a funeral, you don’t have to wait till then to do your own.

This past birthday, I had no intention of writing anything; my plan was to soak in some contemplative time before all the festivities. Yet, something like a eulogy bubbled up as I meandered in the woods that morning.

Dictating on my phone, it began with what doesn’t “define” me. Later, sharing it with each of the people mentioned within, that process became the best birthday gift — to us all.

Write your own epitaph

What do you want inscribed on your gravestone? My mom has said for years that her epitaph would be, “Peace at Last.” To sum up in so few words what you want to leave behind is quite a feat. Take time to ponder and consolidate your legacy.

Complete a life review

I first learned of a life review in my hospice work. By looking over your life and reflecting on the good and bad, you can shapeshift and heal the past, forgive and let go.

Though it may take some time and support, this kind of reckoning has the power to change not only yours, but your loved ones’ lives as well.

Discover your life song

Decades ago, I sourced mine at a Shamanic workshop at Esalen Institute. It seems to resurface when I am at my most lost. Listen to Switchfoot’s “This is Your Life” and come up with your own.

It takes clarity, courage and commitment to live your life through the lens of death. Pay attention. Start with your thinking. Take small, doable steps. Reap the rewards.

Back it up and leave this life as you intended.

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Study: Airplanes have dirty, unsafe water

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A new study is telling us that airplanes are incredibly disgusting and that travelers need to avoid certain things at all costs. Most importantly, avoid onboard water, except that which is from a sealed water bottle.

Don’t wash your hands with it, and certainly don’t drink it. That’s according to the 2019 Airline Water Study.

Developed by DietDetective.com and the Hunter College NYC Food Policy Center, the study tested the quality of water on 11 major airlines and 12 regional airlines. But water isn’t the only thing to make the weary wanderer even more, well, weary.

The studied water was rated on a scale of zero to five, with scores of three and higher constituting water that is safe enough to drink. The zero-to-five scoring is assigned on 10 criteria, including the presence of coliform bacteria or E. coli.

If you fly Alaska Airlines or Allegiant, as of this study, you’re in the best shape regarding flying health, as the two airlines tied for first place. Spirit and JetBlue, however, ranked last. Nearly all regional airlines, except Piedmont, have poor Airline Water Health Scores and a number of federal code violations.

For example, when an aircraft’s water sample tests positive for coliform, the federal government requires that the water be tested again to determine if E. coli is present. If E. coli is not present, the airline must take repeat samples within 24 hours, disinfect and flush the water system within 72 hours; or the airline can shut down the water system within 72 hours, then disinfect and flush.

If the sample is E. coli-positive, the airline must shut off public access to the water system within 24 hours and disinfect and flush. It’s not an easy process.

Perhaps the most shocking thing to come from the study is the researchers’ recommendations about what not to do with the water on the worst of the airlines measured. Other than recommending that people not wash their hands in the airplane bathrooms, they encourage travelers to skip the coffee or tea onboard; and that travelers should never drink water unless it’s known to have come from a sealed bottle.

Spirit, Allegiant, and Frontier did not respond to any questions from surveyors. “Very weak responses” — and responses that didn’t address questions — were provided by American, United, and JetBlue, researchers said.

An aircraft flies to numerous destinations and may pump drinking water into its tanks from various sources at domestic and international locations. The water quality onboard also depends on the safety of the equipment used to transfer the water, such as water cabinets, trucks, carts, and hoses.

Oh, but there’s more to fear on an airplane than just the water. The aircraft are near-cesspools of germs and grime. Airplane restrooms are the worst places for germ contamination, according to a USA Today poll. According to Coverall Cleaning System, the bathrooms rarely are sanitized between flights. The tiny sinks make it hard to wash hands properly, and studies have found E. coli on almost every surface in the plane’s loo.

Outside the water closet, it might be a good idea to bring your own reading material along with you on the flight. Airline magazines and catalogs are also heavily contaminated. This is because people’s hands tend to naturally be dirty and the sinks in the restrooms don’t allow for proper handwashing (plus, the water isn’t fit for washing).

Finally, if attempting to navigate all these germ-ridden areas gets you exhausted, it’s probably a great idea not to reach for an airline pillow and blanket. About 5% of customers on a flight will have a cold or flu, according to USA Today, and many try sleeping it off while in the air. Pillows and blankets are not cleaned between flights, creating a potential risk for those boarding the plane.

As you gear up for holiday travel or a busy business season, know your airplane is one of the least healthy places you could be.

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Preventing ACL injuries in female athletes

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It’s basketball and soccer season. Athletes have been training all throughout the spring and summer in preparation for the final months of 2019 and the first quarter of the 2020.

The goal for most athletes is to have a breakout season. In doing so, an athlete must stay healthy. While this is the season for basketball and soccer, this is also the season for bad knee injuries.

For female athletes, anterior cruciate ligament (ACL) injuries are among the most common. Often, those injuries happen in noncontact fashion. According to an article from Baylor College of Medicine, roughly 70% of ACL tears are noncontact injuries.

The ACL is one of the primary ligaments that assists with the stabilization of your knee joint. Changing direction, making lateral cuts, pivoting, and landing from jumping are why ACLs are so important.

For female athletes, ACL tears tend to rise.

“Female soccer players are one of the highest risk groups among athletes for ACL tears,” said Dr. Theodore Shybut, associate professor in the Joseph Barnhart Department of Orthopedic Surgery at Baylor. “In fact, studies have reported that female athletes are two to 10 times more likely to have ACL tears compared to male athletes.”

So why are ACL tears more common in female athletes? According to Johns Hopkins Medicine, female joints “generally have more looseness and range of motion” than male joints. To add, there’s less muscle mass around the knees of young female athletes, which could lead to instability — and an injury if a ligament is overstretched.

What exactly can be done to prevent ACL tears? That’s a tough question to answer, as these injuries can be unexpected and caused by the slightest irregular movement. But here are a few things that can be done the help prevent tears and other major injuries to the knee.

Make warmups a priority: You never want to start playing cold. It is mandatory to stretch and get your blood circulating. Make sure your joints and muscles are warm — before games and practices.

Develop muscles evenly: When working out, the one thing you don’t want to do is focus on one primary area. Make sure you’re training your body evenly, top to bottom. Don’t ignore an area.

Use proper technique: As you train, proper technique is everything. Whether it’s strength training or cardiovascular training, proper form can be the difference in an outstanding showing on the court or the field and a season cut short because of a bad injury.

The right diet counts: Did you know that improper nutrition can lead to a dip in endurance? Eating the right foods can result in performance improvement and focus enhancement.

Get enough rest: Playing to win, to some, means getting as much work in as possible — and then getting additional work in. Your body needs time to recuperate. Make sure you’re getting enough sleep and alternating rigorous workouts with easier ones.

The last thing you want is to be sidelined with an ACL injury. Make sure you take these injury prevention tips seriously … and enjoy the season!

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The undeniable health benefits of writing

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I’ve been writing most of my adult life. I’ve been working with writers as a group facilitator and teacher for 30 years. In my experience, I can assert with confidence that writing changes lives. There is something healing about putting one’s thoughts, ideas, observations and wisdom onto the page. Some obvious benefits include:

It helps us organize and make sense out of what’s happened in the past or what’s current happening in our lives. It creates order out of chaos, giving us the temporary feeling of being in control of our world.

It allows us to bring buried feelings and deeply held perceptions to the surface so they can be seen and therefore understood. What we don’t know can often hurt us. Becoming conscious and aware of what’s inside opens up a multitude of possibilities to acknowledge, shift and heal ourselves.

If shared, writing helps us to connect with others at a deeper level. Hearing each other’s stories lets us see beyond the social masks we wear into the inner workings of another, fostering great compassion and empathy.

Writing can also be lots of fun. Using one’s imagination to create a story utilizes lots of aspects of ourselves that aren’t often used or expressed. A good story can take us on a playful adventure bringing us unexpected joy and inspiration.

Studies have shown that writing has many health benefits.

According to researcher and professor James Pennebaker, co-author of the book, “Opening Up by Writing it Down: How Expressive Writing Improves Health and Eases Emotional Pain,” writing about life’s challenges helps us heal physically and emotionally. He even goes so far as to say that writing can boost the immune system, helping those with illnesses including HIV/AIDS, asthma and arthritis.

Many other studies have been done that have shown similar results. Much of the research has focused on expressive or journal writing, which makes sense because real benefits come from moving pent-up stress and feelings from inside to outside. It’s kind of like decluttering the mind, so there is less unneeded junk lying around.

In her best-selling book, “The Artist’s Way,” author Julie Cameron asks her readers to write what she calls “morning pages” every morning. She defines them as follows:

“Morning Pages are three pages of longhand, stream of consciousness writing, done first thing in the morning. There is no wrong way to do Morning Pages – they are not high art. They are not even ‘writing.’ They are about anything and everything that crosses your mind – and they are for your eyes only. Morning Pages provoke, clarify, comfort, cajole, prioritize and synchronize the day at hand. Do not over-think Morning Pages: just put three pages of anything on the page…and then do three more pages tomorrow.”

This practice beautifully captures the essence of using writing as a way to know ourselves, to free ourselves and to express ourselves — not for some specific goal or agenda, but to simply increase our awareness and ideally, create some space for inner peace.

My favorite class that I teach is my six-week memoir class. In a very short time, I see students that have a strong desire to write, but no clue about how to start, then blossom into students in love with writing and confident that they can do it.

Many are also facing numerous challenges in their lives. My joy as a teacher comes from knowing that at the end of their time with me, they will have learned how the process of writing returns them to themselves, and if shared, connects them with others.

The highlight of the class comes when my students share their stories out loud. They realize that they’ve not only written something, but they’ve also managed to summon up their courage to share it. They’re elated to have taken this big leap, and once taken, they’re hooked and want more. It is then that I know that my work is done.

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The importance of talking about death

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Inevitably, when we are together, my adult son shepherds people my way introducing me as, “My Mom, who knows all about death.” We were just together in San Francisco at a tech startup conference and he did it again.

When I reflect on the myriad interactions I had that day, 20-somethings were the bulk of who I spoke to. Young people are wondering about death, too, and want — even need — to talk about it.

Perhaps death was on everyone’s minds a bit more because this event coincided with Dia de los Muertos (Day of the Dead) and Halloween festivities. Reimagine End-of-Life, now in its third year, was in full swing there. It’s a community-wide, weeklong event exploring life and death. Two of my hospice and palliative care heroes are on its Board: Ira Byok, MD, and BJ Miller, MD.

One youthful man at the conference engaged with me for over an hour, first in a fascinating philosophical discourse; then, more personally, describing himself as being in an “in-between state.” He had already made his fortune and was now seeking ways to give greater good.

He spoke of meditating frequently on death — finding it a superb practice that informs his living; yet, not being able to find others willing to talk about it. His eyes lit up when I spoke to him about having finished facilitating “A Year to Live” group earlier this year. He was ready to sign up!

The “A Year to Live” experience is magnificently summarized by Learn Out Loud:

“If you only had a year to live, what would you do? In his work with the dying, author Stephen Levine observed the radical changes people can make in the face of death — how they heal relationships, open up to love, act on plans put off for years, even quit dead-end jobs. Levine challenged himself to live an entire year as if it were his last — and in this revealing narrative he shares what he learned. Through a series of month-by-month practices anyone can do, and including special meditations and exercises, A Year to Live teaches a way to live every day of your life with vivid fullness.”

I also referred him to Death Café. Several of us organized one last year in a tiny Texan town wondering if anyone would even show up. It was packed!

People gathered together to eat brownies, drink tea and talk about death. Part of the purpose of Death Café is to help folks make the most of their (finite) lives. It’s a discussion session rather than a grief support or counseling group.

This year my Texas colleagues are offering Death Matters, focusing on family-directed funerals and green burials. Not only can we plan how we wish to die, we can prearrange how we’d like to be remembered and disposed of after we’re dead.

Another conference participant talked about his mother who has lived a fabulous life; yet, as she becomes more and more disabled, she now wants to die. She keeps telling him to take her to Oregon to end her life. Death with Dignity and Medical Aid in Dying are both available in California so they wouldn’t have to go far.

That’s not what I focused on, though. I mainly listened and offered empathy. I also stressed the importance of making sure pain, depression and other issues are well addressed; hospice and palliative care experts excel at relieving suffering and enhancing the quality of life.

Later, finally alone and quiet together, I asked my son, “If you only had one year left to live, would you do anything differently right now?” He said, “No.”

May we all be so fortunate. Let’s keep this conversation going.

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Travel2020: Qantas vies for operation of world’s longest nonstop flight

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After Qantas completed a recent test trip in advance of the launch of the world’s longest nonstop flight linking New York and Sydney, new attention has been given to the development of aircraft that can manage long distances comfortably and the management of passengers and crew to get through these lengthy flights without health concerns.

Qantas may soon get the title for running the world’s longest nonstop flight — a total of 10,200 miles — between New York and Sydney. The flight would edge out current frontrunner, Singapore Airlines, which offers an 18.5-hour nonstop flight between Newark Liberty and Singapore Changi that clocks in a 9,534 miles.

The flight, which took off from New York JFK, ran 19 hours and 16 minutes but carried only 50 passengers and no cargo. It used a Boeing 787-9 aircraft, but the carrier, with the full weight of passengers, cargo and fuel, was not designed for the job.

The new aircraft will enter normal commercial service with Qantas. For the long-haul job, however, the A350 and 777X are throwing their hats into the ring in testing that Qantas is calling “Project Sunrise.” In these tests, which will see another test run of the 10,563-mile nonstop London to Sydney route in November and then another JFK-SYD test in December, researchers are not only watching the performance of aircraft but also the health of pilots and passengers.

Tests ranged from monitoring pilot brain waves, melatonin levels and alertness through to exercise classes for passengers.

“This is a really significant first for aviation. Hopefully, it’s a preview of a regular service that will speed up how people travel from one side of the globe to the other,” said Qantas Group CEO Alan Joyce, following the completion of a JFK-SYD test last week.

“We know ultra-long flights pose some extra challenges but that’s been true every time technology has allowed us to fly further. The research we’re doing should give us better strategies for improving comfort and well-being along the way.”

Four pilots will be on rotation throughout the flight. Two additional pilots will be in the cabin, having flown the aircraft to New York. Flight will travel at 85% of the speed of sound, which is around 577 miles per hour. Cruising altitude will start at 36,000 feet for the first few hours. Then, as the aircraft weight reduces with fuel burn, the cruising altitude will increase to 40,000 feet.

The research is part of a greater vision by Qantas to launch commercial flights between the east coast of Australia (Sydney, Melbourne and Brisbane) and New York and London. The direct flights would save passengers up to four hours in total travel time and follow the successful 17-hour, 9,000-mile Perth-London route, which started in March 2018 and is the only nonstop link between Australia and Europe.

If all goes well, the new long-haul route is looking at a 2022-23 launch window.

Image: Qantas

Battling Distances and Jet Lag

Meanwhile, studies of passengers travelling on these long-haul Qantas flights has revealed the tricks travelers are currently using to help minimize jet lag.

The research is part of ongoing studies the airline is conducting with the University of Sydney’s Charles Perkins Centre (CPC) to identify scientifically backed methods to reduce fatigue. The findings will be used to inform future service and product design aimed at increasing health and comfort during travel.

The initial study findings showed 54% of people surveyed used ear plugs or noise cancelling headsets to help them sleep on long haul flights. Thirty-eight percent drank alcohol to aid their sky slumber and 10% used sleeping tablets.

Thirty-nine percent chose healthy food when they arrived at their destination to help with recovery. The study also revealed what passengers aren’t doing, with less than half of travelers (47%) surveyed not making a conscious effort to venture out into the sunshine upon arrival — a proven way to overcome jet lag.

Specialist sleep researcher Dr. Yu Sun Bin, who is part of the CPC team, said while most people actively try to reduce their jet lag, the study with Qantas shows they are not doing what is most effective.

“We know that going outdoors for sunlight at the destination is one of the most important strategies for syncing the body clock, but only 47% of passengers made the effort to do it,” she said. “Drinking more than a few glasses of alcohol will make jet lag worse. It might make us fall asleep faster but beyond a certain point, it also disrupts the quality of sleep and causes dehydration.”

The detailed in-flight studies were conducted across almost 500 passengers travelling on Qantas international flights longer than nine hours. The aim is to establish a baseline to help researchers and the national carrier design new in-flight strategies to promote in-flight well-being and reduce jet lag.

Among the new strategies already implemented for customers travelling on Qantas’ longest flight — Perth to London — are light therapy in the Perth Transit Lounge to help passenger acclimatize to the time zone, outdoor areas in both the lounge and terminal to provide exposure to natural light and a Wellbeing Studio in the lounge to encourage passengers to stretch.

Qantas is also working with sleep researchers from the Cooperative Research Centre for Alertness, Safety and Productivity (Alertness CRC) who will carry out research on pilots and cabin crew.

“Every time a new aircraft has allowed us to fly for longer, people naturally ask about the comfort factor. The fact that the longest flight on our network today, Perth to London, also has our highest customer satisfaction rating shows that you can design an ultra-long service that passengers enjoy. Plus it has the added benefit of getting you to your destination several hours faster, door to door,” said Joyce.

“Project Sunrise is pushing the boundaries even further. We know we need to think harder about crew and passenger well-being when you’re airborne for almost 20 hours, and that’s why this research is so important. A lot of what we’ll be doing is world-first. We’ll be fitting pilots with equipment to monitor their brain patterns when they’re on the flight deck and when they’re resting.”

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Infographic: Understanding marijuana laws, state-by-state

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Marijuana laws are changing across the country. On an almost daily basis, more states are discussing the legalization of marijuana, especially related to drug testing in the workplace.

Some states have fully legalized marijuana while other states have only legalized it medicinally. Do you know if your state allows employers to drug test for marijuana?

This infographic includes more information on the most lenient and strictest marijuana laws, state by state.

Infographic courtesy NowSourcing

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Enamel: The body part that lasts a lifetime and doesn’t wear out

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Tooth enamel is forever. That’s not quite as catchy as “Diamonds are forever,” but it turns out it’s just as true. Tooth enamel is the hardest substance in the human body. But, until recently, no one knew how it managed to last an entire lifetime.

The authors of a recent study concluded that enamel’s secret lies in the imperfect alignment of crystals.

Consider this. If you cut your skin or break a bone, the injured tissues will repair themselves. Our bodies are really good at recovering from injury.

Tooth enamel, however, cannot regenerate. And the oral cavity is a hostile environment. Every time you sit down to the dinner table, your tooth enamel is put under incredible stress. It also must endure extreme changes in both pH and temperature. It’s a lot to ask.

But despite all these challenges, the tooth enamel that we developed as a child stays with us for our entire lives. How?

The Secret Life of Tooth Enamel

With help from researchers at the Massachusetts Institute of Technology (MIT) and the University of Pittsburgh, the research team, led by Dr. Pupa Gilbert, took a close and detailed look at the structure of tooth enamel.

The team of scientists published the results of their study in the journal Nature Communications. Here’s the gist of what they found:

Enamel is made up of tiny enamel rods, which consist of hydroxyapatite crystals. These long, thin enamel rods are microscopic. By using advanced imaging technology, the team could see how individual crystals in tooth enamel are aligned.

The technique, which Dr. Gilbert developed, is called polarization-dependent imaging contrast (PIC) mapping. Before PIC mapping, it was impossible to study enamel with this level of detail.

Why Does it Matter Which Way the Crystals are Oriented?

To test whether variations in crystal alignment influences the way tooth enamel responds to stress, the team recruited help from the engineering department at MIT. Using a computer model, they simulated the forces that the crystals would experience when a person chews.

Inside the model, they placed two blocks of crystals next to each other so that they touched along one edge. The crystals within each of the two blocks were aligned, but where they came in contact with the other block, they met at an angle.

Over the course of several tests, the scientists changed the angle at which the two blocks of crystals met. If the researchers perfectly aligned the two blocks at the interface where they met, a crack would appear when they applied pressure.

However, when the crystals were just slightly misaligned, the interface deflected the crack and prevented it from spreading.

“Now we know that cracks are deflected at the nanoscale and, thus, can’t propagate very far,” said Dr. Gilbert. “That’s the reason our teeth can last a lifetime without being replaced.”

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Bummed, burnt or just plain beat?

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Lately, my life’s been feeling like an endurance contest — deadline after deadline with piles upon piles of work. I’ve been away from home for months working on a project that’s now nearing completion.

The weather hasn’t helped — it’s been a rainy, cold summer in the mountains. And, I’m temporarily living with an asthmatic roommate who needs the air-conditioning on full bore to counter the humidity just so she can breathe. It’s winter instead of warm! Almost unbearable for this hot summer-loving gal.

It’s got me pondering: am I bummed, burnt or just plain beat?

When we’re wallowing in funky feelings, it can help to pause, determine what we are feeling and needing and take appropriate action. To be clear, I’m talking of “normal” mood fluctuations in this article; not severe depression or suicidal ideation. These are mental health emergencies and need immediate attention (National Suicide Prevention Lifeline: 1-800-273-8255).

As much as we think pushing on even harder may remedy our discomfort, stopping may be the best first thing to do. We can give ourselves “permission to pause.”

In silence and solitude, perhaps in a resting pose for 20 minutes or standing in an empty stairwell at work for only a few moments, we offer ourselves space to relax, renew and regain perspective.


By taking that break and granting ourselves a breather, it may become obvious that we are simply physically exhausted. Then it’s up to us to figure out how we can rest more, sleep better and schedule differently.

This is not necessarily an easy fix. Yet, I now prioritize sleep over every other health behavior habit. If there’s seemingly no time for anything else, I at least try to get enough rest.


By recognizing I lean towards overfunctioning in an effort to ensure things get done and done well, this tendency of mine allows underfunctioners to continue to operate suboptimally. Top that off with me being more of a giver than a taker, and it’s no wonder I can feel like Sisyphus. Burnt out. Toasted.

When such is the case, I need to somehow shift my modus operandi. Become more comfortable with “good enough”? Communicate more clearly regarding expectations, timing and deliverables? Pick my battles? Be more careful with whom I associate?

It’s vital to critically assess what changes we need to make. Otherwise, we risk staying stuck on repeat. Think Bill Murray in the movie “Groundhog Day.”


We all can feel a bit blue on occasion. Could it be hormonal or that we’ve ignored our self-care regimen (healthy eating, regular exercise, meditation, social connecting, laughter, etc.) for too long? Might it be the gray skies? Seasonal affective disorder (SAD) impacts more than 10 million Americans.

Are we being bullied in some way or navigating an unfamiliar environment without strong support? Perhaps we’re swirling in uncertainty and seem a tad lost? It can be hard in the thick of it to find our way out.

Bottom line, for me, coming back to center begins with pausing and sorting through my feelings. If I am bummed, burnt or beat, what is it I need?

Then, I attend to what can I do right now. Refocus on my mission/purpose AND envision/affirm that I am already living it. Remember what has helped me in the past and take one of those (no matter how small) actions towards my goal. You can, too.

From the Yoga Sutras, 1-21, “The more intense the faith and the effort, the closer the goal.” — T.K.V. Desikachar

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Updates on treatment for IT band syndrome

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I recently listened to a great little podcast on IT band syndrome from BMJ Talk Medicine, entitled “Mythbusting iliotibial band pain with Dr Rich Willy – it’s not friction.” I’d definitely recommend giving it a listen yourself, as there are so many great points to take away.

I will do my best to summarize it in this article.


IT band syndrome is the most common cause of lateral knee pain in runners and accounts for up to 14% of all running injuries. It is generally more common in males than females.

Pain occurs on knee flexion from 25-35 degrees, especially as the hip is extending. This occurs most frequently in downhill running or descending stairs. Pain is usually described as sharp or stabbing and gets worse with continued activity, leading the runner to cease altogether.

There has been a huge misconception over the years about the cause of this lateral knee pain condition. It was in fact once known as “Iliotibial Band Friction Syndrome.” How wrong could we be!

Previous thinking was that the source of the pain was the repeated “flicking” of the IT band over the lateral epicondyle causing friction and resultant irritation, inflammation and tissue damage to the underside of the distal band. We now know this is not the case.

The IT band is pretty well tethered to the distal femur and the patella, so there is no “flicking” motion. Instead, the issue is believed to be compression.

The compression at the lateral knee is of the highly innervated adipose tissue which lies between the IT band and the lateral femoral condyle. As the knee flexes past 30 degrees, peak tension is reached in the band which results in a compression of these tissues.

IT band pain is, as all running injuries are, a result of a training load error. Usually, a runner has had a rapid increase in running distance or has been running more downhill or on trails than previously accustomed to. Other factors which may increase the likelihood of developing this condition are:

  • A narrow step width – which increases load on the IT band and so increases compression
  • Increased hip abduction levels – also loads the ITB excessively


There are two “special tests” that have been used consistently for decades to assess for IT band syndrome. However, the use of both of these tests now lie in question.

Ober’s test is designed to assess the tension in the IT band, but we have now established that the IT band is not an elastic structure and so cannot be tight and certainly cannot be stretched. In addition to this, a recent study using cadavers demonstrated that the results of an Ober’s test were not affected once the IT band was cut!

The most likely causes of a positive Ober’s test are tension in the hip capsule or the gluteus medius and minimus muscles.

Noble’s compression test has also been questioned of late. Whilst theoretically it is more solid than Ober’s test, its sensitivity comes under fire as it is prone to false negative results.

The best way to “diagnose” cases of IT band syndrome are via patient history and by ruling out other possible causes of the pain.

Thankfully there are few other structures in this region which could be symptomatic. But it is important to also consider the possibility of pain being referred to the lateral knee from elsewhere. The most likely differential diagnoses are:

  • Patellofemoral knee pain
  • Gluteal tendinopathy
  • Lumbar spine referral
  • Distal femoral stress fractures


Dr. Willy divides the rehab protocol into two phases. Phase 1 is the pain dominant phase where pain is still a feature on a stair descent. The aim of this phase is to reduce pain but continue to move. A therapist may use whatever tools are at their disposal to help with pain reduction.

One of the most important things which a therapist should encourage a client to do is to keep moving. Runners will often instinctively stop running and cease other forms of exercise due to their pain. This, of course, leads to a reduction in symptoms.

However, what this also leads to is a loss in load capacity. And so, when the runner decides to return to running, they have an even lower tolerance and the pain returns even quicker. Instead, it is recommended that the runner continue to exercise, albeit within their pain limits.

This can be achieved in different ways depending on the severity of the individual’s pain. Some may be able to continue to run, using either shorter distances or flat road routes (if a trail runner). For others, a treadmill workout can be utilized, either jogging up a gentle incline or hill walking, since that tends to place less stress on the ITB.

If neither of these are comfortable, then a stationary bike can be used to maintain cardiovascular fitness. Continuing to exercise through injury is not only good for maintaining load tolerance but also for the runner’s mental health.

As well as the above, exercises to strengthen posterolateral hip musculature can also be started. This is often inhibited in line with IT band injury.

In addition, an exercise Dr. Willy describes as a Thomas Test exercise (due to the position in which it is performed) can be used. This involves flexing and extending the knee in a position of non-weight bearing hip extension. A progression from this in a partial weight-bearing position is the single leg bridge.

The Load Dominant phase (incorporating stages 2-5) of rehab can be initiated once stair descent is pain free. Stage 2 begins with heavy, slow resistance training and a continuation of uphill treadmill walking (or similar as described above). Split squat progressions are recommended here as it eccentrically and concentrically loads the relevant muscles and the ITB.

In this case, the injured leg is behind to be in a position of extension as the knee flexes and extends. As much weight as possible should be shifted through the rear leg to load the hip flexors. After the end of the set the injured leg is switched to the front with a concurrent shift in weight to load the hip extensors. Progressions include increasing the height of the rear leg and adding weight.

Stage 3 sees the incorporation of plyometrics to address the energy storage and release demands of the ITB without actually running. Lateral skaters are a good choice due to the loads applied to the posterolateral hip musculature. This can be progressed by adding a resistance band around the waist.

Stage 4 is the initiation of a return to running program. Treadmill running is highly recommended for this program as incline can be controlled, and the session can be stopped immediately if any symptoms arise.

Dr. Willy’s program suggests three runs per week over a four-week period. Each session begins with a five-minute warm up and ends with a four-minute cool down.

It starts at intervals of one minute with a two-minute walk repeated seven times. This increases over the first two weeks to three minutes, then five, eight and then 10 minutes running, initially with two minutes rest and progressing to one by session 4. Reps also decrease from seven for the first four sessions to five, and then four, by session 6.

Over week three, the intervals continue although with longer runs of 13, 15 and 20 minutes repeated three times in sessions 7 and 8 and twice in session 9. A one-minute walk is suggested between reps.

Week four starts with a final interval session of two 22.5-minute runs with a one-minute walk between them. Sessions 11 and 12 are continuous runs of 35 minutes and 45 minutes, respectively.


As you can see, the knowledge we have surrounding the cause, assessment and rehabilitation of IT band syndrome has progressed considerably in the last few years. What was once thought to be a friction injury is now believed to be due to compression.

The way we assess the injury has changed with injury specific testing now playing less of a vital role in “diagnosis.” And rehabilitation has also changed, with the runner no longer advised to rest completely and the focus of rehab moving away from stretching and foam rolling the IT band and strengthening the hip abductors.

We are now advised to keep the athlete moving and loading the involved structures, then steadily increasing the load capacity of the IT band and lateral hip musculature using heavy resistance training, plyometrics and a controlled, gradual return to running.

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