Sleep is the most important cornerstone for optimal health. Without the foundation of a healthy night of sleep, all other health interventions, such as nutrition and exercise, will fall short. Our memory, cognition, and ability to learn new tasks all depend on healthy sleep. ‘Sleep hygiene’ refers to the quality and quantity of sleep you are getting each night. I recommend my patients get 7 to 9 hours of sleep each night, depending on activity level, as well as season. During the winter months, you should opt for close to 9 hours of sleep. During the summer months, 7 hours of sleep may be adequate since days are longer and the nights are shorter. Additionally, more sleep is needed the more active you are as it is important to allow your body adequate time to recover after difficult workouts. When helping patients improve their sleep hygiene, there are three interventions I use most frequently, outlined below. 

 

First morning sunshine

Going outside first thing in the morning with as much skin exposed as possible stimulates the body’s release of the hormone cortisol. Cortisol is known as our ‘awake hormone’ and gives us the energy to start our day. Cortisol naturally starts to decline around lunch time, and by the evening levels should be low as it starts to get dark and we prepare for sleep. Cortisol becomes problematic when levels remain high in the afternoon. When cortisol levels remain elevated, it becomes a stress hormone and causes us to crave sugary and fatty foods. Additionally, high levels of our ‘awake hormone’ in the evening work against us falling and staying asleep. The best way to ensure cortisol levels are low in the evening is to secrete as much as possible in the morning. Sunshine stimulates cortisol secretion, meaning it is optimal to get plenty of sunshine in the first half of the day.

Turn off electronics at least 90 minutes before bed

Blue light exposure tricks your brain into thinking it is still light outside, decreasing the release of your sleep hormone, melatonin. I recommend turning off all electronics 90 minutes before bedtime. Not only does blue light manipulate our brain into thinking it’s light outside, but often the things we are looking at on our screens, such as social media feeds or work emails, stimulate our brain in a way making sleep difficult. Scrolling through your social media feed causes a release of the neurotransmitter, dopamine, which plays a role in the brain’s reward system. When dopamine is released, the brain is stimulated and there are feelings of pleasure. While satisfying at the moment, excessive release of dopamine prior to sleeping will make it harder to fall asleep and stay asleep. Therefore, put those phones away before bed time!

Read fiction before bed

Reading before bed is one of the best ways to prepare our brains for sleep. Giving the brain a singular point of focus, such as a captivating fictional story, will allow you to stop thinking about the stresses of work and life and prepare your brain for sleep. With this in mind, reading materials related to work or checking emails will continue to stimulate our minds and keep us thinking about the day. Consequently, I recommend reading fiction. It is a better way to take your mind away from the pressures of the day. If you are a fan of historical fiction like myself, check out Ken Follet’s new novel, Pillars of the Earth.

 

Post written by Dr. Riley Kulm, DC.  Check out his bio here

Many people experience popping in their hips. Most patients come to the clinic complaining of back or knee pain, and a popping hip may be a secondary complaint. Although typically not a significant pain generator, popping in the hip is a sign of an underlying dysfunction in the hip needing to be addressed. If the popping in the hip is not attended to, more serious orthopedic issues may arise down the road.  

Causes

There are three main causes of a popping hip – external, internal, and intra-articular. External is most frequent and refers to the iliotibial (IT) band snapping over the greater trochanter of the femur. Internal is also common and refers to the iliopsoas (hip flexor) tendon snapping over a bony prominence on the pelvis or at the lesser trochanter of the femur. Intra-articular is least common and refers to a floating loose body within the joint such as a torn labrum. External and internal variations are often due to gradual onset, whereas an intra-articular loose body is often due to trauma. There is a higher incidence of hip popping in females, especially those who perform sports requiring repetitive flexion and extension of the hip such as gymnastics, dance, soccer, and running.  

How to fix it 

Popping in the hip is often related to a stability issue in the hip or the core. To address this, work to improve your hip stability in all three planes of motion. Train slowly, controlling the motion to avoid the pop. Train only through ranges of motion where you can avoid the pop, and gradually increase the range of motion as your stability improves. The external hip pop (ITB over greater trochanter) is often related to poor hip stability in the frontal plane (abduction/adduction), and increasing strength of muscles such as the gluteus medius will be helpful in decreasing the external hip pop. The internal hip pop relates to the iliopsoas muscle. The iliopsoas muscle has shared attachments with the diaphragm. If the diaphragm is not providing a solid anchor point for the iliopsoas muscle, function of the hip flexor will be impaired increasing the likelihood of an internal hip pop. For this, focus working on diaphragmatic breathing to create better stability patterns in your core. Intra-articular hip popping requires an in-depth examination to determine which structures may be injured and to determine the best course of care.

To know exactly which exercises and treatments are best for you, it is important to seek out a therapist who understands hip biomechanics and can help you address the specific stability limitations causing the pop. Whatever the cause, popping in the hip should not be ignored. Even if caused by mild muscle imbalance, a popping hip can worsen over time if not addressed early.  

Post written by Dr. Riley Kulm.  Check out his bio here.

Goal setting has been touted as the most effective way to achieve success in life.  We’ve been told to write them down, stick them to our refrigerator door and even to write them on our bathroom mirror.  You’ve heard that goals should be SMART – specific, measurable, attainable, realistic, and time oriented.  I even wrote a blog post on effective goal setting.  Recently, I’ve moved away from goal setting with both myself and my patients, focusing instead on daily habit formation and the implementation of routines that set you up for success now and in the future.  The inspiration for this change came after listening to the Atomic Habits audiobook by James Clear.  Clear argues that goals are easily procrastinated upon, and can often be too daunting to even get started in the right direction.  By focusing on daily habits and routines, you will improve yourself each day, setting yourself up to achieve success and ultimately to conquer even the loftiest of goals. 

The problem with goal setting

One of the main problems I see with goal setting is that time oriented goals are susceptible to procrastination.  If my goal is to lose 20 lbs. by the end of the year, it’s very easy to let myself wait until 6 or even 3 months are left in the year to start working towards the goal.  Why start now when I have an entire year to accomplish my goal?  A goal that is set out over a year may lose steam after a couple of months, which is what I commonly see with patients looking to make health changes at the beginning of the New Year.  Everyone knows that you will see more people out walking in your neighborhood or exercising at the gym in January, February and March only for it to taper off as the year progresses.  Rather than setting a time oriented goal, instead pick daily habits that will incrementally help you achieve whatever you envision for yourself.

Define your ideal self

Before completely throwing away your list of goals, make sure you have a clear idea in your mind of what you want for yourself.  Envision your ideal job, body composition, and skill set.  Where do you see yourself in 5 or 10 years?  Where do you want to be financially?  How do you define your ideal self?  Once you’ve established these parameters, you are better suited to implementing daily habits that align with this vision.  If you envision yourself as having a fit and healthy body, implementing a daily habit that helps you save money or be more organized doesn’t necessarily bring you closer to your vision.  Instead, for weight loss, pick habits such as a consistent gym routine, a healthy breakfast at the same time each morning, or reading a book before bed to help promote optimal sleep and recovery.  

Do this instead

As stated previously, the alternative to goal setting is the implementation of daily habits and routines.  Habit formation is beneficial because it focuses on daily growth.  If we aim to grow and improve ourselves little by little each day, the culmination of consistent work will be incredible in the long term.  We may not notice the improvements on a day to day, micro level, however, if we step back after a year and look at the macro improvement the results are substantial.  True growth and change does not come with drastic lifestyle changes such as an extreme 10 day fast or juice cleanse but rather with small steps each day in the right direction.  

 

Next, I show you how to reframe your goals into daily habit formation.

Goal #1: ‘I want to lose 20 lbs. before summer’

Habit: I will work to implement a habit where I do 3 sets x 15 push-ups in the morning followed by drinking a 16 ounce glass of water.  

Habit: Weather permitting, I will go outside in the morning for a 10 minute walk in the sunshine before work.

(First morning exercise and sunshine stimulates cortisol release and helps to regulate our circadian rhythm.  Sufficient cortisol release in the AM will decrease cravings for fried and sugary foods in the evening which occurs if cortisol levels remain high.)

Habit: I will place a pan, plate, and eating utensils out in my kitchen before I go to bed each night.  Already having the pan on the stove increases the likelihood that I will cook a homemade breakfast and adopt a more consistent eating schedule that includes breakfast each day.

 

Goal #2: ‘I want to increase my sales at work by 15% this year’

Habit: I will wake up at the same time every day to ensure a consistent sleep schedule and to increase my productivity at work. 

Habit: I will call 2 potential new clients each day prior to leaving for lunch.

Habit: I will send a thank you card to 2 existing clients each week thanking them for their business.  

For work related goals, consider setting up a daily, weekly, and monthly checklist in a binder or whiteboard to track progress of tasks to be completed.  Make these tasks part of your habits at work and you will see your productivity increase.

 

Goal #3: ‘I want to improve my relationship with my parents’ 

Habit: Each morning I will practice gratitude by writing down 3 things in my life that I am grateful as part of a journaling routine. 

Habit: I will call one of my parents every Friday after work to check in.

 

Goal #4: ‘I want to be more organized’

Habit: Each morning I will make my bed as the first task to be completed in my day.  Making your bed each morning sets yourself up for success throughout the rest of your day and helps you to establish a task completion mindset.

Habit: Each morning when my coffee is brewing I will take 5 minutes to tidy up my living room so I leave for work with an organized living space. 

 

Goal #5: ‘I want to get better sleep this year’

Habit: I will develop a habit where I turn off all electronics at least 1 hour before bed time.  Blue light exposure stimulates cortisol release at the wrong time of day and will make falling and staying asleep more difficult. 

Habit: Prior to going to bed I will write out tomorrow’s ‘To Do’ list in a journal that I keep by my night stand.  Getting tomorrow’s tasks written down will give you peace of mind and allow your brain to turn off before going to sleep.

Habit: I will read for 20 minutes before bed.  Reading, especially fiction, gives your brain a singular point of focus, and helps you get your mind off of the day’s stresses.  

 

I hope this article gives you valuable insight into daily habit formation and the power it can have.  I finish with a quote from W.H. Auden – ‘Routine, in an intelligent man (or woman), is a sign of ambition.’

Post written by Dr. Riley Kulm, DC.  Check out his bio here

My Least Favorite Exercise Part 2 – The Quadricep Knee Extension

Continuing with the theme of our last blog post My Least Favorite Exercise – The Clamshell, I’d like to highlight another popular exercise that should be avoided at all costs.  This week, my least favorite exercise is the quadricep knee extension exercise.  I regularly see people at the gym using the quadricep knee extension machine, and I truly worry about their orthopedic health when I’m watching them.  To perform the machine based knee extension exercise, people sit in a chair with a pad on their shins.  Next, they kick their legs straight against the resistance of the machine, contracting the quadriceps muscle.  People perform this exercise because they want to improve the strength and size of their quadriceps muscle – some may even think it’s healthy for their knees; however, the biomechanical consequences of this exercise can be highly detrimental to the health of your knees.  

Open vs. closed chain exercises

The machine based knee extension is a single joint, open chain exercise.  Open chain exercises refer to movements where the distal extremity (hand or foot) is not fixed and is freely moving in space with or without external resistance.  Examples of open chain exercises include a bicep curl, hamstring leg curl, and shoulder fly.  Open chain exercises cause an isolated muscle contraction over a single joint of movement, which some believe to be beneficial in the early stages of an injury rehabilitation program.  Open chain exercises are in contrast to ‘closed chain exercises’ where the hand or foot is fixed to the floor.  Examples of closed chain exercises include the squat, deadlift, or push up.  Closed chain exercises involve multiple muscle groups and require coordinated muscle contractions to complete the compound (multi-joint) movement.  

The forces imparted on the joints differ between open and closed chain exercises.  For open chain exercises (quadricep knee extension) the force imparted by the weighted resistance is transmitted back up the leg and into the knee joint.  This force can cause compression in the knee joint, putting increased pressure on the meniscus, ACL, PCL, and patella-femoral joint.  In contrast, with closed chain exercises (deadlift) the force imparted by the external resistance is transmitted into the ground.  For instance, in a deadlift, the force from the load is pressed through the feet into the ground rather than up the body into the knees and hips.  

The second problem with the exercise is that it is a repetitive concentric exercise.  Remember from my last post, concentric muscle contractions occur when the muscle is shortening and repetitive contractions over time can cause a shortening and tightening of the muscle fibers even while at rest.  Ignoring the eccentric (muscle lengthening) component of a muscle’s function can be detrimental to movement patterns and ultimately put you at an increased risk of injury.  Additionally, a short and tight quadriceps muscle can pull upwards on the patella, altering the mechanics of the patella-femoral joint and cause conditions such as patellar tendinitis which is also known as Jumper’s knee.  

What to do instead – deadlifts, squats, single leg squats, reverse lunges

If you want to strengthen your quads and the rest of the muscles in your leg, the best exercises are closed chain, compound movements that integrate the feet, hips, and core to create a functional and stable lower body.  My favorites are deadlifts and lunges because you can add a lot of weight without placing much force on the knee joint (when performed properly). 

As I said previously, closed chain exercises like the squat and lunge transmit force down into the ground, which is why they are popular for building speed and explosiveness in strength and conditioning programs. 

Post written by Dr. Riley Kulm, DC.  

Check out his bio here.

The Importance of a Morning Routine

If I were to pick one lifestyle intervention for anyone looking to enhance their energy levels, increase productivity, and improve relationships with friends and family, a consistent morning routine would be my top choice.  An effective morning routine will set you up for success throughout the rest of your day. If you start the day by completing small, productive tasks you will establish a feeling of accomplishment immediately after waking up. By finishing these tasks at the beginning of the day, other, more daunting projects related to your work or personal life will seem less intimidating. You will establish a task completion mindset first thing in the morning which will increase productivity throughout the day. Lastly, you will practice gratitude in your morning routine, which will help you appreciate your life and the people in it.  

The five tasks you should complete every morning are: 

  1. Make your bed
  2. Drink a glass of cold water
  3. Five minutes of light exercise
  4. Meditate
  5. Journal

Next, let’s talk about the specifics of each task in your morning routine. 

1. Make your bed

I recommend watching this link of a speech by US Navy Seal Admiral William McRaven titled, ‘If You Want to Change the World, Start Off by Making Your Bed.’ McRaven stresses the importance of completing one small task (making your bed) in the morning, to set you up for success in completing other, more difficult tasks throughout your day. He also discusses how learning to do the small things in life correctly allows you to complete the big things in life correctly. Making your bed does not need to be a lengthy ordeal of tucking in 3 layers of sheets and organizing 12 throw pillows, but rather make your bed presentable enough to give you peace of mind that you completed your first task of the day successfully.  

2. Drink a glass of cold water

You are dehydrated when you wake up and your body is thirsty. Do not drink coffee right away as coffee is a diuretic and will cause you to expel out more fluids than you are taking in. Instead of coffee, start your day with 16-24 ounces of cold water immediately after waking up. By giving your body the hydration it needs first thing in the morning you will notice more stable and consistent energy levels throughout the day.  

3. Perform 5 minutes of light exercise

To assist in waking your body up, perform 5 minutes of light exercise first thing in the morning.  Your movement flow may include stretching, body weight strength exercises, breathing, or yoga. This is not meant to exhaust you, but rather to stimulate your body’s awake hormone, cortisol.  Cortisol gets a bad rap as the body’s stress hormone, but this is not entirely true. Cortisol is normally elevated in the morning and helps to wake up the body and mind for the day ahead. Cortisol becomes problematic when it remains high into the afternoon and evening due to chronic stress, poor nutrition, and excessive exposure to blue light emitting screens. Two of the strongest stimulants for proper cortisol release in the morning are direct sunlight exposure and exercise. By performing light exercise in the morning, you are ensuring an adequate cortisol release in the morning. My 5 minutes of light exercise includes 3 sets each of push-ups and bodyweight squats. In the past I’ve incorporated other movements such as planks, wall-sits, hip stretching, and kettlebell deadlifts. I find that these movements are enough to get my blood and heart pumping without tiring myself out for workouts I have planned later in the day. 

4. Meditate

Perhaps the most important yet difficult task in a successful morning routine is meditation.  Meditation is a mindfulness technique that teaches the individual how to be present in the current moment. Headspace defines meditation as the “intention to be present in the here and now, fully engaged in whatever is happening, free from distraction or judgement, with a soft and open mind.” Guided meditations on apps such as Headspace or Calm use a form of meditation called ‘Vipassana’ which aims to help the individual gain self awareness of body and mind.  

Guided meditations often start with deep breathing exercises utilizing slow, controlled, nasal breaths. Next, the guided meditation will ask you to mentally scan different parts of your body, noticing areas that are relaxed as well as areas that are tense.  Finally, the guided meditation may ask you to count your breaths, with the ultimate goal of focusing on nothing besides the breath. Guided meditations typically end by completely letting go of your focus, allowing your mind to run wild, before bringing your intention back to the breath for a final 2-3 focused breaths.  Many people notice an immediate change in their day to day lives when starting a daily meditation practice. People who meditate are more calm throughout the day, their interpersonal communication is improved, their breathing patterns are better, and they are less agitated by the stress of daily life. Taking just 5-10 minutes to perform a guided meditation first thing in the morning may be the best way to set yourself up for success throughout the rest of the day. 

5. Journal

Another beneficial task to complete every morning is a short journal entry.  You can get creative with this one, but there are two key pieces that are essential. First, use your journaling as a way to reconnect with your ‘why’.  If you read my last blog post Effective Goal Setting 2020, you know the first step towards creating your goals is to establish your why. Your why is your purpose, cause or belief – it is the reason you get out of bed in the morning. Reconnecting with your why using journaling may include writing a quote everyday that reminds you of your passion in life, physically writing out your most important goal, or listing out positive qualities about yourself and the person you want to become. Second, develop a practice of gratitude in your morning journaling. For me, I list three things I’m grateful for every morning. Some days it reads ‘a loving and supportive family,’ or ‘a career that challenges me mentally and physically,’ and some days it’s as simple as ‘a healthy breakfast to fuel my body and mind throughout the day.’  Writing out what you are grateful for first thing in the morning will remind you how good your life truly is and place you in a positive, optimistic mindset.

The Outcome

The goal is to complete all five of these tasks every morning.  You will be busy some mornings and may only have time to complete two or three of these tasks.  For me, I notice that the quality of my day directly correlates to how many of the morning tasks I complete. The more I successfully complete, the better my day tends to be.  When you establish a consistent morning routine you will notice improvements in your energy levels, productivity, interactions with other people, sleep quality, and overall happiness with your life. Attached is the template for the morning routine I use every day. Enjoy!

Post written by Dr. Riley Kulm, DC. Check out his bio here.