In response to “The 5 S’s for Soothing Babies”:
Dr. Harvey Karp is a pediatrician and his 5 “S” method to sooth a baby is simple yet very logical to me. As a new dad-to-be, I have read a lot of research on how to save my sleep (you probably are not surprised I do extensive research on any health-related topic 😉), and I found Dr. Karp’s explanation to be the most useful.
If you are a new parent, or parent to be, I recommend you try Dr. Karp’s techniques!
If you are not a parent, I think it’s still a good read to appreciate how amazing birth is, as well as the processes we learn and adapt as we grow.
“The 5 S’s for Soothing Babies”
All babies cry—and that’s a good thing. How else would we know if our helpless infants were cold, hungry, lonely or in pain? Traditionally, moms and dads have been encouraged to just keep their chins up and wait until the baby grows out of it. But, that’s easier said than done!
Crying Takes a Toll on Babies AND Parents
Typically, babies get increasingly irritable around sundown and can continue for hours. No wonder, parents get concerned, frustrated and very, very tired.
Exhaustion triggered by persistent crying creates huge stress in families, including marital conflict, maternal and paternal depression and obesity. It causes car crashes and other accidents — people make all kinds of poor decisions when stressed and overtired. It also puts babies in danger when a wiped-out parent falls asleep with a baby in his arms, on an unsafe couch or a bed, which increases the risks for SIDs and infant suffocation. And believe it or not, the national costs of complications of infant crying and parental exhaustion total well over $1 billion dollars a year!
My ‘Aha!’ Moment on Calming Babies
Most doctors say that colic (crying for more than 3 hours a day) is a mystery. That’s what I used to say, too, until 1981 when I learned about the !Kung San of the Kalahari Desert, whose mothers usually calm their fussy babies in under a minute! The more I thought about it, the more I realized we could be as successful as !Kung parents, but only if we adopt 2 new ideas:
- All babies are born 3 months early. Newborn horses can run within an hour of birth but not our mushy little babies. A virtual 4th trimester of womb sensations (soft touch, jiggly motion, snug holding, etc.) may just be what they need.
- The rhythms experienced inside the womb trigger a reflex that keeps babies relaxed. This calming reflex is a virtual off-switch for crying and on-switch for sleep.
The !Kung mothers are master baby calmers because they imitate the womb by carrying and rocking their babies 24/7 and feeding them 3 times hour. American parents have long turned to similar womb-mimicking tricks, whether they’ve realized it or not, like going for car rides and turning on the vacuum cleaner to soothe their babies. In fact, smart parents around the world have invented all kinds of variations on the calming womb-like sensations I’ve dubbed the “5 S’s:” Swaddle, Side-Stomach Position, Shush, Swing and Suck.
The 1st S: Swaddle
Swaddling recreates the snug packaging inside the womb and is the cornerstone of calming. It decreases startling and increases sleep. And, wrapped babies respond faster to the other 4 S’s and stay soothed longer because their arms can’t wriggle around. To swaddle correctly, wrap arms snug – straight at the side – but let the hips be loose and flexed. Use a large square blanket, but don’t overheat, cover your baby’s head or allow unravelling. Note: Babies shouldn’t be swaddled all day, just during fussing and sleep.
The 2nd S: Side or Stomach Position
The back is the only safe position for sleeping but it’s the worst position for calming fussiness. This “S” can be activated by holding a baby on her side, on her stomach or over your shoulder. You’ll see your baby mellow in no time.
The 3rd S: Shush
Contrary to myth, babies don’t need total silence to sleep. In the womb the sound of the blood flow is a shush louder than a vacuum cleaner! But, not all white noise is created equal. Hissy fans and ocean sounds often fail because they lack the womb’s rumbly quality. The best way to imitate these magic sounds is white noise. Happiest Baby’s CD / Mp3 has 6 specially engineered sounds to calm crying and boost sleep.
The 4th S: Swing
Life in the womb is very jiggly. Imagine your baby bopping around inside you when you jaunt down the stairs! While slow rocking is fine for keeping quiet babies calm, you need to use fast, tiny motions to soothe a crying infant mid-squawk. My patients call this movement the “Jell-O head Jiggle.” To do it, always support the head/neck, keep your motions small; and move no more than 1 inch back and forth. I really advise watching the DVD to make sure you get it right. (For the safety of your infant, never, ever shake your baby in anger or frustration.)
The 5th S: Suck
Sucking is “the icing on the cake” of calming. Many fussy babies relax into a deep tranquility when they suck. Many babies calm easier with a pacifier.
The 5 S’s Take PRACTICE to Perfect
The 5 S’s technique only works when done exactly right. The calming reflex is just like the knee reflex: Hit one inch too high or low and you’ll get no response, but hit the knee exactly right and, presto! If your little one doesn’t soothe with the S’s, watch the Happiest Baby DVD / Streaming Video again to get it down pat. Or, check with your doctor to make sure illness isn’t preventing calming.
How Do the 5 S’s Relate to Another Favorite S – Sleep?
The keys to good sleep are swaddling and white noise. In another “Aha!” moment, I realized technology could assist parents with their 4th trimester duties. So Happiest Baby invented SNOO, the world’s 1st smart sleeper—an innovative baby bed based on the 5 S’s that helps calm babies and ease them into sleep. Parents especially love when it quickly calms babies for those 2 a.m. wakings!
Karp, Harvey. “The 5 S’s for Soothing Babies.” HappiestBaby.com.
Runners’ Knee Pain Series #2
You’ve got some nerve (pain)!
You’ve got nerves, lots of them, indeed!
Hello again, runners! This is the final installment of the runners’ knee pain series. This will be be an interesting topic to explore, as I feel not many people think that nerve pain can mimic and present as knee pain. Let’s go right into it…
In the picture below, you will notice the saphenous nerve covers almost the whole length of the inner leg.
The nerve is not actually purple!
So why should we care about this nerve? Because it can cause a lot of knee pain in runners!! I always remind my patients this:
“No Nerve, No Pain!”
Some quick human physiology 101:
As you can see, we have nerves everywhere, and the main function of the nerves are to carry signals from our brain to the appropriate tissues.
The nerves travel through many little or big “tunnels” to reach their destination. For our purposes, we are talking about the muscles around the knee.
The nerve can get stretched out or be compressed for a variety of reasons. The most common reason, and the one we want to focus on today, is how the disc at the low back can push on the nerve and cause a whole cascade of pain down its course (which are your legs!).
Sciatica….. sounds scarier than what it actually is!
Stay tuned for next week’s blog on you can alleviate that nagging knee pain!
In response to “How Pregnancy Changes a Runner’s Body”:
My favorite line in this article: “Relying on that gym standby, crunches, won’t do the trick, though…” So true!! And we know that neither will the follow up suggestion of pulling the belly button “up and in.” Modern medicine has debunked the whole idea of sucking in your stomach to contract your abs. That’s just not how abdominal muscles work! Particularly in postpartum, there are many exercises that will do you better than either of those. Planks are the “go to” but, as mentioned in the article, women tend to have a forward tilting pelvis during and after pregnancy that can be exaggerated by planks. Instead, try Paloff Presses, rolling exercises, and lunge variations. Skip those crunches and sit ups… AND feel better!
Check out this video I made with another exercise to do instead of crunches >>
“Help Your Child Nap Well at Any Age”
Follow these guidelines to transition from two naps to one to quiet time as your child gets older.
Parents often wonder when their baby will settle into a “perfect” nap schedule. This can feel quite elusive when you have a newborn, but knowing what to expect based on your baby’s age and development can help.
It’s important to set realistic expectations and to understand nap basics and how to transition your child from two naps to one and then to a quiet time. So I advise parents to follow some guidelines based upon a child’s age.
Newborn to 5 Months
Newborns need as much sleep as possible. Most parents of newborns find that four to five naps per day is not uncommon.
However, newborns don’t settle into a morning nap routine until about 12 to 16 weeks of age. Until then, babies sleep at a variety of times – and for a varied length of time – throughout the day. So at this young age, focus on getting those naps in any way you can. Don’t fret if your baby seems to be dependent on you to get to sleep each time. It’s so important for his rapidly growing brain and body that he gets as much sleep as he needs.
Remember you can’t spoil a newborn! Your goal is to promote good sleep and a close, warm connection between you and your baby. Overall your newborn to 5-month-old should sleep around 12 to 17 hours in a 24-hour period.
6 to 8 Months
Most 6- to 8-month-old babies need between two and three naps per day (ideally 90 minutes each for the first two naps): a morning nap, an afternoon nap and a one-hour (maximum) late afternoon nap to help them make it to bedtime without becoming overtired. From 6 months until 12 months your child needs 12 to 16 hours of total sleep a day, according to the American Academy of Pediatrics’ sleep guidelines.
9 Months to 12 Months
Most children give up the third, late afternoon nap by 9 months – especially if they are napping well for the first two naps. If you notice that your baby takes a long morning nap and a short afternoon nap, you may want to consider shortening the morning nap to no longer than 90 minutes.
13 to 18 Months
Between 15 and 18 months most children transition naturally from two naps to one by dropping their morning nap. Once the child has made that transition, the afternoon nap is ideally two hours and often begins between 12:30 and 2 p.m. If your 12- to 15-month-old has a morning nap, it should be kept to one hour at most if you notice your toddler is resisting his afternoon nap.
18 Months and Beyond
Your child will continue with their established one-nap pattern until they are ready to transition to quiet time. Your child is likely to stop napping between 3 and 4 years of age.
Avoid ‘Disaster Naps’
I would call any nap that is shorter than 45 minutes (for children over 6 months) a “disaster nap.” Such a short nap doesn’t encompass a full sleep cycle, so babies wake up cranky and tired rather than refreshed. You may notice an increase in disaster naps if your child’s sleep schedule changes, like at daycare, or if her wakefulness window – or the amount of time she’s usually awake – is exceeded. If a change in sleep schedule due to daycare is the culprit, I recommend working with your daycare provider to reach a better nap schedule for your child.
Naptime Resistance is Normal
As children grow up, they begin to test boundaries, including their nap routine. Don’t give up, though. Your child needs a nap until 3 or 4 years of age. If your child is resisting naps and nearing a time of transition (when a nap is dropped or he’s able to stay awake longer), you can make adjustments to see if your baby is more willing to nap at a different time in the morning or perhaps a little later in the afternoon. Also, adjust bedtime according to how naps go during the day. It’s important to keep a routine that is flexible.
For a 15-month-old, your flexible schedule may look like this:
- 6:30 to 7 a.m. wake-up
- 9 a.m. morning nap
- 1 p.m. afternoon nap
- 7 to 7:30 p.m. bedtime
If you experience resistance, you can adjust so the nap schedule looks like this:
- 6:30 to 7 a.m. wake-up
- 10 a.m. morning nap
- 1:30 p.m. afternoon nap
- 7 to 7:30 p.m. bedtime
A second adjustment for a resistant napper who is older than 15 months may look like this:
- 7 a.m. wake-up
- 12:30 p.m. afternoon nap
- 7 p.m. bedtime
Transitioning From Two Naps to One
On average, children transition from two naps to one between 15 and 18 months of age. You will begin to notice some of these typical signs when it’s time to transition:
- The morning nap starts later and later.
- The child isn’t sleeping during her morning naptime.
- The child is taking a really big morning nap and not feeling tired for an afternoon nap.
- By the time they feel ready for an afternoon nap, it’s too late: It’s 4:30 or 5 p.m., and a nap at this time will disrupt bedtime.
Watch for these kinds of signs consistently for about a week before you decide to transition from two naps to one. Then, push the start of naptime to about 12 p.m., then 12:30 p.m., and eventually move it to 1 p.m.
Your child may wake up cranky and still tired after an hour and a half. You can try to extend the nap by going in and saying, “It’s not wake-up time, yet. Let’s go back to sleep,” and give him 15 more minutes. This may not work, but it’s worth a shot. During this transition time, he may nod off later in the day while on a walk, for instance, and that’s OK. Let him doze for less than 30 minutes and wake him so that he will be ready for bedtime at a good hour. Until his one afternoon nap is well established, his bedtime may need to be earlier than 8 p.m. During this adjustment phase, it may be closer to 7 p.m.
After a few one-nap days, you may notice excessive crankiness or behavioral issues, which may mean he needs a morning nap. But only let it go 45 minutes, waking him at that point so he can still take an afternoon nap. Be open to an occasional two-nap day during this transition period.
When Your Child Is Ready For Quiet Time
Your toddler or preschooler may drop her nap one day and need it the next. Don’t assume she doesn’t need a nap just because she seemed fine without it the day or two before. Offer her the option of a nap in an environment suited to promote sleep (dark, quiet, cool temperature, familiar items and bedding).
She may choose to enjoy some quiet time instead. Just be sure she is getting between 10 and 13 hours of sleep a day.
Even when children stop napping, they still need a period of quiet time to help them rest, refresh and regroup midway through their day. I like to introduce a quiet time gradually so that the transition is smooth. You will want to set some ground rules such as no loud instruments and only certain activities, like an audio story or books to look at, as well as establishing when they can come out of their room. Stick to the boundaries you set.
Start with just 15 minutes of quiet time and gradually increase it in intervals of 15 to 20 minutes.
Some parents find that a calm, brief video with a healthy snack sets the stage for quiet time. Others find going right into playing quietly works best for their child. Experiment with each to find what suits your preschooler.
If your child naps intermittently – a few days on and a few days off – continue your nap routine as needed and add in the option of a quiet time when he doesn’t feel like sleeping.
Remember, naptime sleep is different than nighttime sleep. There is more going on – the noise and light levels are different, and sometimes babies just don’t want to miss anything. Every baby goes through a period of struggle with finding the perfect naptime. Watching for your child’s wakefulness windows, looking for signs of tiredness and remaining consistent with your baby’s routine will help to ensure that she is getting enough quality naptime sleep.
West, Kim. “Help Your Child Nap Well at Any Age.” U.S. News 25 May 2017.
“How Pregnancy Changes a Runner’s Body”
New research suggests that the biomechanical changes that occur during pregnancy can linger long afterward and significantly affect a woman’s running stride.
There’s never been any doubt, of course, that pregnancy drastically changes a woman’s body. She gains weight, her center of gravity shifts and connective tissues become looser. These changes are desirable and necessary for birth.
But they also affect how a woman moves.
A study published in March in the journal BMC Pregnancy and Childbirth, for instance, documented how women’s walking strides grew wider and shorter as their pregnancies progressed. They began, in essence, to waddle.
But there has been little science available about how pregnancy affects running form, in part because relatively few women have run during and after their pregnancies. That situation is changing, though, thanks in part to strong evidence that running throughout pregnancy does not harm a woman’s fetus, together with well-publicized success stories like those of the marathoners Kara Goucher and Paula Radcliffe, who trained throughout their pregnancies and returned to competition soon after.
But while more pregnant women and new mothers run today, many also experience unaccustomed aches and pains and a niggling feeling that somehow their stride is different now.
Such complaints drive many new mothers to the doctor’s office. And they also sent some to the running clinic at the University of Wisconsin in Madison, whose director, Bryan Heiderscheit, a professor of orthopedics and rehabilitation, could find no studies examining running biomechanics in the pregnancy and postpartum periods.
So he and his colleagues set out to conduct their own. So far, only a handful of women have been studied in depth, but the early results, presented at a 2013 sports medicine scientific meeting and published in The Journal of Orthopaedic & Sports Physical Therapy, are among the first to track biomechanical changes in a pregnant runner’s body and how those changes might effectively be managed.
One of the cases involved a 27-year-old runner who, beginning in the sixth month of her pregnancy, began visiting the university’s exercise lab every four weeks. There, she ran on a treadmill while the scientists used 3-D motion-capture technology to study her form. Her final visit while pregnant came two days before she went into labor. Six months later, she returned to the lab for a follow-up run. By then, she was running on her own about 15 miles a week.
The scientists found that as her pregnancy progressed, her pelvis began tilting forward more and more, altering to some degree how she landed with each stride. Six months postpartum, much of that forward tilt remained. She also displayed more side-to-side pelvic motion while running than she had when she began the study six months into her pregnancy.
She didn’t report any appreciable pain while running. But that wasn’t the case for another postpartum runner studied by Dr. Heiderscheit’s group — a 33-year-old mother of two who visited the running clinic 14 months after her second child was born because of considerable hip and low back pain while running.
After she ran on the lab treadmill, the researchers determined that her pelvis tilted abnormally far forward during running and moved too much from side to side. In effect, her pelvis remained unstable a year after her last pregnancy. Partly in consequence, her right leg struck the ground harder than the left, absorbing about 30 percent more force with each stride.
“None of this was surprising,” Dr. Heiderscheit says. “Pregnancy and labor stretch the muscles and connective tissues in the abdomen,” which allows the slightly unmoored pelvis to tilt and sway. Unless a woman strengthens the affected muscles after pregnancy, the tissues remain stretched.
Relying on that gym standby, crunches, won’t do the trick, though, Dr. Heiderscheit says. They don’t activate the small muscles deep within the abdomen. Instead, he suggests pulling the belly up and in multiple times and also “imagining that you’re trying to cut off the flow of urine.”
Using those techniques, together with traditional abdominal exercises like squats, planks and bridges (instructions for these can be found on The Journal of Orthopaedic & Sports Physical Therapy’s Web site), can help stabilize the pelvic area. They also suggested that the woman shorten her stride by about 10 percent to reduce the pounding that she experienced as she ran.
After seven weeks, the woman reported that her feelings of pain while running had dropped from a constant 9, on a scale of 1 to 10, to an occasional 3. She returned to running about 20 miles a week.
“I think it’s time we acknowledge that having a baby is going to change how you run,” Dr. Heiderscheit says.
The changes are not necessarily deleterious, he adds. There is no evidence that a majority of mothers are slower runners or more injury-prone after giving birth. “But things are likely to feel different,” he says, “and probably for a long time.”
Ongoing studies at his clinic are looking into whether some of the alterations in running form are, in fact, permanent.
For now, he says, his advice to pregnant or postpartum runners is to pay attention to signals from your body. If you feel pain while running, especially in the back or hips, slow down and consult a sports medicine specialist. After medical clearance, consider starting an exercise program designed to strengthen the abdominal muscles.
And if you need inspiration, the mother with the sore back and hips, Dr. Heiderscheit says, recently completed her first half-marathon.
Reynolds, Gretchen. “How Pregnancy Changes a Runner’s Body.” The New York Times 10 July 2013.
Runners’ Knee Pain Series #2
Your Mechanics Matter!
Hello fellow runners! This is the second installment in the runners’ knee pain series, and today we are going to cover how faulty biomechanics can lead to knee pain. First of all, what is biomechanics? Simply put, biomechanics refers to how your body completes a motion.
Most non-traumatic and non-contact sports-related knee pain (a.k.a. most runners’ knee pain) comes from lack of motor control from the waist down. Think your ability to control where and how to place your legs joints onto the ground.
That old children’s song was correct:
our knee bone does attach to our hip bone!
Look at the picture above, and you will notice the knee joints are “stuck” in the middle of your leg between your ankle-foot joint and your hip joint. When we talk about faulty biomechanics, we are usually referring to how the hip joint and the ankle-foot joint do not allow the knee to be in proper alignment, especially during the landing and pushing off phases.
Some quick anatomy planes:
We do move in a 3-dimensional world!
While there are many biomechanical faults we can discuss, we are going to focus right now on the frontal plane. In my humble opinion, the frontal plane is the most difficult and problematic plane for a runner to control. This subsequently causes runners the most trouble.
genu valgum / knees caving in / knock-knee
In the picture above, the lack of motor control at the hip and foot is evident as we see the knees buckle inward. While some runners can get away with this without issue, but most runners will suffer quite a bit of knee pain from this type of running posture.
The next question is: what can you do about it? I am glad you ask! Here are some of my favorite drills to address this particular biomechanical fault:
RUNNERS! Learn how your HIPS can cause your KNEE pain. 💡 Check out our blog for more drills >>> http://bit.ly/2q0NYHJ
Posted by Mobility Plus Sports Rehab on Friday, May 19, 2017
Give these exercises a try, and stay tune for next week’s post on the third top cause of runners’ knee pain.
Runners’ Knee Pain Series #1
Running Too Much, Too Fast, Too Soon
It’s the spring season, and that means it’s also the beginning of running season!
This series is intended to keep runners of all levels staying on the road. Most runners experience knee pain due to their training program, so here are some quick tips on ensuring a good start to a productive running season!
Most runners are excited to go outside and start running! Runners usually try to catch up to the mileage they ended their last season with…on the first week!
For the runners who haven’t been running during the long winter break, we suggest to start off with a quarter of the mileage you ended with last season. If you feel good after running that quarter mileage, stop, and wait for 24 hours to see how you feel. If you feel are without any soreness after 24 hours, do the same mileage again, and continue that mileage for the rest of the week.
Increase 10% running mileage (or your time) next week, and work up to your desired race/personal goal each week.
Doesn’t it feel good to run fast!?
We know you want to pick up the pace, but we also recommend to slow down first. Let’s refer back to our point above: if you run too much (increased mileage or time) and too fast (increased intensity), both will put pressure on your muscles, joints and ligaments very quickly. This can happen so quickly, in fact, that it’s to a point the tissues cannot adapt properly.
What does that mean in plain English? Your muscles and joints are not going to be too happy about it since they can’t catch up. That could expose you to injury in early season.
Rule of thumb here – pick one to increase at the first 4 weeks. For instance, if you increase your mileage, keep the pace the same. Pick the pace you ended with last season, and slow it down to a quarter of it (if you were running a 8-minute/mile pace, slow it down to 10 to 11-minute/mile pace and increase the speed by 10% each week).
3. You are running too often.
This is the most common theme that leads runners to knee pain early in the running season. We are referring to the frequency of running here.
Take your time! Your body needs time to getting used to the recent increase in this new physical stress and adapt. Remember, the recovery AFTER the training is what makes you strong. If you start with running daily, slow it down to every other day.
Start slowly and find that balance point. I know it’s always easier to be said than done, but you can do it! We have helped numerous runners to reach their goals, and we look forward to helping you to reach yours!
Check out THE ARTICLE on triathlons:
“Let’s Try a Triathlon”
Craving a new challenge? Try a triathlon, which incorporates swimming, biking and running all in one race. With more than 3.5 million participants worldwide, triathlons are more about personal goals than competition. A triathlon may seem intimidating, but the event has a reputation for being unusually welcoming and supportive to beginners. You’ll find everyone from the fastest finisher to the aging plodder cheering you to the finish line. The best part? If you’re already exercising regularly, it only takes six dedicated weeks of training to get you to race day.
What’s a Tri?
By definition, a triathlon is a single race, consisting of swimming, biking and running — almost always done in that order. The reason? Safety first. Swimming is the riskiest event, so it’s best completed when the athlete is fresh. If you compare the injury risks of a bike race to a running race, the consequences of an exhaustion-related mishap are lowest on the run, so that event is usually held last.
The main variable in a triathlon is the distance of each event. Officially, there are four main distances — Sprint, Olympic, Half-Iron and Iron. The distances in a sprint triathlon can vary by a lot, depending on the event. The other variable is the location. Runs and bike races may be held on roads or trails; swimming events can happen in open water — rivers, bays, the ocean — and some events are held in swimming pools. See below for the basic triathlon distances, but check out the distance details of an individual race before signing up.
How It All Started
There are records of multi-sport races in France as early as 1920, but, according to the World Triathlon Corporation, the first Ironman distance race wasn’t created until 1977, when a debate began at a running club awards banquet in Hawaii over which athletes — swimmers, cyclists or runners — were toughest.
The only logical way to solve the argument was to make everyone do all three sports back to back to back. An all-day race was planned around the island of Oahu, with a 2.4mile swim (the distance of the annual Waikiki Roughwater Swim, one of the hardest open-water swims in the world), a 112-mile bike ride (the circumference of the island) and a full marathon (26.2 miles). The Ironman triathlon was born.
The first year’s race was won by Gordon Haller, whose strength was running, says Bob Babbitt, an Ironman Hall of Fame inductee and founder of Competitor Magazine. In the second year, a swimmer won. In year three, everyone assumed that John Howard, an Olympic cyclist, would win because cycling takes up the largest proportion of the course and allows a strong cyclist to make up a lot of time. “But when Howard came out of the water an hour behind Dave Scott, a former swimmer and water polo player, he finished in third despite having an amazing bike ride,” said Mr. Babbitt. “It showed that you couldn’t be just a one-sport specialist. You need to be a triathlete to win the Ironman.”
How to Train
How to Start | Pick a Race | Pick a Plan
Understand Your Training Workouts | Get Organized | Get Social
Swim | Bike | Run | Transition
What to Wear on Race Day | Learn to Fix a Flat
What to Eat | When to Eat | During a Race
Water | Drink Up | Too Much Water
Get There Early | Rise, Shine, Eat | Set Up Your Transition Spot
Listen to Instructions | Be Mindful | Jump in the Water Early (if it’s allowed)
Line Up For the Start | Listen for the Gun
From Sim to Bike | From Bike to Run
Follow the Rules – Swim | Bike | Run | Transition
Celebrate | Eat & Move | Consider Next Steps
Shilton, AC. “Let’s Try a Triathlon.” The New York Times.
“The Art of Rest”
Resting “properly” is trickier and more important than most people realize. When you are injured — especially a repetitive strain injury (RSI) — how much rest is enough rest? Is there such a thing as too much rest? What if you get out of shape or lose muscle? Is it necessary to rest completely, or is it adequate to rest only the injured part? Is “taking it easy” enough, and for how long? How do you know when to lay off and when to “use it or lose it”? How can you rest anatomy that you need to use all day, every day?
These questions aren’t especially difficult to answer with regards to most ordinary injuries — you sprain an ankle, you stay off it for a while, no big deal. No “art of rest” there!
They become more of a challenge when there is more at stake, when you have an injury that is not healing well and is dragging on and on, or a pain problem that cannot quite be diagnosed. It is more difficult and more important when you are hurt in a way that keeps you from earning a living, or in a body part that is hard to stop using (feet), or when the amount of rest required for healing seems to be cruel and unusual punishment, as with many overuse injuries — injuries that almost always strike at the heart of your work or play.
Both patients and professionals often pay lip service to the importance of rest, while in practice are nearly ignoring it, or even defying it. Patients are often even encouraged to do precisely the opposite of rest: to “work through” their pain, to push too hard too soon, to value on-going performance and fitness over rehabilitation. The number of cases where resting is actually treated like a meaningful strategy seem to be outnumbered about 10 to 1 by the cases where it is given only the most token consideration.
Until those numbers reverse, it’s a topic well worth writing about.
The most common objection to resting: the fear of getting out of shape
People tend to think rehab is all about a gruelling regimen of therapeutic exercise. That’s the cliché — lots of movie montages have shown it that way. But that’s rarely how it happens. It’s usually lazier.
Before we get rolling, I want to quickly shoot down the most common objection to the suggestion to rest thoroughly: the fear of “going to pot” or getting critically out of shape. This fear is often expressed by the most fit people, who are actually in the least danger. They also often tell me that they have been “warned” by a their doctor (or therapist) that staying in shape is more important than resting, and that they need to be “careful” not to rest too much. That’s backwards! In general, rehabilitation should almost always put physical conditioning on the back burner, especially at first. Worry about healing first, and then concern yourself with restoring any fitness you have lost. Why?
- You certainly will go to pot if you never heal. Chronic pain is a much greater threat to your fitness than resting. And nothing will keep an overuse injury going like more use!
- Peak conditioning is vulnerable, but the bulk of your fitness is actually quite stable and hard to lose. No one goes completely to pot in 3 months. Or even six. And even if you do get out shape, it’s really not that big a deal to get back into shape.
- It’s also usually easy to rest/protect an injury while still maintaining some fitness by exercising in other ways (relative resting strategy).
If you’re worried about getting fat specifically, there are many experts saying loud and clear that calorie intake is by far more relevant to fatness than exercise. Just eat less when you’re not exercising!
Keep perspective: even people with extremely serious injuries, far worse than any case of runner’s knee or shin splints, do recover their fitness. I witnessed this firsthand over the last year, as my wife recovered from multiple fractures without any rehab heroics — just time and modest effort, and only after a lot of resting, when she was good and ready. She ran Vancouver’s Sun Run recently, a little over a year after her car accident. And she didn’t even train for it!
One more time, with feeling: you have to be healed before you can maintain or develop fitness, let alone optimize it. First things first.
“Bed rest” is dead
Let’s get this out of the way early as well: bed rest (a.k.a. total rest) is pretty much dead as a concept in rehabilitation.These days, doctors won’t even cast a fracture if they can avoid it — fractures heal faster when they aren’t completely immobilized. Even a hip fracture doesn’t get you a get-out-of-exercise card any more.
Replacing bed rest is the concept of “early mobilization” or “active rehabilitation.” The idea is to get you moving as soon as possible — short of actually reinjuring you. A great deal of scientific evidence suggests that the stimulation of movement, especially in the early stages of healing, is a crucial part of recovery from injuries and surgeries.
Acute low back pain has been shown to respond much better to normal activity than to bed rest. Achilles tendon ruptures have been shown to heal faster with early mobilization after surgery. Whiplash victims recover much faster if they get moving right away after their accident, rather than wearing a collar.
All of this is why therapeutic exercises like PF-ROM, mobilizations, functional training, reflex stimulation, endurance training, and many more are such a crucial part of serious rehabilitation.
On the other hand, sometimes active rehabilitation is too active …
You can’t exercise your way out of every problem
There is a common attitude in rehabilitation circles that patients can exercise their way out of any problem. I routinely see patients who have been encouraged by health professionals at every turn to challenge their tissues with therapeutic exercise. They receive this advice despite a strong possibility that continued exercise is exactly the wrong thing to do.
Long before breaking under a strain, tissue often gets “sick” — a failure to keep up with maintenance and repair to match the strain. Once that happens, the tissue loses the ability to tolerate even minor stresses. Activities that used to be just fine are suddenly a problem. There’s only one way out of that trap: adequate rest is critical. You have to almost completely stop challenging the tissue, or it will never have a chance to recover.
In my experience, I have often seen patients in this predicament who have suffered years of chronic pain simply because they never rested adequately. (They may believe that they have, but “taking it easy” for a couple weeks is often not actually enough rest.) This predicament is particularly tragic because rest is so cheap and safe that there’s hardly any reason not to try it.
And yet patients are often pushed to exercise too hard, too soon. Why? A little history…
In 1995, a publicly owned insurance company published a report about whiplash, authored by an organization called The Quebec Task Force on Whiplash-Associated Disorders. People in my line of work refer to this report as “The Quebec Task Force,” or even just “Quebec” as in “In 1995, Quebec recommended active rehabilitation,” as though the province of Quebec was somehow personally involved.
“Quebec” was bullish on the whole idea of active rehabilitation, and more or less gave insurance companies everywhere a great reason to push people hard through rehabilitation. Countless insurance adjusters, physiotherapists and doctors started telling accident victims to get back into the gym as soon as possible. But how do you define “as soon as possible”?
Unfortunately, many fans of the QTF were pretty aggressive about it. I’ve seen cases where people were sent to the gym to do strength training exercises within days after an accident, when the tissue is still inflamed. Those of us less enthusiastic about the QTF witnessed a huge increase in the number of patients who had been pushed much too hard, much too soon. Yikes.
There is a balance to be struck. On the one hand, it’s clear that early mobilization and general activity is valuable. On the other hand, it’s just as clear that you can aggravate and even re-injure yourself by trying to do too much, too soon. If you feel that a physiotherapist or doctor is pushing you too hard, there’s a good chance that they are.
Re-injury and collateral injury are real risks. People get hurt trying to get over being hurt all the time. Keep this in mind!
Patellofemoral pain: the perfect example
Of all the repetitive strain injuries, patellofemoral pain is the trickiest to rest effectively. Patellofemoral pain is a type of runner’s knee that affects the joint between the femur and kneecap. It’s unusually sensitive to over and underloading, and can take a long time to recover even under optimal conditions, and so it’s more difficult and more important to rest PFPS properly than other conditions. It emphasizes everything about the challenge of resting.
It’s tricky because the patellofemoral joint is naturally a high performance joint that tolerates intense pressures under the kneecap…even when you aren’t doing anything impressive with it. And when you make a point of exercising your knees, the intensity goes up way more than most people realize. And so, unlike most other RSIs, you can easily overuse your patellofemoral joint without even realizing it.
For most RSIs, getting the rest right is still an interesting challenge. For patellofemoral pain, it’s more like driving a sports car with super sensitive steering. Writing a book about patellofemoral pain forced me to think quite deeply about what it meant to “rest properly.”
Relative rest and allowing adequate recovery
The art of rest is mostly the art of “relative” rest: finding a way to stay active and fit without placing stress on injured or severely fatigued tissues. Like rest in general, it is a neglected concept in rehabilitation. The challenge can and should be tackled with precision and creativity.Done right, it can be the closest thing there is to a “miracle cure” for many common repetitive strain injuries for which there is virtually no other effective treatment.
There are three kinds of people who need relative rest:
- Inactive people who suddenly lose the ability to continue doing the only exercise that they were getting before injury. For instance: a self-confessed couch potato who walks several blocks to work every day, but then stops doing even that when she gets a case of plantar fasciitis.
- Determined, frustrated athletes who find it “impossible” to stop running, or cycling, or swimming, or playing soccer, or whatever it may be that they are passionate about. For instance: a serious runner who gets iliotibial band syndrome, but continues to run 5k/day and claims to be “taking it easy.”
- Healthy, active people who want to optimize their fitness and reduce injury risks.
All of these people need to rest relatively. Even though they have quite different priorities, there is lot of overlap between their needs. All need ways of giving some specific tissues a break while continuing to challenge other tissues. The need to avoid stressing injured tissues is obvious. It’s less obvious how the same principle applies to healthy active people — but still very important.
Surprisingly similar: recovery from injury and recovery from exercise
Every workout is like a mild injury that you have to recover from, shielding yourself temporarily from additional stress on the recovering tissues. And yet few active people and amateur athletes give their tissues enough time to recover and adapt. This can really increase the risk of injury, lead to feeling run-down, and is far from optimal for fitness.
For instance, it’s extremely common for people to go back to the gym long before their muscles have fully healed from the last workout. Progress may be less than it could be, and a sneaky hazard of overly frequent training is that it sucks to be perpetually not quite recovered.
You never actually get to enjoy your full fitness if you are too active, too often. Guys keen on the gym are particularly prone to this, spending far too many days of the month feeling sore and weak — strength remains reduced for days after the obvious sore phase is over — instead of actually feeling and enjoying their full power. It’s most obvious in their case, but the same thing applies to nearly any kind of intense workout: not only do you need adequate rest, you need to spend some of your time actually enjoying the fruits of your labours! How “fit” can you possibly be if you never allow yourself to recover?
Just as injured people must find ways of being active while protecting their vulnerable tissues, the healthy athlete can optimize training and prevent injury by carefully alternating between different kinds of stresses. A common, obvious example is to switch between upper body and lower body workouts — resting half the body while challenging the other half.
You can get a lot more creative than that, though. There are many relative rest tips, tricks and strategies …
Ideas for resting relatively
- As long as you don’t have a hip or leg injury, walking is surprisingly good and non-stressful exercise.
- Swimming is one of the most classic options for relative rest. Obviously it’s not completely stressless: you’re not going to want to swim with injured shoulders at all, and the common knee injuries can be a problem. But you can really do a lot in the water with minimal risk/stress.
- Do a “thermal workout” — exhaust yourself with heating and cooling. For example, switch between a hot tub and a swimming pool. (See the thermal workout section in Contrast Hydrotherapy.)
- Being chilly is another surprisingly exhausting and almost totally passive “workout.” Turn the heat down, put on a T-shirt, and put up with being non-warm for a while.
- Vigorous breathing is a terrific non-standard workout, with numerous benefits: see The Art of Bioenergetic Breathing.
- Power yoga can certainly be intense and hard on the body, but often in a completely different way than most of your other exertions, so it can be a great way to spread the physical stress around.
- Many people who do not normally strength train in a gym should seriously consider it during rehabilitation, because it is a much better and more efficient way to stay in shape than most people realize, and the precision of gym equipment allows you to easily protect your injury while you heal.
And that was just off the top of my head.
Relative rest will come to you naturally if you like to be active, but also respect the importance of taking it easy on your injury. You will be motivated and creative in your quest for alternative activities for the duration of healing.
Warning: are you really resting?
Some patients (you know who you are) take the idea of relative rest as a sort of blank cheque to train and workout as hard as they want, as long as they aren’t directly or obviously irritating their injury. If this is you, you need to carefully ask: are you really resting?
Many activities that do not cause symptoms as quickly as others are still a problem — just less of one. Consider the following classic example:
A runner has plantar fasciitis, a kind of tendinitis on the sole of the foot, and running on pavement clearly irritates the condition within fifteen minutes, so he sensibly refrains from running altogether. Cycling, however, feels fine to him, and so he insists on cycling for an hour every day instead of running: relative rest, right? Maybe …
Unfortunately, cycling — especially in clips — is potentially irritating to plantar fasciitis — just a lot less obviously than running on pavement. It might take up to 90 minutes of cycling before you felt a problem, yet every hour-long ride is causing about two thirds of that irritation. This example person is not really resting at all, and will likely turn up in my office saying, “I don’t understand it, I rested from running for six weeks and the problem is still just as bad as ever!”
These are the kinds of complexities that make up the art of resting!
Handling awkward body parts
Some injured locations are harder to rest than others. Take the feet, for example. (Other tricky locations are the knees, the dominant hand or wrist, the neck, and any body part essential to your job.)
Using plantar fasciitis as a good example again: it’s a painful condition, but not usually crippling. Yet every step is an irritation that keeps it going, or makes it worse. As long as you keep using your feet, it’s probably not going to go away. In such cases, people often think that they have already done enough resting, when in fact they have done no better than “taking it easy” for a few days. I’m going to pick on runners again, because they are invariably the worst offenders:
ME: Have you tried resting?
RUNNER: Yes, I really took it easy for a month.
ME: Did you stop running?
RUNNER: Stop? Oh, no, I just dropped down to 10K.
ME: A week?
RUNNER: A day.
ME: Sounds like you were still running quite a bit.
RUNNER: There was the half marathon, too …
Runners are often their own worst enemies!
But for all patients, healing from plantar fasciitis does seem to require an unfair and unreasonable amount of inconvenience: this nagging pain in your feet, a mere irritated slip of connective tissue, can require nearly as much rest as a broken leg in the worst cases.
Unfortunately, hardly anyone takes plantar fasciitis seriously enough to rest as much as they need to. A change in perspective may be necessary: think of your feet as broken, and you’re on the right track. They are broken! And they’ll probably stay broken if you don’t get off them for a while.
So, um … how long?
Let’s recap: you know that bed rest is dead and some movement of all but the most serious injuries is important … but you can’t over do it either. I’ve explained that you can use the concept of “relative rest” to rest your injured part, but otherwise remain active. And we’ve discussed how injuries in some locations are especially tricky to rest. The astute reader will have noticed that I still haven’t said how long: there is still a need to rest something, and the $64,000-question is, “How long?”
As long as it takes, of course.
With some injuries, you can tell whether or not you’re better yet, and you don’t have to guess about how long you need to rest: you just rest until you can tell that it feels better, and then add another couple weeks just to be safe. Easy!
But lots of injuries are “quiet” when you are resting. They only act up after 30 minutes of running, say. Some injuries are completely undetectable with anything less than competition intensity. Running soccer drills might be fine, but soccer itself still impossible. Skiing itself might be fine, but falling down is still a problem.
Plantar fasciitis, medial tibial stress syndrome, whiplash, carpal tunnel syndrome, iliotibial band syndrome, tennis elbow … these common problems, and many more, can feel more or less completely fine until you’ve been working/playing for a little while, and then you discover the hard way, after already irritating it, that it’s still vulnerable. How can you know how long to rest such a condition? How can you “test” it without pissing it off again?
Every case is different. In some cases you can (sort of) test it without irritating it (much). In other cases, there is no hope of this: testing will irritate the condition and potentially delay recovery.
In these cases, you must choose between two methods: the “get it over with method” and the “if at first you don’t succeed” method.
Two styles of resting
You can see why I avoided saying “how long” at first: it depends on the individual’s situation and risk tolerance. There is no “right” answer. It’s like — exactly like, actually — trying to tell someone whether they should choose safe investments, or riskier but more profitable investments: it all comes down to your personal situation and style, and how you feel
Method 1: Get it over with …
Some people prefer the “get it over with” or “overkill” method, and choose to rest a lot on the first try, to generously rest for at least 2–3 weeks that you really think is necessary “just in case,” and not to challenge/test your injured part at all during the rest period. The benefit of this approach is that it is virtually foolproof. The disadvantage, of course, is that you may actually end up resting much more than you actually needed to.
This method is fine for people who enjoy a better-safe-than-sorry approach to life, and for people who are patient. But if you are the sort of person who can’t wait to open your Christmas presents …
Method 2: If at first you don’t succeed …
Others are so unable or unwilling to rest that they prefer the “if at first you don’t succeed” or “go for the parking spot you want” method, in which you try resting the minimum amount that might work. The advantage? You might succeed on the first or second try, getting away with a relatively small amount of inconvenience.
The disadvantage, of course, is that your desire for efficiency could backfire, and you could end up having to try five progressively longer rest periods, resulting a much larger investment in rehabilitation than if you’d just rested adequately the first time. Ouch.
As you can see, even if you have to try twice, you might succeed on your second try and have about the same total weeks of resting as the “get it over with” method. Or you might not. The worst case scenario with method 2 is pretty bad!
The risk is real: last year I had a client, a young woman athlete with shin splints, who had tentatively tried resting for several periods of 2–4 weeks spread out over an entire year, not one of which was adequate. It was only when I counselled her to rest adequately, no matter how “painful,” that she finally started to make progress. The final rest took three full months. In all likelihood, she could have rested successfully for just 3–4 weeks on the first try, a full year before!
Here are a few more points to bear in mind when deciding how long you should try to rest:
- Old problems are usually more prone to being irritated, and usually require more rest to recover from.
- Don’t be too afraid of “testing” an injured part. There are almost always creative methods of testing that minimize stress to the injury, but can still tell you something about how it’s doing.
- It’s up to you to decide how deeply to “bury” a problem. Do you need it to mostly go away? Or completely go away? If the goal is perfection, you’re going to have to rest longer.
If you can’t take the heat …
“But I can’t do nothing!!”
“I can’t quit everything!”
“I have to do something!”
These are the howls of protest I hear from athletes and active younger patients when they start to realize that “relative rest” isn’t perfect, and doing it properly means (temporarily) giving up everything they consider to be fun or rewarding. They may still be able to swim or walk or aerobics classes or yoga, but if they are shut out of their favourite activities — skiing, running, ultimate, whatever — they tend to think the world is coming to an end.
I sympathize. I really do! I’ve been there.
And this is just part of being an athlete. Treat it like earning a scout badge. Rehabilitation is a rite of passage: there is hardly a serious athlete in the world who hasn’t had to go through it. Twice. Goes with the territory. If you can’t take the heat, stay out of the kitchen.
Riddle me this: which of these things is worse?
- Really truly resting for a few months, like any serious athlete has to do when they get a nasty injury?
- Never recovering at all because you just couldn’t bring yourself to rest?
Seriously, how do you think the elite athletes do it? Do you really think their coaches let them get away with abusing a badly injured piece of anatomy? Do you reckon that’s a winning strategy?
Well? Think about it! Sometimes being a “real” athlete means sucking it up and knocking it off for a while.
The hard part is just coming to emotional grips with the fact that seemingly “minor” injuries like plantar fasciitis, iliotibial band syndrome, shin splints, chronic low back pain, tennis elbow, etc, are actually not going to go away until they are actually treated like real injuries.
Enjoy your own “rehab montage.” Have fun with it. And if you can’t take the heat? Stay out of the kitchen! Give 110% to something else for a while.