health – Dr. Jennifer Palmer

Global PT Connect

January 23, 2018June 24, 2018Jennifer Palmer PT, DPT

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NPS (Nail Patella Syndrome) – General Clinical Presentation

January 23, 2018January 27, 2018Jennifer Palmer PT, DPT

Hey Everyone!

Rare diseases – there are a ton of them, right? They can often times be difficult to treat just because they are not as common, the population may be widespread, and there just simply hasn’t been much research done to effectively help the people and remain “evidence-based.”

I’ve decided to try to undergo a little series here in regards to helping people with a rare genetic disease called “Nail Patella Syndrome.” Why, you may ask? Oh wait, because I have it too! While this syndrome varies widely in presentation, many factors and things seen are similar.

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Those of you who have NPS may not need this brief overview, but I’ll just summarize some typical physical clinical findings and a general presentation. Please remember that EVERYONE with NPS varies in presentation – there is not just “one” type of presentation. Due to other co-morbidities, health conditions, lifestyle factors, etc., nobody presents exactly the same.

Nails – people will generally have abnormal looking fingernails and toenails, especially the thumbnails.

Elbows – people may be unable to fully extend the arm at the elbow, they may also be unable to supinate fully at the forearm due to an increased growth of the radial head (this made it SUPER easy for my partners to palpate my radial head during PT school, ha). On the other hand – people may have underdeveloped bones in the elbow, leading it to be easily dislocated.

Shoulders – not usually talked about, but due to the inability for some to turn the palms up (supinate), the shoulders may become more unstable and demonstrate increased external rotation. Think about it – if you can’t turn your palms up all the way, you will compensate and use what you have next up the chain — your shoulder! Many also present with underdeveloped scapulae.

Back – Generally, people with NPS present with increased lumbar lordosis – meaning a little more curve in the lower spine. This may make the buttocks appear more prominent. This extra curvature could also make gaining weight in the stomach region and pregnancy even more painful in the lower back. With weight in the stomach, gravity naturally pulls your body more forward, creating an angle in your lumbar spine. Already having an angle there may just make the pain a little more evident.

Hips – When I asked my professor about “iliac horns” in PT school, she looked at me like I had 2 heads. Yes, these are talked about being present on diagnostic imaging; however, they generally do not affect anything. Hips, as with most people, may tend to be stiff and inflexible. At times, people may complain of pain in the groin area due to a muscular imbalance in the hip and core region which may cause a hip impingement.

Knees – People may present with abnormally small kneecaps, or at times, no kneecap at all. This can predispose these people for dislocations if there is decreased musculature around the surrounding areas. The small size of these kneecaps and easy dislocation ability may also then cause pain under the kneecap where it improperly glides and/or partially dislocates in/out of place.

General appearance – It may be difficult for this population to gain weight, particularly muscle, especially in the proximal musculature (upper arm and upper leg). While difficult, it is not impossible by any means. It certainly just takes more work and dedication and the proper exercise program.

Fatigue – Many will note chronic fatigue syndrome. Many times this may be due to lack of activity due to abnormal kneecaps, other underdevelopments of the musculoskeletal system, or even fear of getting involved due to social reasons with the abnormality. The more active you are – whatever it may be – over time, your body will build up endurance, allowing you to participate in more activities and feel more energy.

Pain – Many will also complain of general pain, chronic pain, etc. especially at the knee joint and other joints in the body. While people with NPS have a different musculoskeletal makeup, it is at times not all that different. To feel more stable in your joints, you must have more musculature supporting them. The issue here is that it tends to be more difficult to gain muscle when you have NPS.

So, you get a general picture, right? Some people have things worse, some better. The word syndrome defined, per good ole Merriam-Webster, “a group of signs and symptoms that occur together and characterize a particular abnormality or condition.” Meaning NPS is mainly a collection of signs and symptoms that tend to present together and make up this condition. Having NPS doesn’t mean NPS will cause something necessarily, it is just the makeup of the body with NPS (the genetic mutation, the other parts of your genetic history, your diet and exercise habits) that then may cause other things to happen. Don’t get me wrong, obviously abnormal kneecaps and fingernails were caused from the genetic mutation – but you must be careful when talking about certain symptoms that may not be associated directly with NPS.

If you’d like to read up more about the disease, I have provided a few public links below. Again, these are just a few. A quick google search will give you more available links:

https://rarediseases.org/rare-diseases/nail-patella-syndrome/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1735400/pdf/v040p00153.pdf

https://www.nhs.uk/conditions/nail-patella-syndrome/

So..you have NPS. What next? Stay tuned as I write up a few exercise programs, tips, tricks, and adaptations to help you manage your pain, improve your function, and hopefully improve your quality of life! Not to mention helping you understand NPS and your body a little better 🙂

Keep an eye out for the first blog — NPS and Knee Pain!

Until next time,

Jen

The Generalist PT

January 14, 2018January 23, 2018Jennifer Palmer PT, DPT

It’s 2018. I’ve been out of PT school for about 2.5 years now. Time flies, right? I can’t believe it. I’ve been working in acute care mainly, a little PRN help in SNFs and outpatient facilities… Ya know, the typical post-grad-need-to-pay-off-my-loans thing. Meanwhile, I feel like everyone around me is getting certified in a million different things. I mean, I’ve been doing my continuing ed (and some extra), but I still feel like I’m behind because I don’t have any certifications…

But do I want any? I’m honestly not sure. Each certification is hundreds to thousands of dollars, and of course certain ones require that you get approved before you can sit for the exam. It’s a lot of time and money to dedicate to something that I’m not 100% sure and confident that I want. But what do I do then? Am I falling behind? Am I going to be able to keep a job without adding letters to my name? Am I overreacting? Probably, but maybe not. I truly feel like so many PTs around me are doing residencies and fellowships and publishing articles and doing these amazing things. And for that, I applaud them (and you if you’re one of them). Frankly, I think I’m a little jealous that others know exactly what path they want to take in this career. I want to make a difference, but I want to be in it 100% – not just to add some letters or pad my resume. Not to mention I’m still drowning in over 100k of student loan debt.. and trying to experience life a little here and there..

These questions and thoughts go through my head on a very regular basis. I have looked at various certifications that I think would be good for my “life goals” but continue to have a difficult time deciding which one I want to choose (commitment issues, much?). Truthfully, I feel like I want to continue learning and improving my skills as a “General PT.” I think I made this up – but basically, I want to be like the “family practitioner” of PT. I want to learn as much as I can about a variety of things so that I can be that primary care PT who can help with differential diagnosis so that the patient can get the appropriate treatment – whether that be from me or not.

I want to work with a team of nurses and physicians and other healthcare workers to derive the best plan for a patient – whether they are a pediatric patient or geriatric patient, total knee replacement or post-CVA. I want to understand and learn as much as I can. I want physicians to look at me and ask me questions when they are deciding the best plan of care, so that they have my respected perspective on it too. I want to collaborate, I want to help.

I want to keep taking continuing ed on clubfoot and the Ponseti method and then next month take it on traumatic spinal cord injuries… and then in a few months on treating Parkinson’s. I want to confidently know the difference between an allergic reaction and cellulitis when a patient walks into my clinic. I want to understand the McKenzie method and other ways to treat low back pain – never settling with using only one tool, one technique, or one specific method.

I want to be able to read diagnostic imaging, maybe hopefully down the road (pending the state), even order it. I want to be able to determine if someone just had a stroke or if they just have facial droop from Bell’s palsy. I want to be able to notice that a patient’s back pain is caused by something that needs medical treatment instead of physical therapy treatement. I want to be an expert in differential diagnosis. Not just good, but great.

I essentially want to be that New Grad PT… but better. I want to not be pigeonholed into one category – afraid that I may lose my manual skills (which truly has already happened only 2.5 years out after mainly working in acute care), afraid I might forget how to talk to a 2 year old and be creative during treatment, afraid I may only want to do repeated extensions for everything musculoskeletal, afraid I may keep repeating the same treatment for every older person who has a fall without personalizing it.

I want to interact with people all over the world in the PT profession. Because even though I know I will always want to stay up to date generally, maybe there is something else out there, somewhere else, where my skills are in need and can provide the greatest benefit. Maybe I just haven’t found it yet.

But how? How do I demonstrate this on my resume? How do I keep improving as a generalist PT? Are there any certifications for differential diagnosis and understanding pathologies at this primary care level? Are there any interdisciplinary courses that are offered that involve all members of the healthcare team? So that we can learn and grow together?

I think this is okay to feel like this. Again, I’m not sure, but I think so. But how do we change this? How do we make these thoughts and notions about being a generalist PT feel okay? I’m simply not ready to step into the neuro world, or the ortho world, or the pediatric world, or becoming a yoga therapist… I’m not ready to fully dedicate my life to one area. And, yes, I know this doesn’t mean I can never take courses in those again, but it does mean I will be characterized by the OCS, CSCS, COMT, or the GCS or whatever letters appear behind my name. People may feel that because I did a residency with the geriatric population that I am only equipped to treat them – and completely leave out my love for the sports population. I don’t want that.

This blog isn’t meant to have answers. Mainly questions and insights for us as a profession (and other professions) to build and grow together. And for other “generalist” PTs that may feel lost to know that you are not alone. I’m not advocating for certifications or not – I’m simply saying I am personally not ready to commit, and I’m not sure when I will be. But until then, I want to keep improving my skills to show that we, as PTs, can be great as generalists.

It shouldn’t be frowned upon to be a generalist, as long as we are improving ourselves in whatever way will lead us towards our goals. And again, I’m not saying it is frowned upon necessarily, but I do know that I personally feel pressure all of the time from the advancing PT world to pursue one specific area. I’m not ready for that, and it’s okay. I’m allowing myself to feel okay about it. I know I will do my best to make a difference however I can.

Until then, I will keep seeking opportunities, progress a little, fail a little, and learn as much as I can. And I hope you will too.

– Jen

Going Vegan in Japan

January 9, 2018January 23, 2018Jennifer Palmer PT, DPT

Going vegan seems to be the hottest new trend in health and diets out there. Recently, my husband and I watched the Netflix documentary, “What The Health.” While I do feel that some of the documentary was a little dramatized, there were definitely some great takeaway points and facts that I didn’t know prior to watching. I won’t go into detail, but you should check it out yourself, whether you decide to take the vegan plunge or not!

After watching, we were a little disturbed with some of the foods we consumed. There are definitely some vivid, lasting images in my mind that I can never unsee. As a physical therapist, promoting health and wellness is part of my role in life, so this all seemed like something I should definitely listen to and try. Seeing how dairy and eggs alone can lead to a higher risk of disease was enough to make me want to try switching to a vegan diet.

Over the last few years, I have come to realize firsthand the part that nutrition plays in my health. Two years ago, for about 3-4 months, I kept a food diary and completed an “elimination diet.” To break this down – I eliminated all major allergens and food intolerances that would be questionable (dairy, eggs, soy, gluten, etc.) and then reintroduced one thing (dairy), ate a lot of it one day, and then tracked how my body reacted the next 3 days. Then I would introduce the next thing. It’s a bit more complicated than that, and it definitely requires self-discipline. It was very much worth it though. Now I can “pick my battles” when it comes to food based on if I want to feel bloated that day, or if I want my allergies to act up, etc. It’s pretty interesting. Shoot me a message if you’re interested even more 😉

With this history of eliminating many of these foods from my diet, I felt like I already had an upper hand on the whole “vegan” thing. I knew there were decent dairy and egg-free pizzas, cheeses, milks, yogurts, etc. I just had never gone without meat before – Ah!

The even trickier part to starting this is how limited we are with groceries in Japan. Neither of us can read Japanese, we can hardly speak the bare minimum conversationally, so we don’t know much of what we can buy at the grocery store besides your fresh items. Of course, we have the grocery store on the naval base, but again, it is a limited selection since only certain things are shipped from the US.

Scott and I agreed that we would try, but we also agreed to not give up hope if we couldn’t make it work in Japan. We will be in San Diego, CA in just about 2 months and we know it will be much easier to adapt to a vegan lifestyle there.

Oh and did I mention – in Japan, they don’t have ovens in their homes!? Yeah, so we can only use the stovetop and our microwave. We could buy a toaster oven and/or a crockpot – BUT we’re also in a predicament here. You see, all of my 1 bedroom apartment belongings (food processor, crockpot, George Forman grill) are all back in MD… so we obviously don’t want to buy too much more and have duplicates of items that we already have (and will be reunited with soon).

So to get started, we did a lot of searching online. From Pinterest to Instagram to random other websites. I have my basic recipes, but we wouldn’t to make sure we didn’t get bored. I’ll post a few links below that helped us out, specifically the ones that were easy and tasty 🙂

Our general grocery list looks like this:

Bananas
Fruit that is on sale (blueberries, pineapple..)
Baby spinach
Potatoes (regular or sweet depending on what is accessible)
Onions
Green and Red Peppers
Broccoli
Baby Carrots
Mushrooms (I know there are different kinds but we’re not that smart yet)
Dried fruit (raisins, mangos..)
Nutritional Yeast
Fortified Cereals (Cheerios)
Granola
Ground Flax seed
Frozen fruits and veggies (whatever is on sale)
Granola bars (whatever we can find that is Vegan and somewhat healthy)
Almond milk (usually unsweetened vanilla.. but chocolate is also delish)
Tofu and/or some other “meatless meat” in the frozen section (hoping to eventually only rely on the frozen ones every once in awhile)
Quinoa
Rice
Pasta
Avocados
Salsa
Black Beans
Pinto Beans
Hummus
Pretzel crisps (or other chips for dipping/snack)
Spaghetti Sauce (to at least have around, even if you don’t use it right away)
Seasonings (we already have a few, but basic sea salt, ground pepper, garlic salt, chili powder are helpful.. others too – but again, we are on a time constraint)
Coconut Oil
Nut butter (we already had almond butter and peanut butter)
Vegetable broth
Coconut Water
Vegan Protein Powder (because we like to work out a good bit)
Enjoy Life chocolate chips (very optional but we love chocolate so..)

Okay so that is a basic list for the two of us for about a week (maybe more, maybe less). Of course sometimes we have to run out and get something else, but that’s usually only one thing and it changes all the time!

So for breakfast, we generally eat cereal/granola and almond milk with some sort of fresh fruit. I will also make smoothies (fresh and frozen fruit with some flax seed, coconut water, and almond milk) occasionally, oatmeal, overnight oats, I’ve even made vegan pancakes pending what we have in the cupboard. And of course, I’ll have a cup of coffee usually. Right now we’ve been drinking ours black, but I know there are almond, soy, and coconut milk creamers back in the US.. just none available to us here!

When you think about not eating meat, the first thing you probably think about is a protein deficiency. There are plenty of articles that go into depth with this – but what I didn’t think about were other deficiencies, the main one being Vitamin B12. Okay, so you could buy a supplement (I love gummy vitamins, not gonna lie). BUT you can actually get B12 in Fortified cereals (Cheerios, for example) and nutritional yeast! This was something I definitely didn’t know until I did some research.

Easy Lunch and/or Dinner meals:

Smoothie Bowls (AKA make a smoothie and sprinkle whatever toppings you want on top)

– Usually my smoothies consist of banana, frozen fruit, flax, coconut water, almond milk. I’m kind of plain and stick to that often, but feel free to make your own and switch it up! I’ve made green smoothies plenty of times with kale, spinach, and/or avocado!
– Toppings may be: granola, sliced almonds, coconut flakes, flax seed, chia seed, other fresh fruit.

Salads

Be creative with salads because they can get old quick!

Usually our salads include some sort of darker leaf (spinach), sometimes we mix other types of lettuce in (romaine, arugula). Toppings include things like: dried fruit (craisins), almond slices, tomatoes, onions, peppers, fresh fruit (strawberries), avocado, cucumbers, zucchini, garbanzo beans, vegan cheese … really whatever you have and seems to go together!

Rice/Quinoa Bowls

Quinoa bowl – The one below is a Spinach Quinoa “Risotto” that was sooo good. See the recipe here!

Poke Bowl – This is just your basic “sushi bowl” … kind of. Use white or brown rice – whatever you prefer – and throw some raw veggies on top! We cut up some carrots, avocado, cucumber, and then threw some soy sauce on there! You can definitely top it with tons of others, it was just what we had at the time! Super easy!

Rice and Veggies – Simple cook your rice (or make it in bulk so you can use it for other ones above too) and then sautéed vegetables.. throw them together and voila! If you want to add a salsa or vegan cheese.. hot sauce..liquid smoke.. the options are endless!

Mexican bowl – Again, plop whatever rice and/or quinoa in a bowl. Throw in some salsa, black beans, if you want any seitan or tofu that is seasoned to taste, avocado, vegan cheese, lettuce, tomatoes, onions.. literally whatever!!

Tacos/Wraps

Tacos – For our tacos, we used seitan ground “beef” that we bought in the frozen center. We grabbed a taco seasoning packet and then made the “meat” according to the packet – super easy! We grabbed some tortillas, cut up some tomatoes, lettuce, avocado, vegan cheese, and added some salsa.. yum! You can also just make black bean tacos.. And I’m sure you could substitute the black beans for the seitan even!? Not sure, but it’s worth a try!!

Veggie Wraps –

You know all those veggies that are about to go bad? Well, we used leftover tortillas and all our leftover veggies, put them in a wrap together and put some salsa and vegan cheese on it. Or you can add hummus. Again, the options are endless and really depends on what you have! Super simple and tasty!! And helps us get rid of veggies that are about to go bad…

Vegan Sushi

— This may be tricky, but as long as you get the sticky white rice, you should be good. You will need a bamboo wrap thing too (not sure what the fancy name is, just being real here). I didn’t do this one, my husband did. I’m a little more impatient so I think it was better for him to do 😉 Haha. We used this video to help us out!

Chili

So for this, I ended up boiling some regular potatoes first. I put them in the Tupperware containers and then poured the chili over top so that it gave a little “meal.” I based everything off of this recipe – but I’ll be honest, I really changed it and kind of just “winged it” (how I cook most of the time, let’s be real). I also really want to try making pumpkin chili one time… I had it once in the past from a co-worker and it was amazing!

Pastas

Basic Spaghetti – Okay, this is for real the most simple. Grab a vegan spaghetti sauce and some noodles of your choice. What I ended up doing to add a little extra – I sautéed some spinach, onions, and green peppers together and then added them to the sauce and let it simmer a little. I threw in some chick peas then for a little extra protein! You can get creative with this, though! And if you want to make your own sauce – by all means, go for it!

Another easy pasta dish we tried (recipe below)…

Creamy Vegan One Pot Pasta

Snacks

Hummus and pretzel crisps/veggies. Anyone who knows me knows I’ve been doing this foreverrrr anyways, haha.

Banana “Nice Cream” – There are so many varieties of this you can look up. There’s even a whole Instagram account dedicated to it! I do recommend a food processor, my blender had some issues with grinding up the frozen bananas and it was a little frustrating.

Oat balls – Amazing. I’m obsessed with both kinds. Peanut butter chocolate chip and almond butter with raisins. Note: I’ve had to change these both a little bit – I’m not sure if my proportions were off or what, but I usually end up with more dry ingredients…? Just as a heads up 😉

Complete Cookies (okay, we buy these). They aren’t too bad for you and they definitely help a sweet tooth! You may be able to find limited flavors some places, or you can order in bulk here.

I hope this gives you a good idea on how to eat vegan even with limited resources. Will it take time to learn – yes, definitely. But if you’re committed, there shouldn’t be anything stopping you!! You can do it! 🙂

Oh and if you’re in Kamakura, Japan, I highly recommend checking out Vegetus – an all vegan restaurant that we visited for a night out. It was delicious whether you’re vegan or not!! We found it on Happycow.net — which is an amazing restaurant that can help you find Vegan restaurants (or options) near you!

Good luck if you want to try it out! If not, you can still try the recipes 😉 You might be surprised!

– Jen

(Follow me on Instagram – @jennstrack19 if you want to check my vegan progress!)

Travel on a Budget: 3 Days in Singapore

November 13, 2017January 23, 2018Jennifer Palmer PT, DPT

While Singapore was not my first solo traveling trip, I was surprisingly nervous to go. That being said, I also googled a few things and learned that it is a very safe country to travel in. I didn’t have a ton of money to spend here – as I am only working part time at the moment and my student loans show no mercy towards me. So, I stuck to a budget with a goal of spending around $100 USD once in the country (flights not included).

This goal was a little more difficult in Singapore (as compared to my 2 days in Kuala Lumpur, Malaysia), and I did end up going a little over. But I now also see places where I could have not splurged as much – or even places I could have a little more.

My flight from Tokyo was, of course, the cheapest and most direct one I could find. I really didn’t want any layovers for this trip since I knew the two major cities I would be going to are also huge airports that host a lot of layovers. I flew Delta on the way there (will update my flight blog soon!) and it was great. They actually let you have free messaging on longer flights now!? So I could keep in touch with people on the ground via Facebook Messenger, iMessage, or WhatsApp. It was a nice surprise, for sure.

I landed in Changi Airport (named the best airport for many years – apparently it has a slide, which I sadly didn’t get to see) around 12:30 AM, just after midnight. When I booked this flight, I decided to forego a hostel for that first night, especially knowing that there could have been a flight delay, essentially paying for a bed I wouldn’t be sleeping in. Not to mention, the train system (MRT) doesn’t run all night long – so I would have to take a taxi to my place. Still not super expensive, but it wasn’t something I wanted to do.

I had slept a little on the flight, but I knew I would need to find somewhere in the airport to nap for a few hours. I left the arrivals area, grabbed a SIM card (it was the StarHub Happy Prepaid card – worked great in Singapore, but it wouldn’t let me roam once I left the country – which I had bought it for that reason, AND customer service couldn’t help me out… just as a heads up). I walked around a little and found a carpeted area where a lot of people were sleeping, so I joined in.

So – as I will later explain in my blog from Kuala Lumpur – I had only one carry-on bag and it had to weigh <7kg. Delta did not restrict me, but my flight back on AirAsia would. And the time of my return back to Tokyo will make it difficult for me to check a bag, as I likely would not make the train home in time. So, again, I have one book bag filled with a few outfits, some granola bars, a few of my favorite complete cookies, my neck pillow, and some toiletries. I will go further into the packing specifics on another post. 😉

So I slept a few hours, probably like 2.5 before I got up and found a charger. I knew the MRT would start running around 5 AM or so, and I wanted to get out of the airport and start exploring! I started following the signs to the MRT, got a little lost, asked one security guard (who kind of gave me a snide “it’s not open yet”) -like yes, I know, but it will be in 20 minutes and I still need to get there so — duh. The other one was very kind and laughed and tried to explain it to me. As I headed back the way I came, a man in front of me stopped and – yes- took a picture of me. There was nobody behind me at this point in time, and if you didn’t know, cell phones produced in Asia for some reason cannot have their pictures muted. So yeah – I heard it. It was strange. BUT – this is my warning for any blondes traveling in Asian countries. It happens a lot more than you think. It’s usually friendly, but sometimes it just creeps ya out. Like in this instance, when I just walked incredibly fast past this man then.

I found the MRT finally – it wasn’t tough really, just had to follow the signs. I bought an MRT card from the main desk area – again, very simple and there are signs. You can buy a ticket if you think you’re not going to take the MRT often, but it’s definitely a cheaper option than a taxi, and very easy to navigate in my opinion (even easier than Japan for me, because it’s in English!!) If you buy the MRT card, you can also use this on the buses, which I did often.

So.. Current price total: SIM card $32, MRT card: $12 — $44.

With my fancy new card, I hopped on the MRT out of the airport towards Merlion Park – one destination I wanted to see. I ended up hopping out at the River Walk area (can’t remember the stop) and did that while walking to Merlion Park. The sun was just beginning to rise – it was such a beautiful time to see everything! Mostly everything was quiet besides the few runners and bikers that I saw.

The best thing about all of this beauty — it’s totally FREE 🙂

After hanging out at the park and wandering around a little bit, I had an appointment of my own across the city. Something you could do while in this area is check out Chinatown as it’s fairly close.

My little trip consisted of meeting with a Singapore physical therapist. Before I met with him, I had a late breakfast/brunch – “Singapore style” – of Kopi with Kaya toast and soft boiled eggs. It was definitely good – but phew – it was kind of sweet for me! They really like their butter. That being said, it also kept me full for awhile. Something I didn’t know is that many people put soy sauce in their soft-boiled eggs (I eventually tried this in Malaysia and it was really good!).

My breakfast? $4. That brings the total to $48 (Singapore dollars)

After my few hours visiting the local university, I finally headed back to check-in at my hostel – and walked quite a ways. My hostel total was about $15 x 3 nights — $45 (different websites give different deals – so be sure to check that out!). Another money saver to check when booking is – do they give free breakfast?? Mine did. Although it was only bread/toast with jelly or Nutella and coffee/tea – you better believe I ate SANDWICHES before I left each morning 😉

Running total: $93

Since I was pretty exhausted that night, I decided to just shower and relax and walk around the area a little bit. I ended up finding a 7-11 where I grabbed some water and a few snacks (about $7 for 2 bottles and chips) and a hawker center that looked decent?! People were staring, so I just acted confident, as always, and ordered a rice and steamed chicken meal – which I heard you should do. So, rice, steamed chicken, and miso soup. How much? $3.50 !! WINNING!

Total: $103.50

I went back to the hostel that night and planned what I was going to do the next day. I decided to go to Little India and then see Gardens By the Bay – one of the highly rated attractions. Best part about it? You can go see most of the Gardens for FREEEEEE (such a great word, am I right?)

The morning started out rainy. Again, I had a lovely breakfast of Nutella and peanut butter sandwiches (hehe). I stocked up with my carbs before I hit the road. With the SIM card, it was super easy to navigate everywhere. One thing I did learn though – is to make sure you make it OBVIOUS that you want a bus. They will not stop. I had one pass me twice. I also don’t even think it was trying to come over, but hey, whatever. It happened to another guy too – so it wasn’t just me. They don’t wait for anyone here!

Anywho, so Little India was a cute little area. I just walked along and window shopped – knowing I had no room for expansion in my backpack. There are a lot of cheap things in this area – so if you want to spend a little, go for it.

I ate lunch at an Indian place. Azmati and chicken curry. It was really good! The other thing about Asia though, is that there are NEVER napkins out freely – I swear. Many people bring their own napkins. So here I am, napkin-less, being stared at, half-dying from the heat of the curry (I can’t handle a lot of spice), trying to make sure it’s not on my face or in my hair yet still feeling like it’s everywhere…yeah, you get the point. It was all very delicious and.. $5 ! woo woo!

Total: $108.50

I then headed out and went to the Gardens by the Bay. I wanted to time this right, because I knew there was a light show at night, but I still wanted to explore the Gardens during the day. To me, there is PLENTY to do in the free area that can entertain you for hours. It wasn’t hard, and I didn’t even get to see everything. I ended up buying the access to the others ($22 on a discount website for Cloud Forest and the Flower Dome) and splurged a little. But, truthfully, I regretted it. It was great, and if I had been there longer, I think I could’ve enjoyed it more. But for one day to do everything, it was a little overwhelming and kind of redundant. Stick to the free things if you only have a day, for sure.

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As you can see, the trees were beautiful, and the gardens, again, were amazing. It was a very relaxing time just wandering and looking around. Not to mention the light show was awesome! Hands down the best light show I have ever seen. Again – all free!

Total: $130.50

After the light show, everyone booked it out to the MRT. I ended up staying back a little and just hung out. Oh, by the way, the port-a-potty they had also had a plant in it!? Crazy, right? Made me laugh.

I still hadn’t had dinner by this time, and I was hungry. Just because of time – I ended up stopping at the 7-11 on the way home. I grabbed a sandwich and, yes, some more snacks. Probably ended up totaling $7.

Total $137.50.

The next morning, I woke up and wasn’t too sure what to do – but I knew I wanted to enjoy the sun (and heat) a little bit. Of course, I ate my free breakfast 😉 and then decided to head to East Coast Park around 11 AM or so. I wasn’t in any rush, so it wasn’t a huge deal when I left. I used my google maps and took the bus to the park. It was definitely a hot day — I wish I had wore my bathing suit instead, haha.

I chilled out by the beach for a bit. This park is less of a swimming place and much more of an activities kind of place. Many people rented bicycles and there was even a fitness park! I ended up doing a little workout before I left. After about an hour, I decided to go for a little stroll to find some water or something cold.

My lunch ended up being some frozen yogurt. Not the healthiest – but I’m an adult, right 😉 haha. It was filled with fruit and just hit the spot! And it was $5!

Total $142.50

After I was done relaxing in the heat, it was already 2-3 PM, so I headed back to the hostel. I decided to shower once I got back and take a little nap (because I love naps, and that heat drained me!)

Now this is where I ended up splurging. I went to find Chili Crabs (which I knew would be a little expensive).. I ended up spending $30 on the crabs and $2 on my smoothie. Being from Maryland, I felt like I had to at least compare these Singapore crabs (they’re actually from Sri Lanka) to the crabs I’m used to. They were good, but they were sweeter than I am used to. And of course, they didn’t have any old bay seasoning. The way they are cooked, they ended up being extremely easy to break apart and eat.

This puts my total at $174.50 Singapore dollars. I ended up stopping at 7-11 again after to grab another bottle of water and a Milo drink for the morning (just to try it). Totaling $3. So, $177.50.

Of course, I had to be up early for check out in the morning to head to my bus. I snagged a few sandwiches and headed to the bus station (which I had chosen to be nearby). It was a little confusing to get there – but I gave myself extra time to find it, luckily.

My total cost of my Singapore trip was $177.50 Singapore dollars, which converts to about $130 USD. Things I would recommend to anyone for next time: Don’t book the extra things at Gardens By the Bay. That alone will save you $20 or so. Also, if you don’t want to splurge on the crabs – Don’t! Again, that will save you $30 right there. So maybe instead you would eat a $5 dinner. If I hadn’t spent money on those 2 things, I would have saved about $45 on my trip, which would mean I would have spent $132.50 Singapore dollars AKA $97 USD! You can also save money by not purchasing the SIM card (take another $30ish dollars away). Wifi isn’t always accessible, but everything is in English and you can usually ask someone or find a coffee shop with access!

And of course, you can DEFINITELY splurge if you have the money! I just chose not to 🙂 This is just a guide from what I recommend.

Another note, I ended up taking a bus to Kuala Lumpur. It cost me about $20 Singapore dollars when I booked in advance. If you book there, I believe it cost people $30. Many people fly as it is quicker, but it can cost $50 or more. Again, not a bad price – but I enjoyed seeing some of the countryside as I traveled between countries. I think I left around 9:30 AM and arrived in Kuala Lumpur around 4 PM.

Stay tuned for my Kuala Lumpur on a budget blog! I spent even less in Malaysia than I did in Singapore. So awesome!

Until next time,

Jen

Dynamic Stretching: Part 1… “The Basics”

March 1, 2015March 1, 2015Jennifer Palmer PT, DPT

If you’re like me, you’ve been doing dynamic stretches practically forever. I grew up always performing “high-knees,” “butt kicks,” and “toy soldiers” before every practice and game. Of course, in college I actually had an idea of what I was doing, compared to when I was younger, but nobody ever told me why I was doing these. My coaches would just tell me to stretch and that it was good for me and I, as well as my teammates, accepted that. Lucky for me, I got into a profession where I can finally figure out why I am doing these sometimes-crazy-looking-stretches and how they are going to affect my performance. Let’s start off with the basics… but, beware, this is part of an in-service presentation I am giving, so it can get a little science-y.. (I left a “bottom line” portion at the end of each paragraph or so, if that helps)

What is dynamic stretching?

Dynamic stretching is a form of stretching that incorporates whole body movements in an active manner. Dynamic stretching does not involve bouncing movements that exceed comfortable ranges of motion. This type of stretching would be known as ballistic stretching and is not to be confused with dynamic stretching.¹

What is the difference between dynamic and static stretching?

Static stretching is a prolonged, passive stretch that is generally held for a few seconds up to about 90 seconds. Static stretching is said to acutely depress the reflex activity of a muscle and increase muscle compliance. The increase in muscle compliance then increases the time to and decreases the force of a myofibril contraction during muscle performance.¹ In a comparison, dynamic stretching is said to help preserve this muscle-tendon unit stiffness in order to enhance muscle performance instead of stunt it. In a systematic review, static stretching of the upper body was shown to have neutral effects on power, whereas it was shown to negatively affect physiological outcomes (Ex: heart rate, vO2).² It is important to include static stretching in sports that require static flexibility; however, 90 seconds of static stretching has been shown to produce impairments on dynamic movements.³

Bottom Line: Static stretching is okay to improve passive motion; however, it can impair activities that involve strength and power.

Why does it work? (#science)

One theory behind dynamic stretching is known as postactivation potentiation (PAP). PAP increases cross bridge cycling via an increase in myosin phosphorylation of the regulatory light chains.³ In more basic terms, by performing similar muscle contractions, you are conditioning the muscle and its contractility so that it is more, in a sense, “ready” to perform more contractions. Essentially, you are progressively warming up the muscle so that it may contract more efficiently in the exercise that follows.⁴ PAP is said to increase the rate and ability of a muscle to develop force; therefore, it influences and increases a muscle’s mechanical power.⁴

Some other thoughts behind dynamic stretching include its ability to increase heart rate and increase core and muscle temperature. By doing so, the blood flow is increased throughout the body so that the body may move more efficiently during activity.⁴ In addition, dynamic stretching is said to improve kinesthetic awareness and enhance motor unit excitability.¹

Bottom Line: Dynamic stretching can enhance your performance in activities that follow by improving a muscle’s effectiveness and efficiency during muscle contractions. It helps get your muscles ready for the important stuff!!

How will this benefit me?

If you are performing any sort of active motion, you will want to initiate dynamic stretching instead of static stretching. While static stretching has been shown to improve static flexibility, most required functional tasks and/or exercises involve active movement, which requires dynamic stretching to improve.

Types of dynamic stretching are important to consider based on the tasks/activities performed after the warm up.^{2, 4} The velocity and intensity of lower body dynamic stretching has been shown to impact and improve both vertical jump and long jump performance.⁴ In a study by Chatzopoulos et al, dynamic stretching was shown to improve balance on a stability board whereas static stretching was shown to harm balance. This is attributed to the quick movements needed to maintain one’s balance.

It should be noted that if a person already has a way they like to warm up or some sort of stretching routine involving static stretching that they are not willing to change, static stretching deficits should not exceed 5% in comparison to no stretching.⁶

Bottom Line: When you move, you use your muscles differently than when you stand still. So why warm up by standing still? Get out there and MOVE to warm up! Also, just remember that some people are stubborn and won’t change their ways – they shouldn’t be negatively affected greatly by static stretching before exercise, but they will be affected (and YOU will be better than them, duh).

Does it affect the upper and lower body differently?

Currently in the literature, there are no articles to investigate the effects of dynamic stretching of the upper body and its impact on injury prevention. High-load dynamic stretching in the upper body (anything greater than 20% of maximum effort, ex: plyometrics) has been shown to improve strength and power with good evidence, flexibility, and delayed onset muscle soreness with moderate evidence .² In the upper body, there was also no benefit in performing low-load dynamic stretching (Ex: repetitively gripping a sponge) prior to exercise. Specifically for those who play baseball, dynamic task-specific warm-ups (swinging a bat) at the standard weight has been shown to improve swing speed more than using a heavier or lighter weighted bat.²

One study of the upper body also demonstrated that a low-volume dynamic stretch of the pectoralis and triceps brachii muscles showed a decrease in the maximal isometic peak force during the bench press exercise. There was also no short-term effect on the time to maximal isometric force or the rate of force production following dynamic stretching. In the same study, there was a negative effect induced by static stretching when performing upper body tasks after. This must be taken with caution, again, as we do not know the proper load and duration to perform dynamic stretching. We must also consider that there are articles out there that say otherwise (that dynamic stretching improves performance). Additionally, the 2 dynamic stretches performed in this study may not have been appropriate in fully stretching or warming up the muscles in a dynamic, task-specific manner.⁷

In regards to the lower body, a study by Curry et al. compared static vs. dynamic stretching in females in their mid-20s and its effect on lower body balance, force production, reaction time, and power output. In these females, who were recreational athletes, time to peak performance improved with both 10 minutes of dynamic stretching and a 5 minute bout of light cycling. These improvements were seen 5 minutes after stretching had occurred. 30 minutes after stretching had occurred, time to peak force began to increase with the basic cycling; however, it remained fairly steady in those who performed the dynamic stretching routine.

Bottom Line: There is little to no research out there to show any evidence in dynamic stretching decreasing a risk of injury in the upper or lower body. While there is more research on the lower body, both the upper and lower body generally seem to have impairments of power and strength following static stretching while there are enhancements following dynamic stretching. Wade cautiously, though, some studies don’t have many subjects.. There definitely needs to be more research.

How long should I stretch?

For upper body dynamic stretching, there has been no research to determine proper load and duration that provides maximal effectiveness to improve strength and power.²

In regards to lower body dynamic stretching, a study by Ryan et al. compared 3 groups who performed different warm-up activities: A-5 minute jog and 6 minutes of dynamic stretching, B-5 minute jog and 12 minutes of dynamic stretching, C-5 minute jog only. Those in group B who performed a longer duration of dynamic stretching showed a decrease in muscular endurance, attributed to a decrease in high-energy phosphates and a repeated high-intensity contraction to failure. Both groups A and B showed an increase in vertical jump height and velocity. Group C, who did not perform any dynamic stretching, had no effect on the vertical jump; however, did show an increase in flexibility. Overall, the most appropriate volume, as concluded by this study, indicates that 6 minutes of dynamic stretching after a 5 minute jog is adequate in stretching the hip and thigh musculature, improving vertical jump performance, and not affecting muscular endurance. To be noted, this study was performed with recreationally active men in their mid-20s.

Bottom Line: Don’t stretch too little because you won’t see a great effect. Don’t stretch too long because then you’re going to have tired muscles. Simple as that. 6-10 minutes is most likely adequate; however, it will depend on how “in shape” or well-trained you are. The higher training you have, the more it will take before you fatigue.

But I’m not a young, 20 year old, competitive athlete?

This will still help you!! While most of the literature focuses on high-school aged to mid-20s recreational and competitive athletes, a study by Behm et al. recognizes the similarities and differences in dynamic stretching effects in regards to young and middle-aged men. The study mentions that dynamic stretching provides similar improvements to static flexibility as static stretching does. It also notes that static stretch-induced impairments and dynamic stretch-induced enhancements of the countermovement jump are not affected by the difference in age, meaning they respond similarly as the younger counterparts. The article also mentions previous literature that discusses that older, untrained women experienced a deficit in strength training following static stretching, similar to younger female athletes studied. While these demonstrate similar effects on middle-aged people, we must keep in mind the elderly and frail have not yet been studied in regards to effects of dynamic stretching.

Bottom Line: It doesn’t matter how young or old you are, dynamic stretching still works the same! Age is not an excuse!!

Is there anything I should be cautious about?

Caution should be taken when performing dynamic stretching prior to any activity that may have a higher risk of knee injury in regards to an improper hamstring:quadriceps ratio.⁸ In a study by Costa et al, an overall decrease in hamstring:quadriceps ratio was seen, suggesting that the hamstrings may respond to this type of stretch differently than the quadriceps. The hamstrings provide a great deal of eccentric control in the last 3^rd of the swing phase during running as well as assist the anterior cruciate ligament (that darn ACL everybody hears about..) in decreasing anterior tibial translation. As this study shows a decrease in peak torque of the hamstrings, caution must be taken in order to maintain a proper balance between muscles. While this is not a true contraindication and more of a precautionary measure, clinical judgment should be made before introducing dynamic stretching. As this is only one study, there should be further research to determine if there is a higher risk of injury in certain regions after performing dynamic stretches of particular muscles or if this study is merely an outlier.

Bottom Line: There is one study that says to be cautious performing dynamic stretching before activities that cause a higher risk of knee injury (basketball, soccer, etc.) HOWEVER, this is ONE study and to be conclusive to the larger population, there needs to be more standardization, subjects, and further research in general. Proceed with the same caution you would proceed with when performing any activity.. just use your noggin!!

So… now you know the basics. Stay tuned for some upcoming posts with different examples and what they are targeting, etc.

Have a great day! 🙂

-Jen

References

¹Curry B, Chengkalath D, Crouch G, Romance M, Manns P. Acute effects of dynamic stretching, static stretching, and light aerobic activity on muscular performance in women.Journal Of Strength And Conditioning Research / National Strength & Conditioning Association [serial online]. September 2009;23(6):1811-1819. Available from: MEDLINE, Ipswich, MA.

²McCrary J, Ackermann B, Halaki M. A systematic review of the effects of upper body warm-up on performance and injury. British Journal Of Sports Medicine [serial online]. February 18, 2015;Available from: MEDLINE, Ipswich, MA.

³Samson M, Button D, Chaouachi A, Behm D. Effects of dynamic and static stretching within general and activity specific warm-up protocols. Journal Of Sports Science & Medicine [serial online]. June 1, 2012;11(2):279-285. Available from: MEDLINE, Ipswich, MA.

⁴Ryan E, Everett K, Fiddler R, et al. Acute effects of different volumes of dynamic stretching on vertical jump performance, flexibility and muscular endurance. Clinical Physiology And Functional Imaging [serial online]. November 2014;34(6):485-492. Available from: MEDLINE, Ipswich, MA.

⁵Chatzopoulos D, Galazoulas C, Patikas D, Kotzamanidis C. Acute effects of static and dynamic stretching on balance, agility, reaction time and movement time. Journal Of Sports Science & Medicine [serial online]. May 1, 2014;13(2):403-409. Available from: MEDLINE, Ipswich, MA.

⁶Behm D, Plewe S, Button D, et al. Relative static stretch-induced impairments and dynamic stretch-induced enhancements are similar in young and middle-aged men. Applied Physiology, Nutrition, And Metabolism = Physiologie Appliquée, Nutrition Et Métabolisme [serial online]. December 2011;36(6):790-797. Available from: MEDLINE, Ipswich, MA.

⁷Leone D, Pezarat P, Valamatos M, Fernandes O, Freitas S, Moraes A. Upper body force production after a low-volume static and dynamic stretching. European Journal Of Sport Science [serial online]. 2014;14(1):69-75. Available from: MEDLINE, Ipswich, MA.

⁸Costa P, Herda T, Herda A, Cramer J. Effects of dynamic stretching on strength, muscle imbalance, and muscle activation. Medicine And Science In Sports And Exercise [serial online]. March 2014;46(3):586-593. Available from: MEDLINE, Ipswich, MA.

Give me liberty or give me death! Or just give me food.

January 26, 2015January 26, 2015Jennifer Palmer PT, DPT

I’m sure you have all heard that exercise is not as effective without proper nutrition. I mean, think about it.. If you spend x amount of time working out and then get home only to find yourself eating a bunch of cookies, you are fighting a continuous battle against yourself! Recently I had a discussion with a few friends in regards to different smoothies, ways to use protein, recipes, etc. While this is not necessarily my “specialty,” I have a few recommendations based on the foods that I eat on a fairly regular basis for breakfast or a snack/dessert. These are just some quick and easy things that I do (because I’m usually on a time crunch) that are healthy and can be as packed with protein, or not, as you want! 🙂

Before I start this off, I just want to say that one of the most beneficial kitchen items I have ever bought is a personal Hamilton Beach blender. I use this thing ALL of the time! Obviously, you can pick any blender to make a smoothie in- but in case you want to see what I have, here is a link: http://www.hamiltonbeach.com/personal-blenders-single-serve-blender-with-travel-lid-black-51101b.html

Option 1) Double Decker Protein Pancake Madness
There are 2 parts to this recipe. First, you have to make a few protein pancakes. Next, you have to build a beautiful (or not so beautiful) fortress of deliciousness. Here is the recipe I use for protein pancakes:

1/4 cup egg whites (equivalent to 1 large egg)
1/2 banana
Protein powder (any flavor depending on what you have!)
Cinnamon (optional, again depending on what protein you use)

Mix these 3 and then make it on the stove like a normal pancake! If you don’t have protein powder, you can easily substitute and just use 1 whole banana and 2 eggs to make the pancakes! There are literally SO many different ways you can make these – feel free to try throwing in oats, flax/chia seeds, other fruit inside the pancake – EXPERIMENT!! That’s what makes this fun 🙂

After making these protein pancakes, gather up a few of the following ingredients for part 2:
Plain greek yogurt, granola, flax/chia seeds, cinnamon, ANY fruit you like (blueberries, strawberries, more bananas, raspberries, etc).

Separate your protein pancakes, then layer them filling each layer with greek yogurt and whatever YOU want to add! I added bananas into each layer (pictured above). Then, once you put together your leaning tower of pancakes, top it with a little more greek yogurt, some granola, and more fruit. I also added flax and chia seeds because I like to add a little extra omega-3s to my life. Then, I sprinkled a little cinnamon on top to add a little flavor without adding any sugar.

Option 2) Don’t have anything to make protein pancakes? Or no time? Just make a yogurt parfait then, with all the ingredients from the second part of the above recipe! Just as great, slightly less protein-packed, but an awesome breakfast/snack nonetheless!! (See below – yum!)

Option 3) Smoothies or smoothie bowls!

Sweet vintage bowls, right? 😉 Above, I made a chocolate strawberry protein smoothie bowl. The ingredients I used are: chocolate protein powder, dark chocolate almond milk, a cup full of chopped strawberries, flax and chia seeds. Then, I put it in a bowl, cut up a few more strawberries and sprinkled some granola, and more flax and chia seeds into the mix. Super quick and easy! And if you don’t want to make the bowl, you definitely don’t have to!! You can just drink the strawberry-chocolate deliciousness by itself.

Like I said before, there are really no set recipes to these smoothies – have some fun and enjoy yourself! If you like the taste of something, throw it in there! Some items I throw in on a regular basis are:

Bananas – always gives a nice texture. Plus they are inexpensive (comparatively) and delicious!
Kale/Spinach – making a green smoothie always makes me feel a little better about myself.. just be careful and make sure it is completely blended up before you drink it!
Avocado- Just make sure it is not TOO ripe – because it then alters the flavor and can taste a little strange. I’d also recommend not using an avocado and a banana together because the smoothie may then become a little too thick for your drinking likes!
Oats – this tends to fill me up a little more when I have these in my smoothies.
Strawberries, blueberries – they are just always yummy and blueberries are packed with antioxidants, so why not?
Milk – whether it be almond milk (lower in fat), soy milk, or regular milk (higher in protein), I use milk as a base a good bit to help smooth everything out.
Coconut water – This helps to improve hydration even more than just regular water!

Just remember, when noting any recipe, you must realize that EVERY person is different based on the lifestyle you live, what activities you do, etc. Whereas a weightlifter or bodybuilder may be looking to have a high protein diet and at times disregard carbohydrates, a runner or endurance athlete may look to increase carbohydrates – especially the week before a race. It is also important to recognize how your body responds to various food types. Allowing at least 3-4 hours between a meal and a contest/race/competition may be necessary for those who experience any sort of anxiety or stomach aches, whereas a pre-workout meal 10 minutes before may be necessary for those who experience hunger during their workout – because hunger can be distracting!! Especially if you get hangry (so hungry, you get angry) like I do ;). Even with those who compete in all day tournaments, track meets, or other longer competitions, eating throughout may be necessary to keep energy levels high and maintain proper nutrition. (1) Make sure you listen to YOUR body and what it is telling you!

I will post more recipes that are easy to do as I make them! I have to admit it can be difficult to take pictures of the food, however, because I like to eat… and sometimes stopping to take a picture is just too long of a wait. 😉

Have a great day, everyone!! I hope you get a chance to experiment with some healthy foods soon. Maybe even try them tomorrow morning? 🙂 Look forward to more exercise moves next post!

1) Baechle, T. R., Earle, R. W., & National Strength & Conditioning Association (U.S.). (2008). Essentials of strength training and conditioning. Leeds: Human Kinetics.

“One cannot think well, love well, sleep well, if one has not dined well.” ―Virginia Woolf