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Crepitus: Expectations vs. Reality

By | Recovery | No Comments

Crepitus is the menacingly-named phenomenon of noises produced by a joint during movement. It is common to hear snaps, crackles, and pops when flexing or extending a knee or an elbow. At times, these noises can be accompanied by a sensation of mechanical stiffness. When combined, these can cause distress, evoking deep-seated fears people have about their bodies “wearing out”. It leads many to seek consultation with a health care provider, even in the absence of pain or functional limitation. The good news is that not only is crepitus very common, it does not necessarily portend dire outcomes, nor should…

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Shoulder, Part IV: The Rotator Cuff Teardown

By | Training | No Comments

Reviewed & Edited by Austin Baraki, MD Introduction The “rotator cuff” is a set of four muscles around the glenohumeral joint including the supraspinatus, infraspinatus, subscapularis, and teres minor (see figure). These muscles all originate from the scapula, insert at various points on the humerus, and serve multiple coordinated functions including abduction, adduction internal rotation, external rotation, and stabilization. Each muscle is considered to have its own unique action on scapulohumeral movement (sometimes described as scapulohumeral rhythm, as discussed in the first installment of the shoulder series here). Unfortunately, the cuff muscles are often viewed as both the source and…

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Handling Hunger

By | Nutrition | One Comment

If you’ve ever tried to lose weight, have ever missed a meal, or have even just driven by your favorite bakery…chances are you’ve experienced hunger. Hunger can be annoying, distracting, and is frequently blamed as “diet derailing,” yet it’s part of our normal physiology and something that can’t be avoided entirely. Background Hunger is defined as a feeling of discomfort caused by lack of food, followed by a desire to eat. Conversely, satiety is the feeling of being full and no longer desiring a meal. Hunger and satiety both stem from the interactions of biological, psychological, and social factors, which…

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Nutrition Science, Part IV – Moving Forward: Improving the approach

By | Nutrition | No Comments

It is important to note that the assumptions discussed in the last article are not arbitrary to the biomedical model, but legitimized through common sense in the context of a given research topic (32). A common-sense approach to nutrition, therefore, is one which can legitimize a modified approach to scientific inquiry into diet-disease relationships. Although not exhaustive, a number of potential features and alternatives could modify the approach. The first is to move away from the narrow focus on isolated nutrients/compounds, to emphasizing food as the exposure of interest and design “whole-diet” interventions which reflect that the fundamental unit in…

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Nutrition Science, Part III – The Awkward Fit: RCTs and Nutrition Science

By | Nutrition | One Comment

In the second part of this article series we discussed the utility, limitations, and misconceptions related to the prospective cohort design for nutrition science. As discussed in part I, the reductionist biomedical model and its gold standard randomized controlled trial (RCT) is ill-equipped for studying complex dietary patterns in a way that can effectively inform public policy. In this article we will examine the randomized controlled nutrition trial design in more detail. ..there are fundamental differences between the subject of inquiry for which the RCT model evolved to investigate (drugs) and the subject of inquiry to which it is now…

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Nutrition Science, Part II: The Prospective Cohort Design

By | Nutrition | No Comments

In the first article in this series we discussed the history of nutrition science and traced its evolution alongside the biomedical model. We also introduced the discussion of nutritional epidemiology in comparison to the “gold standard” biomedical trial design: the randomized controlled trial. In this second article, we’ll discuss the utility, limitations, and misunderstandings about the prospective cohort study design for nutrition science. Prospective cohort studies are the only practical research design to investigate the long-term relationship between diet and disease, particularly with the preponderance of current evidence in nutrition indicating that whole diet patterns are more informative of diet-disease…

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Nutrition Science, Part I: How Did We Get Here?

By | Nutrition | 4 Comments

Introduction To anyone versed in biomedicine, the so-called “hierarchy of evidence” is well-established and unquestioned. The randomized, double-blind, placebo-controlled trial (RCT) is considered the gold standard trial design, because it offers the ability to randomly allocate a treatment, minimize potential sources of bias, and compare the exposure or intervention of interest to a placebo. There is absolutely nothing wrong with this model, or this hierarchy … if the subject of inquiry is pharmaceutical drugs or the molecular mechanisms of disease. At its core, the biomedical model is based on a presupposition that all disease can be studied with such a reductionist…

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The Shoulder, Part III: Internal Impingement

By | Training | No Comments

by Dr. Michael Ray and Dr. Austin Baraki In part 2 of our shoulder series we discussed the topic of “shoulder impingement”, which is commonly understood as the mechanical compression of the tissues beneath the acromion process, resulting in pain or dysfunction — better known as external impingement. We described the biomechanical theory behind this diagnosis, and examined the available research evidence on the topic. Ultimately, we found a lack of compelling evidence — and in fact, a substantial amount of contradictory evidence — for our historical mechanically-focused understanding of this topic. Another lesser-known type of impingement, known as “internal” impingement,…

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The Shoulder, Part II: External Impingement

By | Mobility, Training, Uncategorized | 4 Comments

by Dr. Austin Baraki, Dr. Michael Ray, and Dr. Derek Miles. In the first article of this series we discussed the concept of “normal” or “abnormal” scapular movement (i.e., scapular dyskinesis), which is the pathomechanical foundation upon which other shoulder-related diagnoses and narratives are built. “Shoulder impingement” is one of these ideas that is commonly discussed in the coaching, rehab, and orthopedic worlds. The narrative describes soft tissue structures around the shoulder (e.g., rotator cuff tendons and bursae) becoming compressed between the bony surfaces of the joint. Two types are discussed in the scientific literature: “internal” and “external” impingement. Let’s…

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The Shoulder, Part I: Scapular Dyskinesis

By | Training | 5 Comments

The shoulder joint is complex, and pain affecting its use in daily activities and sport is common. This article series will review common shoulder diagnoses, critically assess the associated narratives provided to patients, and describe their impact on real-world outcomes. We will begin with the assessment of the scapula and its movement. The interaction between the scapula, thorax, and humerus during shoulder movement has been termed “scapulohumeral rhythm” or “glenohumeral rhythm”. The underlying assumption in this context is that normal scapulohumeral rhythm is well-defined in humans. Scapular dyskinesis, then, refers to any abnormality or deviation from “normal” kinematics of the…

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