Category Archives: exercise

Urban Cycling, Part 2: Hit and Run Drivers and Bike Helmets

A doctor colleague of the skeptical cardiologist was riding his bike on a quiet road here in St. Louis recently when he suddenly awoke in a hospital bed. His friend who was riding in front of him heard a crash, turned and saw a black car making a U-turn and speeding off. Fortunately, the good doctor, suffered only the concussion and multiple bruised ribs and will live to ride again

He is in his seventies and I asked him if he would, indeed, climb onto the saddle of a two-wheeled vehicle in the future and he indicated yes, but never again on roads shared with cars.

I also inquired as to the state of his bike helmet post-trauma: it was shattered into multiple pieces.

In a previous post I pondered the question: Does cycling to work make you more or less likely to die?

cycling to work for many individuals would provide the daily physical activity that is recommended for cardiovascular benefits. However, cycling in general, and urban cycling in particular, carries a significant risk of trauma and death from accidents and possibly greater exposure to urban pollutants.

In the Netherlands cycling to work likely makes you less likely to die.

One study quantified the impact on all-cause mortality if 500,000  people made a  transition from car to bicycle for short trips on a daily basis in the Netherlands and concluded

For individuals who shift from car to bicycle, we estimated that beneficial effects of increased physical activity are substantially larger (3–14 months gained) than the potential mortality effect of increased inhaled air pollution doses (0.8–40 days lost) and the increase in traffic accidents (5–9 days lost). Societal benefits are even larger because of a modest reduction in air pollution and greenhouse gas emissions and traffic accidents.

In St. Louis, however, I suspect my longevity would be substantially reduced by cycling the 15 miles of heavily trafficked roads from University City to St. Lukes Hospital in Chesterfield. I would be cheek to jowl with SUVs, pick-up trucks, and mini-vans full of distracted, texting and chatting commuters.

Should  Bike Helmets Be Mandated?

Like most people I know, my colleague wears a bike helmet religiously when cycling. He, like many who have shared their bike accident stories with me, believes the bike helmet saved his life. I certainly can’t refute that possibility but it is impossible to know with certainty.

I’ve posted my analysis of the wisdom of mandating bike helmets here and even after hearing the good doctor’s story,  I still refuse to wear one.

Typical skeptical cardiologist bike riding garb. No helmet but safari (not bee-keeper) hat because sun is not his facial friend.

A commonly cited statistic is that bike helmets reduce serious head injuries by 85% and brain injuries by 88%.  This comes from an observational  study  published in 1989 which has serious limitations and has never been reproduced. For an exhaustive critique of these data see here.

I think a fair summary is in this British Medical Journal editorial which is behind a paywall but can be reviewed as a PDF here (bmj-june-2013.pdfbicycle helmets and the law).

 

Larry Husten, a journalist, who writes an excellent cardiology blog at cardiobrief.org apparently agrees with me and has recently written about “The Unintended Consequences of Bike Helmets.”

I encourage everyone to read his post which can be found here.

Here is his main point:

I am opposed to public health campaigns that focus on helmets, thereby implanting in people’s minds the dangers of cycling. Instead, in my view, the public health agenda regarding cycling should be to promote the far greater health benefits of cycling. The overarching goal of any public health campaign should be to dramatically increase cycling in the US, thereby encouraging physical activity and helping to reduce obesity and diabetes.  In tiny Denmark, by way of example, one expert, Lars Bo Andersen, PhD, of Western Copenhagen University of Applied Sciences, reports that “26 persons were killed in the whole country in cycle accidents last year, but more than 6000 deaths were avoided due to the huge amount of physical activity this behavior is a result of.”

Circuitously Yours,

-ACP

Speaking of Holland, the skeptical cardiologist will be visiting this hotbed of cycling, tulips and dikes in July.

I’ll be staying in Haarlem but wandering around the country researching cycling, assisted suicide and the Dutch dairy industry which may be responsible for the Dutch having gone from being among the shortest people in Europe to being the tallest in the world.

Nonskeptical Musical Thoughts On Dick Dale and the Dead While Running For Longevity

Since determining that running would lower my cardiovascular risk and that it was actually good for my wonky knees (running is associated with a lower risk of ostearthritis or hip replacement, see here), I’ve been trying to do it regularly.

It has become therapeutic in many ways, aiding sleep and reducing stress levels. And, unlike my bike riding adventures, I have yet to fall and injure myself running and I don’t get dirty looks for not wearing a helmet.

I’ve even contemplated running 5 kilometers,  although not as part of any formal exhibition: just a personal , private goal. To this end I have for the first time recently run 4 kilometers.

Listening to music during these longer runs greatly helps the time pass and sometimes I am able to find songs which fit my running cadence, albeit not through any systematic analysis but through mere serendipity. I let my entire musical collection (nicely streamed by Apple music) be my running playlist and this ranges from the Talking Heads to Thelonius Monk to Bach.

This morning’s run (the second time I reached 4K) I was aided by two songs: one by the king of surf guitar, the other by the kings of psychedelic jam rock.

Dick Dale and Miserlou

Although, Dick Dale was huge in the early sixties, he did not register on my musical radar until  I watched Pulp Fiction and in its dazzling opening scene and  was jolted by Dale’s staccato machine gun guitar riffs alternating with his plaintive trumpet solo on  “Miserlou“.

I immediately strapped on my Strat and began trying to emulate his unique playing style.

Here’s Dick and the Del-Tones performing their version for the movie “A Swinging’ Affair”

This version contains none of the rhythmic power and electrifying guitar attack of the single and the band appears to be on tranquilizers. To make matters worse, Dick  doesn’t play that magical melodic moaning trumpet solo which contrasts so brilliantly with the pile-driving reverb-drenched guitar riffs on the original version.

You can see some of the power of the left-handed Dale in this live performance of Miserlou from 1995 but alas, no trumpet solo.

Dick Dale, remarkably, is still touring and playing well at age 80.

As fortune would have it the beats per
minute of this song is 173 which fits my preferred running speed stride cadence perfectly.

The Other One (Not Cryptical Envelopment)

The next song to aid me on my run was a live performance from the Grateful Dead’s 1972 European Tour  which is 36 minutes long.

I was slow to revere the Dead but when I first listened to their live album Europe ’72 I was hooked. Instead of studying in college, I spent way too many hours playing Sugar Magnolia (and Blue Sky, et al..)  thereafter.

The Other One highlights their free and wild improvisational style. While running I could focus on what Keith Godchaux was doing on the piano and that takes me to a psychic place in which I feel no pain.

Please excuse my hubris but I am convinced that I could have done a good job as the Dead keyboardist.  It’s probably a good thing I never got that gig, however, as it carries a very high mortality rate (not to mention that I’m a much better cardiologist than keyboardist.)

As Billboard pointed out in its obituary on the last keyboardist, Vince Welnick (who committed suicide by slitting his throat at age 55 in 2006):

Welnick was the last in a long line of Grateful Dead keyboardists, several of whom died prematurely, leading some of the group’s fans to conclude that the position came with a curse.

Welnick had replaced Brent Mydland, who died of a drug overdose in 1990. Mydland succeeded Keith Godchaux, who died in a car crash shortly after leaving the band. And Godchaux had replaced the band’s original keyboard player, Ron “Pigpen” McKernan, who died at 27 in 1973.

Last week a very good Grateful Dead documentary (Long Strange Trip) was released on Netflix. I’ve been somewhat mesmerized by what I’ve watched so far.  For example, at one point, Phil Lesh reveals that Jerry Garcia asked him to join the band as their bassist even though he had never played the instrument. (If only he had asked me!)

Strangetrippingly Yours

-ACP

N.B. Miserlou is a very old folk song with a scale that sounds exotic to Western ears: the double harmonic scale

per Wikipedia

The song’s oriental melody has been so popular for so long that many people, from Morocco to Iraq, claim it to be a folk song from their own country. In fact, in the realm of Middle Eastern music, the song is a very simplistic one, since it is little more than going up and down the Hijaz Kar or double harmonic scale (E-F-G#-A-B-C-D#). It still remains a well known Greek, Klezmer, and Arab folk song.

 

 

 

Longevity: Lifespan, Healthspan and Swimming Underwater At Age 98

img_7056
Eugene and Naomi.

The skeptical cardiologist has a few nonagenarian patients who seemingly defy the ravages of aging and remain vibrant and active into their late 90’s.

Eugene, for example, still ballroom
dances regularly with his wife, Naomi and swims underwater significant distances.

In this video, recorded when he was 97, you can see him swim the length of a swimming pool underwater

As life expectancy at birth has increased  from 35 years in 1900 to over 80 years now, we see more and more individuals reaching their nineties. Ongoing research seeks to further extend our lifespan.

But just as important as increasing lifespan is increasing healthspan, the portion of the life span during which function is sufficient to maintain autonomy, control, independence, productivity and well-being.

Eugene is an example of someone with a long lifespan and healthspan and this is what we truly seek, the combination of living well and living long.

Peter Attila writes that lifespan is driven by how long one can avoid the onset of diseases caused by atherosclerosis such heart attacks and strokes (see my  discussions on subclinical atherosclerosis here), cancer and neurodegenerative disease.

Healthspan,  Attila writes, is about preserving three elements of life as long as possible:

  1. Brain—namely, how long can you preserve cognition and executive function

  2. Body—specifically, how long can you maintain muscle mass, functional strength, flexibility, and freedom from pain

  3. “Spirit”—how robust is your social support network and your sense of purpose.

Problems with the body result in frailty, recognized as a major cause of disability and related falls, hospitalizations and death in the elderly.

The single best tool for warding off frailty appears to be physical exercise.

img_7051
Eugene and Noami tripping the light fantastic in our exam room

So, if you want to life a long life with lots of quality years at the
end of that life be like Eugene: swim and dance with your loved ones. Keep moving, stretch and exercise in some manner regularly.

Gerontologically Yours,

-ACP

Should Fitness Be A Vital Sign?

The skeptical cardiologist routinely probes his patients’ activity and exercise levels and encourages them to engage in 150 minutes of moderate exercise weekly. However, I’m somewhat skeptical of the benefit of treating such assessments as a vital sign (like blood pressure or heart rate)  as a recent AHA scientific statement suggests.

I can only envision still another item  on a chart checklist that will have to be recorded in the EHR or already over-worked physicians will have their payments withheld.

The AHA statement suggests that ideally we should be measuring  our patients’ fitness by obtaining  maximal oxygen consumption (VO2 max) utilizing an expensive and rarely utilized cardiopulmonary exercise test. Failing that we should consider doing a treadmill stress test. Failing that, rather than utilizing my simple question to patients: “How active have you been?”,  the statement recommends doctors utilize some sort of formal questionnaire to estimate their patients’ cardiorespiratory fitness (CRF) such as the one at World Fitness Level.

I went online to take this CRF estimator (based on this paper) and I remain skeptical.

The online site and  a free smartphone app both ask the following questions:

  • Country and City
  • Ethnicity
  • Highest Level of Education
  • Gender/Age/Height/Weight
  • Resting and Maximal Pulse
  • How often do you exercise?
  • How long is your workout each time? (over/under 30 minutes)
  • How hard do you train? (I had to choose between “I go all out”or “Little hard breathing and sweating”)

 

screen-shot-2016-12-03-at-11-33-13-amWhen you have finished answering the questions you are given an estimate of your fitness age. When I did this online a few days ago and answered truthfully I got the result to the right: I had the fitness of a 41 year old with an estimated VO2 max of 49 ! (interestingly this estimate corresponds exactly with VO2 max derived from a recent stress test I completed.)

I used the app (which unlike the online version did not ask me my waistline measurement) and changed a few parameters:

  • I increased my resting heart rate or pulse  from 60 to 68 beats per minute (BPM)
  • I increased my maximal heart rate from what I know is 158 BPM to what the app calculated (173 BPM, which makes no sense)
  • I switched from exercising 2-3 times per week  and longer than 30 minutes  at “all out” level to the lowest level for all 3 questions.

The change was dramatic and depressing: I went from 39 years old to 67 years old in the bat of an eyelid!img_8073

 

 

 

The app and online site direct you to a non-profit site where you can get information on a 7 week program to increase your fitness level. I haven’t checked this out.

I’ll be trying out this CRF estimator on my patients: assessing whether it adds anything to my usual line of questioning on activity and fitness.

I encourage you to give the CRF estimator a try. Let me know in the comments how you feel it works for you. Does it motivate you to exercise more knowing that, for example, your fitness age is substantially higher than your chronological age?

Running For Longevity: From A-Punk to Aba Daba Honeymoon

About two years ago I wrote about a study that found that any amount of leisure-time running was associated with a lower risk of cardiovascular disease which  made me reconsider my usual advice to patients on exercise:

As part of a prospective longitudinal cohort study at the Cooper Clinic in Dallas, Texas, Lee, et al. looked at data from a group of 55,137 adults on whom they had information on running or jogging activity during the previous 3 months.
Those individuals who described themselves as having done any running in the last 3 months had a 30% lower risk of all-cause mortality and a 45% lower cardiovascular mortality.

Amazingly, it didn’t matter how much you ran.

Those who ran <51 minutes per week did just as well as those who ran >176 minutes per week.

At the time I felt the study was not definitive, but food for thought. Evidently, it got me thinking so much that I began running regularly (despite my previous dislike of running).

Music and the Tempo of Running

During my runs I listen to music on my iPhone, either through Apple Music or songs that I have purchased.

Today, after deciding Leonard Cohen’s Live in Dublin (although awesome, and one of the best live albums I’ve ever heard) was not motivating enough, I hit the first song on my iPhone: A-punk by Vampire Weekend.

A-Punk is one of my favorite songs released in the last decade. It’s very upbeat.. perfect for a running accompaniment. The opening guitar riff is simple, fast and catchy. It’s simple enough that I can play it on guitar but, so fast that my fingers fatigue quickly.  The bridge portion features a wonderfully fast and complicated bass line with punchy drums and an overlying synth flute melody. You can watch a video of it here:

As I ran I realized that the tempo of A-Punk was perfectly suited to my preferred running speed of 6.1 MPH. You’re probably wondering what the tempo of A-Punk is. It’s likely that the only time song tempo comes up in general conversation is when talking about CPR and the need to compress the sternum at 100 beats per minute, the alleged tempo of The Bee Gees Stayin’ Alive (it’s actually 104 BPM.)

A-Punk’s tempo turned out to be 175 BPM. If you are not inclined to count the actual beats in a minute to determine the tempo of a song, you can enter the song into this site to get the number or download a smart phone app for the purpose.

Oddly enough, the next song on my alphabetical listing of songs, Hoagy Carmichael’s version of Aba Daba Honeymoon, also had a screen-shot-2016-10-02-at-8-45-44-amtempo (174 BPM) perfectly suited to my running speed. (The song after that was my old band Whistling Cadaver attempting to play the medley at the end of Abbey Road at our 30 year high school reunion in 2002-not good for running to, but immensely entertaining).

Monetizing Music For Running

Having observed that the tempo of certain songs matched perfectly to my running tempo, I wondered if there were any advantages to selecting such songs. Would I run faster or longer or with less discomfort or less injuries?

The web site run2rhythm would certainly like me to believe that screen-shot-2016-10-02-at-9-45-42-amrunning to the right tempo song will improve my performance. This site claims that “the wrong musical playlists can be detrimental to your training as they will not provide any synchronization between the body, the music and the mind. The body is almost always out of sync with the music.”

screen-shot-2016-10-02-at-9-03-39-amRun2rhythm provides a chart of the BPM that corresponds to different running speeds and sells playlists starting at $3.99 corresponding to specific tempos. These are playlists by unknown artists created for run2rhythm and the samples were not inspiring to me.

Here’s an example:screen-shot-2016-10-02-at-9-05-39-am

 

 

Is Music a Legal Drug For Athletes?

It turns out that there is a body of scientific literature related to music and exercise, and the vast majority of it seems to come from one man,  Dr Costas Karageorghis at Brunel University in London, an expert on the effects of music on exercise.  In his 2010 book, Inside Sport Psychology, he claims that listening to music while running can boost performance by up to 15%.

In media articles on the topic he is often quoted as saying “Music is a legal drug for athletes.”

However, in a 2012 review article he is more circumspect, concluding:

Music is now rarely viewed in a manner akin to the ‘vitamin model’ described by Sloboda (2008) wherein one can ascribe immutable effects to a specific musical selection for all listeners and at all times. The beneficial consequences of music use stem from an interaction between elements of the musical stimulus itself and factors relating to the traits and experiences of the listener, and aspects of the exercise environment and task. In particular, the role of music is dependent on when it is introduced in relation to the task and the intensity of the exercise undertaken. In closing, the evidence presented in this review demonstrates that music has a consistent and measurable effect on the psychological state and behaviour of exercise participants

Creating Your Own Tempo Playlist

The research on music and exercise suggests that songs with inspirational themes (apparently, “Gonna Fly Now,” the Rocky theme, is the most popular workout song of all time) are more effective performance enhancers. Also, self-selection of songs works better.

For me, running while listening allows me to focus on nuances of instrumentation, timing  and lyrics that otherwise I would not pay attention to. It is essential, then, to have songs that are worthy of such close listening.

I wondered if anyone has compiled lists of songs of a certain BPM that were originals and good songs.  Sure enough, the folks at jog.fm have exactly such a function.  My search for songs with tempo of 175 BPM yielded A-Punk and hundreds of other songs, screen-shot-2016-10-02-at-10-10-58-amincluding some I like (thumbs down for Footloose and Wonderwall (which is really 1/2 of 175 BPM or  88 BPM), thumbs up for Dancing With Myself).

You will note that my preferred tempo of 175 BPM corresponds to a much faster running speed than my preferred 6.1 MPH. This may have to do with my short legs or my running style. It makes sense to count the number of steps you take per minute at your optimal speed rather than rely on charts or averages.

Achieving the Right Dose of Exercise

Whatever you listen to while running, walking, cycling or hopping, hopefully it will assist you to achieve the dose of exercise per week that results in improved cardiovascular outcomes.

This chart from recent European guidelines on lifestyle for prevention of disease describes different intensities of aerobic exercise:

screen-shot-2016-10-01-at-10-18-34-am
If you engage in vigorous exercise such as running or jogging, cycling fast or singles tennis, you only need to achieve 75 minutes per week. Moderate exercise such as walking or elliptical work-outs requires 150 minutes/week.

As a result of switching to running, I’ve cut down my total exercise time per week by half leaving me more time to create music!

Readers – feel free to share your favorite workout songs and let me know what tempo works best for you.

Synchronously Yours,

-ACP

Yikes! This is a silly video. I’m not sure I can run to the song anymore.

 

 

Walking To Público: Leeks and Life Extension

Last weekend the skeptical cardiologist and his Eternal Fiancee’ walked to Público, a restaurant in the Delmar loop that was recently named the best new restaurant in St. Louis by Sauce magazine.

Walking (instead of driving) to restaurants is a great way for us to get aerobic exercise into our hectic days, which we know makes us feel better and which may also be improving the quality and quantity of our years.

A presentation at the 2015 European Society of Cardiology meetings which was widely picked up by various media outlets with the headline “25 Minutes Of Daily Walking Adds 7 Years To Your Life”  touches on this.

The author of that study, a British cardiologist, was quoted as saying:

‘Exercise buys you three to seven additional years of life. It is an anti-depressant, it improves cognitive function and there is now evidence that it may retard the onset of dementia.’

and

“we may never avoid becoming completely old, but we may delay the time we become old. We may look younger when we’re 70 and may live into our 90s.

Health Benefits of Neighborhood Walkability 

We moved to University City from the western suburbs of St. Louis for, among many reasons, the opportunity to do more walking around our neighborhood for errands, recreation, dining out and entertainment.

Researchers have studied how such factors can influence lifestyle.

A study in Ghent, Belgium investigated whether neighborhood walkability (higher residential density, land use mix, street connectivity) was positively associated with physical activity in Belgian adults.

Twenty-four neighborhoods were selected, stratified on GIS-based walkability and neighborhood SES. In total, 1200 adults (aged 20-65 years; 50 per neighborhood) completed the International Physical Activity Questionnaire and wore an accelerometer for seven days.
Living in a high-walkable neighborhood was associated with more accelerometer-based minutes of moderate-to-vigorous physical activity (38.6 vs. 31.8 min/day, p<0.001), transportational walking and cycling, recreational walking, and less motorized transport (all p<0.05).

This study confirmed previous similar studies in Australia and the United States, demonstrating that the design of your neighborhood strongly influences how much you drive a car versus walk.

Measuring Your Neighborhoods Walkability

Walkability has been defined as “the extent to which the built environment is walking friendly.”
Walkscore.com is a website (which my friend, and legendary New York City flaneur, David Alquist, made me aware of), which attempts to quantify walkability.
Enter your zip code or address and the site will use its patented methodology to give you a Walk Score for your neighborhood.
Walk Score measures the walkability of any address using a patented system. For each address, Walk Score analyzes hundreds of walking routes to nearby amenities. Points are awarded based on the distance to amenities in each category. Amenities within a 5 minute walk (.25 miles) are given maximum points. A decay function is used to give points to more distant amenities, with no points given after a 30 minute walk.
Walk Score also measures pedestrian friendliness by analyzing population density and road metrics such as block length and intersection density. Data sources include Google, Education.com, Open Street Map, the U.S. Census, Localeze, and places added by the Walk Score user community.
Walk Score® Description
90–100 Walker’s Paradise
Daily errands do not require a car.
70–89 Very Walkable
Most errands can be accomplished on foot.
50–69 Somewhat Walkable
Some errands can be accomplished on foot.
25–49 Car-Dependent
Most errands require a car.
0–24 Car-Dependent
Almost all errands require a car.
 Benefits Of High Walk Score Neighborhoods
According to Walk Score, there are numerous benefits of living in a high Walk Score neighborhood:
Health: The average resident of a walkable neighborhood weighs 6-10 pounds less than someone who lives in a sprawling neighborhood.1
Cities with good public transit and access to amenities promote happiness.2
Environment: 82% of CO2 emissions are from burning fossil fuels.3 Your feet are zero-pollution transportation machines.
Finances: Cars are the second largest household expense in the U.S.4 One point of Walk Score is worth up to $3,000 of value for your property.5Read the research report.
Communities: Studies show that for every 10 minutes a person spends in a daily car commute, time spent in community activities falls by 10%.6

Park Slope, New York City Versus University City

Screen Shot 2016-01-17 at 7.57.47 AM Screen Shot 2016-01-17 at 7.56.48 AMDespite my perception that our new neighborhood allows us much more opportunity to engage in pleasant walking for recreation and transportation, the Walk Score for our zip code is only 54, putting us in the somewhat walkable category.

David’s neighborhood of Park Slope, on the other hand, has a score of 97, one of the best places in the world for walkability.

Obviously, the Walk Score is not a perfect measure of true walkability but it’s a start at looking at the issue.

Publico and the Leeks

After walking 1.1 miles (2250 steps) to Público, the Eternal Fiancee’ and I felt really good about sampling some of their awesome Latin-inspired dishes.
leeksI could not resist ordering the Leeks (aji rocoto, arbol, crema, blis roe),the national emblem of my birthplace, Wales.

The leeks were great; I concur with what this reviewer wrote:

“A simple order of leeks arrived as a work of art, decorated with bright roe and surrounded by crema that demanded to be licked from the plate. ”

Walking home from Público, we passed the chain that the Eternal Fiancee’ unsuccessfully tried to hurdle a few weeks earlier after a run to the Delmar Loop. Although the fall that resulted from that failure resulted in severe elbow and back injuries, we are still convinced that using our feet for transportation is healthier in the long run.

For 2016 I encourage all my patients to walk more and eat more leeks!

Happy MLK day,

-ACP

If you’d like to read a good, in-depth article from Slate about Walk score, see here.

And if you’d like to visit Público here is there info:

6679 Delmar Blvd.

University City, MO 63130

Map & Directions

314.833.5780

 

Burpees and the Dizziness of Aging

Last week a patient that I treat for an arrhythmia who is 60 years old and in outstanding shape told me that he was experiencing dizziness after doing burpees. His personal trainer told him he should talk to his cardiologist about it.

Dizziness is a common complaint of my older patients. Indeed, 30% of individuals older than 65 report dizziness and 50% of the “very old” (older than 85 years) experience dizziness.

If the dizziness is described to me as a sensation that the patient is about to “pass out” or lose consciousness or a feeling of everything turning black I figure it has a cardiovascular cause with the blood pressure in the brain arteries globally reduced transiently. I always take this very seriously as this type of dizziness may be the precursor of total loss of consciousness (syncope) or sudden death.

One study showed that 57% of patients with dizziness age 65-95 were ultimately felt to have a cardiovascular cause.

I find a common cause of dizziness in my patients, especially as they age and if they are on mediations which lower the blood pressure is orthostatic hypotension (.OH)

Orthostatic Hypotension.

Bear with me as I attempt to succinctly describe this very important physiologic phenomenon which everybody has experienced at one time or another.

Orthostatic (meaning related to standing) hypotension (low blood pressure) is defined as a sustained reduction of systolic BP >20 mmHg or diastolic BP >10 mmHg within 3 minutes of standing or following head-up tilt to ≥60o.[

Dizziness due to OH occurs when you stand up quickly or rise from  a kneeling position.

During the process of going from lying or sitting to standing your body has to make some major adjustments to ensure that blood flow to the brain is maintained. As you stand up from lying down your brain suddenly goes from being at the same height as your heart to being (depending on how tall you are) a foot or more higher. Thus, a higher pressure is suddenly needed to keep blood flowing to the brain. The major sensors of blood pressure (baroreceptors) within the vascular system are located in the carotid arteries (large neck arteries providing blood to the brain) and these are constantly sending feedback to the brain.

The carotid sinus baroceptors are stretch sensitive mechanoreceptors that modulate what is called the autonomic nervous system to keep arterial blood pressure constant.

A second process that occurs with standing is pooling of blood due to gravity in veins in the legs and abdomen. This pooling takes blood, in essence, out of the circulatory system, thus lowering the pressure in the heart which in turn can lead to less blood being pumped into the arteries. Part of the autonomic reflex response to standing then involves constricting veins to reduce pooling.

Things that make it more likely you will experience dizziness from OH include

-anything that lowers the volume of blood in your circulatory system. Thus being dehydrated (from vomiting or diarrhea, diuretics, excess alcohol, sweating) or losing blood. A common scenario for passing out from OH is the prep for colonoscopy which induces diarrhea and possible dehydration. Another common scenario is after surgery which causes a combination of blood loss and dehydration (plus other factors) .

-Medications which lower blood pressure

Burpees

burpee 1If you’ve been paying attention and know what a burpee is then you have probably deduced that my patient was suffering from orthostatic hypotension.

I was unaware of the term burpee although I had seen members of my gym (under the watchful eye of their personal trainers who seem to specialize in having their clients undergo bizarre and embarrassing exercises (most likely to justify their fees, After all, you don’t need a personal trainer to show you how to run on a treadmill and properly use resistance machines which, arguably, provides all the aerobic and isometric exercise you need for maintaining optimal cardiovascular and muscular fitness)).

It was named for an American, Royal H. Burpee, who wrote his PhD thesis on this exercise as a measure of fitness. Subsequently, the burpee or squat thrust was adopted by  the US military to assess the fitness of recruits in WWII.

burpee 2According to this Popular Science article from 1944 the army did not consider a soldier ready for the rigors of war until he could do 40 to 50 at an easy pace without resting.

Many personal trainers and boot camps are enamored of this exercise and Men’s fitness magazine  calls them “the most badass exercise”

One personal trainer, Jamie Atlas, believes you should not  do burpees because they put too much stress on the knees and lower back, the two most frequently injured areas of the body. He also points out that the burpee is a good test for a soldier:

the burpee is probably the very best exercise for the military. Or should I say more specifically, for people being shot at by other people with guns. It stands to reason that if a soldier can’t quickly get down to the ground and then quickly get back up again, they’re simply fodder for target practice. A primary need is to be able to drop into a firing position and then bounce back up lightning-fast to move to a safe position — and without a certain standard of ability to complete that particular movement, they are at a significantly higher risk of getting shot than their other, more agile companions.

Burpees and Orthostatic Hypotension

It would be hard to design an exercise that puts a greater stress than multiple burpees on the autonomic reflexes involved in keeping blood flow to the brain constant (I’m somewhat reticent to mention this because I may soon see members of my gym doing it but if you had an exercise that involved standing on your head and suddenly flopping to the ground then jumping up to a standing position that would be a greater stress. If this hasn’t been invented yet, I claim credit and would like it to be called a pearson ©).

My patient said that after doing his required 30 burpees he would stagger around in circles with a sensation that he couldn’t see properly and that he was in imminent danger of passing out and  falling down.

Added to the above-mentioned issues of moving from supine to standing we are now moving from a squat position. In this position the large muscles in the legs are tightened, thus squeezing blood back to the heart and initiating reflexes that are the opposite of those needed to compensate when standing is resumed.

To compound the confusion his body was feeling, my patient’s personal trainer had him jump or spring up from the squat position with his arms raised in the air and his feet leaving the ground. This further adds to the gravitational effects of blood pooling in the legs and abdomen.

Aging and orthostatic hypotension

Dizziness due to OH is more common as we age. We don’t know exactly why but it is likely related to multiple age-related changes in the cardiovascular system and the autonomic nervous system.

Some factors that may play a role include a decrease in baroreflex sensitivity, a decreased vasoconstrictor response to sympathetic stimulation, decreased parasympathetic activity and impaired relaxation of the heart muscle.

It may be possible for the young and fit to do multiple burpees without dizziness but I suspect that the vast majority of sixty somethings are going to notice significant dizziness with this kind of exercise.

Despite what my patient’s personal trainer him, I don’t think dizziness experienced with burpees is a reason to be evaluated by a cardiologist. I think dizziness experienced with burpees is a reason not to do burpees

Perhaps, personal trainers could change from the burpee to the Weak Horse, another exotic exercise and “toughening up” game that comes to us from the military.

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Dizziness experienced with aerobic exercise such as running  or rapid walking can be a sign of a serious cardiovascular disorder and merits being reported to your physician.

-nonburpeeingly yours

ACP