Book Review: Every Woman’s Guide to Foot Pain Relief

In case you hadn’t noticed from my previous blogs about foot care and going barefoot… I am kind of obsessed with healthy feet. As a Chiropractor, I see the spinal changes and postural changes that occur in my patients from poor footwear choices or injured feet on a daily basis.

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Katy Bowman’s book, Every Woman’s Guide to Foot Pain Relief, belongs on every household’s bookshelf! In her book, Bowman breaks down the details of how your feet move, how they are built, and the basics of both self foot maintenance and rehabilitation. The reality is that most women will experience severe foot pain at some point in their lives. With simple daily activities and stretches… and maybe some better footwear choices… these can be overcome, but most importantly prevented.

Here are some of my favorite take-home points from this book:

  1. Wearing shoes all the time is like living your life with mittens on.x-ray-223836_1920
  2. Your feet are unlike anyone else’s.
  3. Your toes should be able to move independently (This sounds crazy, I KNOW! But I am currently working on this feat).
  4. A shoe whose sole is taller at the back than the front is a heel… even if it’s a running shoe.
  5. Shoes should be foot-shaped.
  6. Ditch the Flip-Flop.
  7. Barefoot time is essential!!
  8. You have the power to change your own feet- and your HEALTH.

I also really appreciated the practical exercises in the back of the book and am implementing them into my own nightly routine. I highly recommend reading this book and starting to assess and correct your footwear and your feet. I am also excited to start reading more of Katy Bowman’s books 🙂

I’ll leave you with this quote from her book:

feet-619399_1920“Human tissue is phenomenal stuff. When you make small changes in your movement patterns, you nudge yourself down a new physiological path. The body works to tear down old or underused tissue every day, and builds up tissues that are in greatest demand. The body continuously adapts to whatever you are doing now. Changing your habits will change your life!”- Katy Bowman

 

Top Apps for Healthy Living

Staying healthy can be tough! It is hard to stay on top of the latest in healthy eating, shopping, and fitness. Luckily, there’s an app for that!

Dr. Samelak has put together a list of her Top Apps for Healthy Living.

vegetables-3386212_1920.jpgFooducate

Fooducate is a free app that makes shopping a breeze! Simply scan the barcode on your food to learn more about it. The experts at Fooducate have created a database that grades your food based upon its ingredients. It even provides suggestions for healthier alternatives! Did you scan something not in their database? Simply submit it for evaluation by the Fooducate team and they will research the ingredients and add it to their list!

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The Environmental Working Group, EWG, is a US based environmental group that, “specializes in research and advocacy in the areas of toxic chemicals, agriculture subsidies, public lands, and corporate accountability”. [Wikipedia] EWG has released a Healthy Living App that works like Fooducate for your personal care products. This helps take the guesswork out of buying shampoo or toothpaste. Suddenly, you don’t have to be a chemist to shop smarter and healthier. EWG touts that you can, “scan a product, review its rating, and pick the better choice” in your purchases.

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We’ve all heard about the benefits of meditation in a myriad of areas in our lives… but where to start? Many times, we set out to meditate only to end up writing our grocery list in our heads or worrying about whether you were the one in charge of carpool pickup from soccer tonight. Enter: Headspace. The Headspace app specializes in providing guided meditations that are themed for different needs and work to help busy people take a break and create some headspace.

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There are a lot of fitness apps and they all have their benefits and drawbacks. My personal favorite is Runkeeper. I use this app to help myself stay accountable to my fitness, track workouts of various kinds, and ensure that I don’t put too many miles on my running shoes. The app even includes a goal setting area and even training workouts. If you need the push, you can even allow notifications from the app to your phone’s lock screen to encourage you to get out and move.

Do you have an app that you can’t live without? Let us know about it in the comments!

Can too much sugar effect bone density?

With Halloween next week, what could be more appropriate than a discussion about Bones and Candy, right?!

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The Western diet, high in protein and sugar is associated with an increase in all kinds of metabolic conditions from cardiovascular disease and Type II Diabetes Mellitus to osteopenia and osteoporosis. As a Chiropractor, bone density is a very important topic and it deserves some discussion.

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Let’s take a closer look at how our bones function in the human body. Our bones provide a framework for our muscles to hang upon. They create a safe space for our organs to live. They act as levers to allow us to move. These are all things that we have been told about before. But, did you know that your bones are actually the largest mineral reservoir in the body? From Guyton and Hall’s Textbook of Medical Physiology[1] we know the following. Our bones are constantly in flux with minerals like calcium, phosphate, and magnesium being borrowed and stored to maintain our body’s pH. 99% of the body’s calcium and over half of it’s magnesium is stored in bone.

skull-778075_1920pH refers to how acidic or alkaline the body is. We live within a tight tolerance and have several systems that make sure that this is regulated. Body fluids can push the balance one way or another within a fraction of a second, the respiratory system can make changes in minutes by changing our breathing to either eliminate or preserve CO2, and the kidneys respond slowly but are the most powerful  buffers of pH in the body. This is where we will focus.

When the body has an acidic environment, our body fluids, breathing, and kidneys work to shift it back to the middle. Our body increases the free calcium in extracellular fluid to correct the imbalance which tells the kidneys to excrete magnesium in urine. These minerals are usually sourced from our bones.

Now that we have reviewed the physiology of the pH balance system, let’s apply it to everyday life.

When we have a diet that causes our body to trend toward acidity, this buffer system is continually pulling minerals from bone. Odds are, more quickly than we can effectively store it.

Think of your bones like a bank. There is a bank balance that is your bone density. When your body needs to borrow some, it makes a withdraw. When it takes in calcium and magnesium from food, it deposits. This system works well when it is balanced. However, osteopenia and osteoporosis happen when you overdraw the account.

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Therefore, it is important to balance the budget. Reduction in sugar consumption can help to reduce the withdraws being made from your bones. Improving absorption of dietary minerals helps you to build up your account.

Guyton and Hall [1] discuss the importance of Vitamin D in the absorption of calcium. They report the following mechanisms:

  • increases intestinal calcium absorption by helping the cells to form calcium binding proteins within 2 days.
  • helps to improve phosphate absorption (another important mineral in bone).
  • helps to decrease kidney excretion of calcium and phosphate.
  • promotes bone calcification by transporting ions through cell membranes

This lets us know that appropriate Vitamin D levels are important in healthy bones. Many people in the northern hemisphere do not make or consume enough vitamin D to have adequate levels when tested in the blood. This is an important conversation to have with your primary care physician.

x-ray-223836_1920Bone density is much more complex than just the biochemistry/physiology; however, there are some tried and true methods for helping to improve your bone density:

Improve your diet. Reduce acidic foods, especially grains and sugars. Consume more green leafy vegetables.

Get your vitamin D levels evaluated.

Start participating in weight bearing exercise! Bone responds to stress. If you do not ask your bones to do work, they do not store as many minerals.

As always, please remember: This blog is intended to provide you with tools and information about the human body. Please speak with your own health care provider before making major lifestyle changes.

Below is a citation for Guyton and Hall.

[1]Guyton, Arthur C., and John E. Hall. “Textbook of Medical Physiology.” Textbook of Medical Physiology, 11th ed., Elsevier Saunders, 2007, pp. 371–985.

For additional reading on the topic, check out these links:

Why is Sugar Bad For You?

Calcium and Osteoporosis

Effect of consuming different caloric sweeteners on bone health and possible mechanisms.

Fat, Sugar, and Bone Health

 

Travel Smart- Chiropractic Travel Tips for Flying

Flying can be a pain. Literally. You haul yourself through lines at security, toting your carry on luggage. You wait for your flight in uncomfortable seating or on the floor. The planes are cramped with uncomfortable seats and not enough leg room. The air is dry and blows into your face. You finally reach your destination and are so thankful to be done flying that you haul your carry on luggage down the aisle of the plane and breathe a sigh of relief.

It can be better with some planning.

  1. Carry On Luggage
    • Your carry on suitcase is a strategic decision.
      • It is important to choose a lightweight suitcase, preferably with multi-directional wheels. This allows you to push it down the narrow aisle of the airplane and more easily lift it into the overhead bin.
      • Lifting your case into the overhead compartments can be a challenge. By keeping the case light, and talking with your chiropractor about proper lifting technique, you can spare yourself some discomfort in maneuvering your luggage.
    • Your personal item can make or break your trip.
      • A tote bag or large purse seems like a good idea for a personal item. They hold a lot and can be quite fashionable.
      • I prefer and recommend a backpack for your personal item. You can pack your empty purse inside or in your main luggage. Remember to place your belongings in the backpack with the heaviest closest to your body (ie: laptop). Lighter items can be placed farther from the body.
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        A backpack is an excellent choice for a personal item when flying.

        Most backpacks have many compartments which allow you to stay organized and evenly distribute weight. I prefer packs made by backpacking companies like Osprey or Deuter because they are lightweight with many compartments.

  2. Dress the Part
    • Between security checkpoints and the prolonged sitting involved in plane travel, clothing can be an important part of trip planning.
    • Ladies, your hairstyle matters!
      • I have longer hair and have to be sure that my hair is either down or in a top knot. If my hair is in a ponytail or on the back of my head, it forces anterior head positioning.
      • Anterior head positioning causes increased tension in the muscles of the neck and shoulders as well as promoting further poor posture
    • Wear comfortable shoes
      • Shoes should be easily removable for security, but should also be comfortable and practical.
      • High Heel ShoesHeels should be avoided because of the extreme angulation that they place the ankles in- not to mention the positioning of the pelvis while walking.  ***Stay tuned for a future blog that discusses the problems with high heels and their health impact***
    • Choose pants that allow for full hip range of motion. Tight pants, especially jeans can cause nerve and blood vessel impingement with prolonged sitting.
    • Consider compression socks for longer flights. These socks help improve circulation and can help with leg aching with prolonged inactivity.
  3. Remember Posture
    • We mentioned posture when choosing your hairstyle on a travel day… But it goes so much further. Good posture will help prevent low back pain and upper back pain from traveling.
    • Sit fully back in your seat and make sure that you are sitting on your “sit bones” not your tailbone.
    • Place both feet flat on the floor.
    • Adjust your headrest for optimum support.
    • Focus on alignment.
      • Think of your rib cage and your pelvis like 2 bowls.
      • Start by making sure that the bowl of  your pelvis is balanced and upright.
      • Now, line up your rib cage over it.
      • Make sure that your low back is not rounded or crunched forward.
  4. Hydrate
    • The dry environment in an airplane can dry out your mucous membranes- hydrating can keep them healthy and protect you from getting a cold while on an airplane.
      • When your nose dries out, it doesn’t protect you as well from viruses and bacteria.
  5. Sun Salutations!Forward Fold
    • Following your flight, it is time to move. I love how gentle yoga is to help me work the kinks out of my body after a day of travel. Sun salutations will help you to lengthen your spine and loosen tight muscles.

I hope that some of these tools will help you to feel better and be better prepared when you next travel. Please remember that this blog is intended for educational purposes. It is good to speak to your Chiropractor or Primary Care Physician to ensure that these tips are right for you.

MRI Study Demonstrates Lumbar Disc Herniation Heals!

backpain-1944329_1920.pngMany times in practice, a patient presents with symptoms of lumbar (low back) disc injury. They have pain into the leg, often have difficulty standing upright, and have accompanying low back pain.

This generally occurs when a disc bulge or herniation places pressure on the spinal nerves or the spinal cord. As shown in the image below, where the purple shape is pressing on the green nerve.

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Chiropractic care is a great conservative way to manage the pain and, often, it will centralize and resolve in a matter of weeks. A home exercise program is then prescribed to help prevent re-occurrence and strengthen key muscles. When symptoms do not improve with a trial of care, a referral is made to an Orthopedist for further evaluation and MRI. Sometimes surgery is warranted.

Previous studies suggested that, while it was possible to remove symptoms, disc injuries do not fully resolve- think of them like a sleeping dragon. This article, published in the New England Journal of Medicine, is a case study that describes resolution of the patient’s disc injury, documented on MRI. This is incredibly promising and supports conservative management of  lumbar disc injuries with chiropractic care and physical therapy before a surgical option is considered.

***This blog post is intended solely for informational purposes. It is always essential to consult with your own health care provider when making decisions about low back pain or leg pain. ***

 

3 Simple Tools to Improve Your Sleep

Poor sleep is one of the most common problems that gets reported on my patient’s health history forms. In fact, according to the National Sleep Foundation’s 2014 survey, 45% of Americans reported that they have poor or insufficient sleep that affected their daily activities over the past week.

As Americans, why do we sleep so poorly?yawning-1895561_1920

What are we missing?

How is this affecting our health?

Check out this article from Healthline about the detrimental impact of sleep deprivation on the Central Nervous System, Immune System, Respiratory System, Digestion, Hormones, and so much more.

Do you think that you are sleep-deprived? Look at this list of symptoms, if you identify with these, you may be sleeping poorly on a regular basis:

  • Sleepiness
  • Pain
  • Frequent illness
  • Mood changes
  • Difficulty concentrating
  • Trouble with memory
  • Disorientation
  • A feeling of being dull

Win back your life and your health using these three tools for more effective sleep.

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Create a sleep schedule

Did you ever wonder why small children thrive on a sleep schedule? They can devolve from happy, playful tiny humans into meltdown quickly when naptime is missed or a storm keeps them from their usual routine. You can apply this same principle to your own schedule.

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Are you going to bed at the same time each evening? Are you waking up at the same time each morning? Our bodies cycle the hormones Melatonin and Serotonin throughout the course of a day. Serotonin is one of your happy hormones and Melatonin is for sleep. When you have an inconsistent sleep schedule, it is easy to create an imbalance in these important hormones, leading to mood disorders.

Don’t let technology rule your life

Electronics are backlit and emit blue frequencies of light that prevent the release of (you guessed it) melatonin! Outside of this, electronics create an unhealthy series of habits that can be detrimental to sleep.

Can you remember the last time that you began or ended your day without your cell phone? Do you check your personal, or worse, work email before your feet even touch the ground each morning? Do you and your significant other sit next to each other on your phones before sleep each night?

It is time to institute boundaries. In my home, we don’t keep our phones by our beds. Instead, there is a bowl just inside our bedroom where our phones get parked each night. This may not work for you, but consider switching to a regular alarm clock instead of using your phone, putting your phone on “do not disturb” and not checking your notifications until your morning coffee, or reading before bed- from an actual book. I hope it goes without saying, but kick the TV out of the bedroom.

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Create total darkness.

Even the smallest bit of light (like on your TV) or the light that filters in through your blinds can keep you from dropping into the deepest levels of sleep. This affects our circadian rhythms.

Try this tonight, sit in your bedroom with the lights off- just like you would at bedtime. Look around you. Do you see light? Is there a smoke detector or power adaptor that blinks into the darkness? Do your curtains have a line of light that wraps around the periphery? Now try and eliminate these sources of light to improve your sleep environment.

These 3 steps have greatly improved my sleep hygiene and overall quality of sleep. I hope that they will help you as well!

Please remember, this blog is for informative purposes only. If you are having difficulty sleeping, please consult with your health care provider.

 

 

 

A Parent’s Guide to Backpack Safety

Summer is coming to a close and it is time to purchase new school supplies and especially, Backpacks. Instead of choosing the coolest new superhero or princess backpack, I encourage you to ensure that your child’s backpack fits appropriately.

A backpack that is too large or heavy, or even worn improperly, can be detrimental to your child’s posture and spinal health. Textbooks and school supplies are heavy and it is important to choose a properly sized backpack that will make sure that kids are staying safe this school year.

Size

Many children’s backpacks are more focused on bright colors and appealing to kids cartoons than they are on function. They are often oversized and impractical. When choosing a backpack, it is important to fit the bag to the size of the child.

Below, the top left image, demonstrates a backpack that is likely a little large for the child, though if the straps were shortened it may fit more appropriately. The right image demonstrates a bag that is slightly too tall and a little too wide. The boy in the bottom image has a bag that fits correctly.

A properly fitting backpack should reach from shoulder blade to shoulder blade and from the shoulders to just below the waist. Check out this article with a convenient drawing demonstrating proper landmarks for sizing.

A backpack that is too large will place stress in the wrong part of the spine and can be filled far beyond capacity.

Weight

Kids are little! A child’s backpack should weigh no more than 10-15% of their body weight. The forces through the spine from carrying a heavy backpack can be compressive and cause the child to stand with shoulders hunched forward, head forward, and a curved spine.

Packing the weight into the bag correctly is also important. Heavier items like textbooks should be placed closer to the body, while lighter/smaller items can be further forward. Weight can also be managed by minimizing how much actually goes into the backpack. Which books need to be brought home for homework? What can stay in a locker and what needs to be carried home or between classes?

Proper weight distribution comes from a number of factors in a backpack. The pack should be light when empty. Multiple compartments will aid in packing. Wide straps keep the pack from digging into the shoulders. A waist strap can help to stabilize the load.

Overall

A backpack can be fun and functional. If your child is small in stature, consider picking a backpack that is appropriately sized in a plain color and decorating it with patches or fun paints. Minimizing wear and tear on your child from their backpack can help keep them in great shape.

Do you have questions about backpack sizing? Talk to your local chiropractor to have them check your child’s fit!

No Pain, No Gain- An Outdated Fitness Concept

No Pain, No Gain

I remember being in high school sports and repeatedly hearing people laugh and say, “No pain, no gain” as we pushed ourselves to make gains in the weight room or in the pool. We worked out to exhaustion, more focused on completing the workout or the set in the weight room than on form or perfection. Coaches said things like, “Pain is weakness leaving the body.” We got strong, sure. We gained speed. We thought we were so cool as we showed off our bruises and iced down our shoulders.

The reality, though, is that we were injuring ourselves. We were building poorly coordinated neural pathways. We were altering our biomechanics and causing overuse injuries.

 

Now that I am years out of that scenario, I often work with athletes, like myself, who are driven to excel and want to improve in their sport. One of the biggest discussions we have is surrounding this concept of “No pain. No gain.”

A workout should build you up, not break you down.

It is important to work out in a way that pushes your capacity, but does not allow for the break down of your mechanics. For example, when I assign rehab exercises in my practice, we always discuss:

  • The goals of the exercise
  • What you should feel when you perform the exercise
  • What are the “fails” of the exercise (ie: what things let you know that you have completed as many exercises as your body can handle)

It all comes down to the neural edge. This is the limit to which the brain can control the exercise and where we can actively create new pathways. Here is where we can safely make gains in our training.

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Beyond rehab, think of it like this… If you are on a run and you have decided that you will run 6 miles today. However, at 4 miles you notice that your left foot is hurting in the arch with some knee pain as well. Do you decide to continue running? -OR-  Do you listen to your body and stop your run at 4 miles? Should you continue to run, you are risking causing damage in your body that may keep you from running later in the week or season. It is important to evaluate (or to be evaluated by a professional) why the pain is present? Are your supporting or stabilizing muscles doing their jobs? Are you wearing appropriate shoes for your feet and the surface you are running on? Do you have proper nutrition?

Running through pain or working out through pain can be extremely detrimental to training, overall. It can result in overuse injuries and in neural patterning that lends itself to future injuries. Instead, it is imperative to train intelligently. Work smart. Get evaluated to be sure that you are making safe gains and discuss your training with a coach and functional movement specialist.

Let’s forget No Pain, No Gain

Let’s shift our focus in training. Let’s teach our athletes, young and old, to listen to their bodies and find their edge.  Let’s lead by example and learn to work out smart- and hard.

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***This blog is intended to provide educational content and is not for diagnostic purposes nor to provide health care advice. Please speak with your health care professional prior to changing your workout routine.***

Same Weight, Different Body- It’s time to ditch the scale and take a broader view of health!

As a Chiropractor, my health is an important part of my practice. I try to “live my brand” and do not recommend things to my clients that I would not be willing to do for myself. That being said, I am incredibly human. I have health challenges. I do not always remember to take my supplements. Sometimes, I eat dessert- in fact, I am writing this in a Starbucks where I am treating myself to a Frappuccino. Recently, thanks to Facebook and my wardrobe, I have come to the realization that my health has drastically changed over the past 1.5-2 years (for the better).

About 2 years ago, I became aware that I was not taking care of myself the way I should be. I have food allergies and sensitivities, and while I had cut quite a bit of them out of my diet, I was desperately clinging on to dairy and rice. At a Standard Process seminar, I made the decision to take my health into my own hands and address how my food sensitivities have impacted me.

2 years ago, I was battling depression, my weight, acne, sleep, and the list could go on. I was also working out regularly, had just finished my first triathlon, working on my spiritual well being, sleeping at least 7.5 hours per night, and getting adjusted regularly. Most people looked at me and called me healthy- but I was far from it.

I was faking it and hoping to make it. When each week ended, I spent the weekends in my pajamas sleeping too much and always tired. I would find myself crying over the smallest things. I was always feeling behind and having panic attacks regularly.

It was time for a change.harmony-1229886_1920

The past 2 years have been a quite a journey. I started by cleaning up my diet further- finally giving up my beloved dairy and rice. Within weeks, I was sleeping more deeply. Within months, my skin was clearer. Soon, my clothes fit better. Slowly, I was climbing out of the hole I had dug myself into during grad school and my first years in practice.

I started to really love who I am again. I started to feel like the fun and upbeat person I pretended to be for years. I scaled my workouts back to yoga, swimming, and weight training to allow my body time to heal and balance without as much repetitive stress. I budgeted time for relaxation and recreational reading.

Then, just over a year ago, my husband and I took a month and a half off to visit Europe and move out to Seattle from our first real home together in the Detroit area. The total reset that this allowed for my emotions was unreal and I truly felt in control of my emotions for the first time since puberty.

All told, this was almost a year long process.

The best part was that even moving across the country, finding a place to live, starting a new practice from scratch, dancing this dream awake, didn’t shake my cool. In the year that we have been in Seattle, I continue to be healthier, I can hike and run again, even completing my first half marathon this past June.

Looking at pictures of myself now, the change in my health really hits home. I look happy. I feel healthy. I am significantly more fit. What’s funny, though, is that pesky scale. You know the one. The bathroom scale. Over these past 2 years, it has not budged more than 5-10 pounds in either direction. In fact, during my most unhealthy years it was both at its highest and lowest weight. As I have worked to recapture my wellness and love my body, I have settled somewhere in between- even though my dress size is smaller.

Here’s the thing. And it is a big thing. Something that took me a long time to learn and something that I continue to learn each day. Health is not any one thing. Some of the people who look the healthiest are not well on the inside. Like me, they battle depression or anxiety.

Health is not merely the absence of disease or pain. Health is the constant pursuit of joy in your body and in your soul. It is ever changing. It is not measured on the scale, nor is it truly quantifiable. “Healthy” me is going to be different from “healthy” you. You can be stick thin or curvy and be healthy or unhealthy. It is important to work with health care providers that are focused on wellness and to build your tribe around you that can support your transformation. Find someone to assess you and listen to you. Health is a discussion.

My story of the past 2 years is in no way unique. But. I hope you were inspired in some way to assess your own health.

Start the conversation.

Take those first steps toward your best self.

Hydration is Key to Performance!

Summer is here as are summer sports! This past weekend I participated in the Ragnar Northwest Passage Race, where I was reminded of the importance of proper hydration when exercising as well as in daily life. IMG_20170716_213251_01

All too often, we forget to stay hydrated, leave the water bottle at home, and find ourselves with a dry mouth or muscle cramps, etc later. This is extremely evident when looking at runners, cyclists, and triathletes who compete in long duration activities. Even slight dehydration can immensely impact performance and recovery.

Exercise performance is impaired when an individual is dehydrated by as little as 2% of body weight. Losses in excess of 5% of body weight can decrease the capacity for work by about 30% (Armstrong et al. 1985; Craig and Cummings 1966; Maughan 1991; Sawka and Pandolf 1990).

As indicated by the above quote, it is possible to determine your level of hydration vs dehydration using your bathroom scale. A best practice is to weigh yourself naked before your workout, then again after. When you compare the numbers, you can see if you were adequately hydrating during your exercise. A discrepancy indicates that you need to increase your fluid intake during the course of your workout.

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Remember, that drinking only when thirsty is not an accurate way to assess hydration. You are already dehydrated when you are thirsty! Drinking plenty of fluids throughout the course of every day is beneficial to overall health and it is best not to be dehydrated when beginning your exercise!

It may also be of benefit to discuss your hydration levels and training practices with your coach, medical doctor, chiropractor, PT, etc and assess your specific needs including electrolyte intake.

While dehydration impacts overall health, many times we first see this as a drop in performance.

According to Human Kinetics, dehydration impacts performance for the following reasons: reduction in blood volume, decreased skin blood flow, decreased sweat rate, decreased heat dissipation, increased core temperature, and increased rate of muscle glycogen use.

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Please speak with your health care provider regarding your individual needs as an athlete, whether you run 5K’s or 100 mile races. Each person’s body has unique needs and this blog is intended for informational purposes only. If you would like to speak with Seed of Life Chiropractic and Wellness, LLC about your health, please make an appointment!