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The Lunge No One Loves

The simple drop lunge is an exercise that will improve your hip mobility, enhance athletic performance, and reduce the chances of injury to the knees and lower back.  The drop lunge trains a movement pattern you have to perform in nearly every sport.  To play tennis, basketball, or even bowling, you must be able to efficiently cross the one leg back and behind the other leg.

The reason most people do not utilize the drop lunge is that it requires consistent practice, a degree of single leg balance, and lots of hip mobility to achieve any level of proficiency.  It is not a muscle isolation, bodybuilding type exercise, so you will not find it highlighted in Mega Muscle magazine.  The more you struggle with the drop lunge, the more you need to include this essential movement pattern in your training program.

In physical therapy, we use the drop lunge with most of our lower extremity patients.   In programming for fitness clients, I use the drop lunge as a movement preparation drill and rarely add extra resistance.  The drop lunge can be loaded with a medicine ball, barbell, or with a pair of dumbbells.

Drop Lunges
Stand with the feet at shoulder width.  Step with the right leg behind the left leg and drop into a squat position.   How far you lunge across with the right leg will depend on the length of your legs and your mobility.  The heels will be off the ground and you will have to come up onto the balls of your feet.  Keep the torso tall and the abdominal muscles braced.   Return to the starting position.   Perform the next repetition with the left leg reaching behind the right.  Alternate legs and perform five on each side.   If you find one side is more proficient than the other, perform extra repetitions on the limited side in an effort to train away the movement asymmetry.

Common Mistakes:
Keeping the front knee too straight and failing to perform a full lunge,  losing your balance,  allowing the torso to fall forward,  looking down at the floor.

Michael S. O’Hara, P.T., OCS, CSCS

Unlucky Me

In my sports and fitness life, I have some regrets.  I spent too much time in activities that turned out to be worthless or worse, unhealthy.  I missed some opportunities to learn new skills and have more fun.  Looking back, I would change several aspects of my fitness life.

Bad Coaches
Growing up, I had some great coaches—Dad, Coach Sharpe, Coach Boulus, Coach Ross–Thank you.   However, some of my coaches were horrible.  They had no idea what they were doing or how they should interact with young kids.  They usually had a child on the team and this was their true motivation for coaching.  They smoked, obviously did not practice what they preached in regards to exercise, and were poor role models.  I was taught not to quit on a team, but looking back, I should have opted out.  The drills we performed were often punitive.  They denied us water, gave us salt pills, and made us participate in ridiculous training exercises.  Unfortunately, many of my friends dropped completely out of organized sports at early ages because of these coaches.  I think this is still happening today.

Too Much Team and Not Enough Solo Sports
From grade school to high school, I played team sports–baseball, football, and basketball.  In retrospect, I should have tried more solo athletic activities.  I did not start playing golf until my mid forties and I really enjoy it.  I did not try snow skiing until I was in my twenties.  You can participate in these sports through an entire life span.  My big wish is to be able to play golf, tennis, or frisbee with my grandchildren.

Nautilus Stupidus
When Arthur Jones came out with the incredibly intricate “cam gear” driven Nautilus machines in 1977, I jumped in head first.  They were big, shiny, and complicated, so they had to be good for me.  The Nautilus sales pitch was that 30 minutes of intense training twice a week would turn you into a physical super hero.  I bought a membership at a Nautilus equipped gym, and spent two years wedging my body into all sixteen of these mammoth machines.  I got better at moving a lot more plates on each of the machines, but I saw no improvement in my vertical leap or performance on the basketball court.  During that two year period, I became more and more physically limited.  When my shoulders started to ache at night, I had to give up the pullover machine.  When I developed tendonitis in my knee, I had to give up the leg curl and “squat” machine.  I suffered an abdominal strain working on the “torso trainer”.  I ended my Nautilus Era limited to only six of the sixteen machines.  I learned the hard way that seated, strapped in, muscle isolation resistance training is a waste of time.

Synchronized Drowning
My body is not made to swim—I am too dense (no jokes please).  I don’t float–my body sinks like a stone.  In my early twenties, I spent six months trying to learn how to be a proficient swimmer.  I never became any better at moving horizontally through the water—just vertically.  I had great coaching, but the harder I tried, the more my shoulders hurt and my neck ached.  The sensory isolation of looking down at the line in the pool was more than I could psychologically bear.  In the future, I will spend less time on trying to master an activity that physically is inappropriate for my body type.

Road Running Era
I spent three years distance running.  My goal was to run a sub forty minute ten kilometer race time.  I liked being outside and enjoyed the camaraderie of my fellow runners.  In three years of running, my body composition changed from 195 pounds at 12% bodyfat to 175 pounds and 16% bodyfat—I got smaller and fatter.  I went from ten pull ups to three, sixty push ups to twenty two, and my strength in the weight room plummeted.  My vertical leap went down and I got pushed all over the basketball court.  I did get faster in the ten kilometer run, but the running left we weak, tight., and slow.  It took me two years to fully recover.

Michael S. O’Hara, P.T., OCS, CSCS

Lucky Me

Good or bad, you are the sum of the influences in your life.  When I read the latest and greatest research on motor control development in children and listen to the experts on sports performance and injury prevention, I realize I was very fortunate.  Some of my story may help you in fostering an optimal environment for your children.

My Father
My Dad was a high school teacher who also coached basketball and football.  We always had barbells, medicine balls, and jump ropes in the house.  We had a ladder nailed to the ceiling in the basement to climb on and a balance beam in the back yard that was three feet off the ground.  We had a swimming pool, swing sets, ropes to climb, and heavy bags to tackle and hit.  I was encouraged to play everything from football to badminton.  When I read the latest research on the development of motor control in children, I realize I was provided the ideal environment.

The Felician Sisters
In grade school, following recess, the sisters would line us up in the parking lot–no one was permitted to opt out.  They brought out a big box that Sister Ludmilla or Sister Euphrasia would stand on while using a bullhorn to lead us in calisthenics.  Six hundred kids did 20 minutes of jumping jacks, push ups, squat jumps, and lunges.  I always liked it because it was the one portion of the school day that you did not get into trouble for moving around.  As a third grader, I became pretty good at push ups and jump squats.  I do not know of a single guy or gal that grew up doing the Felician Sister Fitness program who tore an ACL or destroyed their shoulder playing sports in high school.  I have always wondered if that was coincidence, early training of neuromuscular control, or just divine intervention.

Minimal Equipment and Maximal Coaching
My high school weight room was small and poorly equipped.  In my basement were some dumbbells and a barbell.  My strength training options were limited.  As I look back, this was an enormous blessing in disguise.  It made me concentrate on the basics of strength training.  No wasted effort on decline bench press, lat pull downs, or preacher curls.  I did squats, lunges, overhead press (no bench for bench press), chin ups, push ups, and cleans.  What I did have was consistent coaching that kept me safe and motivated.  Despite all of the sports I played, I never had a major injury.  The last twenty years of sports performance research has reinforced the importance of basic movement patterns performed extremely well.  If an athlete is strong and moves efficiently, he or she is far less likely to be injured.

My Friend Frank
I met Frank when I was in pre physical therapy college classes.  Frank was an incredibly well read student of fitness and human performance.  He had been a physical education teacher, army fitness instructor, and former professional boxer.  He was nearly seventy years old when I met him and his advice was priceless.  He pulled me out of bodybuilding type training and taught me the essential components of being athletic and moving efficiently.  Now as a physical therapist listening to presentations on the latest research in strength and conditioning, I often laugh because Frank told me the same things more than thirty years ago.

Michael S. O’Hara, P.T., OCS, CSCS

Year 56 Fitness Goals

Reinforcing the mental motivation to stay consistent with exercise is important.  Keeping an exercise log and writing down achievable fitness goals helps to keep me motivated.  I focus primarily on process goals.  I want to remain injury free, metabolically healthy, fight off postural deterioration, and keep a consistent exercise habit.  I have found that if I reach all process goals, the performance goals–stronger, leaner, faster, all tend to follow.  Year to year, many of my goals are the same, but some years I emphasis one specific challenge.  These are my year 56 fitness goals.  I encourage you to write some of your own.

Stay Consistent
My goal is 200 training sessions a year.  That is about 17 sessions a month.  All the big benefits of exercise occur with long term, habitual performance of an exercise regimen.  Consistency is king, everything else is details.

No Dings, Dents, or Medications
I want to move well and remain pain free for a lifetime.  My fitness program will focus on injury prevention and a strong awareness of the risk to reward ratio involved in all exercise selection.  I plan on spending more time on movement preparation drills and soft tissue regeneration activities.  I want to be able to handle a fall and absorb impact without an injury.  I will keep my blood pressure readings normal, and my blood sugar and lipid numbers in a healthy range.  I do not take any medications and I want to keep it that way for another year.

Colonoscopy Number Three
My father was diagnosed with colon cancer at the age of 45 and died from the disease at the age of 49.  Because of my family history, I started early with this test.  This will be colonoscopy number three and all prior tests have gone well.  The preparation is no fun, but the test itself is an IV and a short nap.  There were about 143,000 new cases of colon cancer and 52,000 deaths in the United States last year.  Colon cancer is extremely treatable when caught early and most people are cured.  If you are over fifty you should get a colonoscopy.

Move More EfficientlyIMG_3853
I need to achieve a level of mastery in unilateral exercises.  In life and athletics, it is all about single leg or single arm.  I will work on more step ups, skater squats, Turkish get ups, slider push ups, and land mine presses.  I used to be able to do one arm push ups and I would like to reclaim that ability.  Strength is a skill that is more neurological than muscular, so practice is important.  See the video.

More Hikes
My favorite “cardio” is putting on my boots, throwing on the backpack, and hiking up and down some steep terrain.  I believe the best gym cardio is high (15%) incline walking.  It is low impact, and it improves your posture by training the muscles most likely to shrivel as we age—the gluteals and hamstrings.   My favorite vacations involve long mountain hikes.  After a hike, I feel mentally and physically recharged.  Last year, I got in twenty-five solid, long hikes.  This year I am aiming for forty.

Michael S. O’Hara, P.T., O.C.S., C.S.C.S.

The Incredible Shrinking Man

The How, Why, And What To Do About Getting Shorter

Starting at about age 40, we begin losing height at a rate of four tenths of an inch every decade.  The trip from 40 to 80 years of age can easily take two and a half inches off of your height.  Some of the loss occurs as part of the normal aging process, and some because of disease and deconditioning.  The reasons we get shorter are well understood, and the good news is that we can do something about many of the causes.

Thinning Discs
One third of our spinal height is made up of the intervertebral discs.  The disks are made up of the same type of tissue as your nose.  The capacity of the discs to deform and bounce back to their starting shape permits one vertebrae to move on the other vertebrae.  The discs have a fluid filled center that helps attenuate force in multiple directions, similar to a shock absorber.  As we age, the discs between the vertebrae tend to become thinner.  If the distance between the top of your sacrum and the base of your skull is 33 inches, you have a potential 11 inches of disc height you can lose to father time.  Sitting increases the load on the tallest discs and a lifetime of prolonged sitting can accelerate your shrinkage.

Strength and Spinal Changes
Strength deficits in the postural muscles of the neck, posterior shoulders and upper back permit the head and thoracic spine to fall forward.  Extreme changes can create the hyperkyphotic spine or Dowagers Hump in the upper back.  Poor core stabilizer control will cause the pelvis to fall forward and the lumbar spine to collapse.  Obesity accelerates these alterations in spinal posture, as the weak muscles must support greater loads.  The muscles are the guy wires that hold the spine tall.  Lose tension on those wires and the tower starts to twist, bend, and get shorter.

Compression Fractures
The body of each spinal vertebrae resembles a cylindrical can with a webbing of reinforcing bone on the inside of the can.  As we age, osteoporosis can take a toll on the bone density of the vertebral body.  A compression fracture of the vertebral body is similar to standing a soda can on end and crumpling the can.  A crushed vertebrae is much shorter, thereby reducing overall spinal height.  Many people suffer small spinal compression fractures and are unaware of the damage until they undergo an imaging test.

The Fight For Height
So what can you do to maintain your elevation?  Keep your body strong and your weight under control.  Pay particular attention to the muscles on the posterior aspect of the body.  These muscles must fight the war against gravity every day.  They keep your spine tall and prevent the postural collapse that is all too common in the elderly.  Sit less and stand more.  The compressive forces of prolonged sitting on your spine are just one of the many bad things that sitting does to your body.  Exercise caution in regards to activities that compress your spine.  I would not recommend a sixty year old take up motocross or begin an exercise program that consists of deadlifts and Olympic lifting.  Be proactive about getting your bone density assessed, especially if you are a woman who went through menopause at an early age.  Have your vitamin D level checked, and if necessary, start supplementing on a consistent basis.  If you are diagnosed with osteopenia/osteoporosis, work closely with your physician on  medical treatment.

Michael S. O’Hara, P.T., O.C.S., C.S.C.S.

No Guts, No Glory

Exercise, Ibuprofen, And Colonic Seepage—Ewwww!

A new study* joins other evidence that ibuprofen taken before a workout may be causing disagreeable physical damage to the intestines and inhibiting muscle recovery.  Many runners, cyclists, and general fitness enthusiasts often down a dose of ibuprofen as a preemptive strike against post exercise soreness.  The habitual use of ibuprofen appears to have some significant health considerations for those of us who exercise.

Research studies have shown that strenuous exercise alone commonly results in a small amount of intestinal trauma.  Blood flow during prolonged exercise is shunted away from the gut to the laboring muscles, heart, and lungs.  This produces a transient blood flow ischemia in the sensitive intestinal lining and some degree of intestinal cell death.  Markers for this intestinal damage have been measured in the blood of endurance runners and cyclists.  This damage is generally short lived and resolves in a few hours.

A recent study of cyclists found that those participants who downed ibuprofen before a session of exercise had significantly higher levels of “intestinal leakage” into the blood stream than those who did not use the ibuprofen.  The concern the research physicians have is that chronic use of ibuprofen and strenuous exercise can lead to the leakage of digestive enzymes and bacteria into the blood stream.  Damage to the intestinal lining reduces the absorption of nutrients that are critical to recovery from a strenuous exercise session.  Tired muscles are unable to sufficiently regenerate because the gut cannot supply the nutrients necessary for muscle tissue rebuilding.

A study from a few years ago** found that runners from the Western States 100 Mile Endurance Run who were regular ibuprofen users had small amounts of colonic bacteria in their bloodstreams.  The bacterial incursion caused by “colonic seepage” actually causes higher levels of systemic inflammation.  The ibuprofen taken to reduce inflammation instead had the reverse effect and created more inflammation.

So, the next time you watch the drug company’s commercial of the woman who pops two pills and is able to run without pain, think about the bacteria sprinting through her bloodstream after her training session.
*Aggravation of Exercise Induced Intestinal Injury by Ibuprofen in Athletes, Medicine and Science in Sports and Exercise, December 2012, Van Wijck et. al.

**Ibuprofen Use, Endotoxemia, Inflammation, and Plasma Cytokines During Ultramarathon Competition, Journal of Immunology, November 2006 Nieman et. al.

Barbara O’Hara, RPh

Thanks Bob, I Think

Coach Bob Gajda’s Brutally Effective Training Advice

I like to pair up, triple up, and sometimes quadruple up exercise activities.  The exercises chosen are based on selected goals and performed in a circuit fashion.  I have found that this format makes the best use of available training time and is optimal for remodeling a specific area of function.  If you want to get stronger, lose bodyfat, improve coordination, or resolve a movement asymmetry, you will get there faster with using this type of training.

For most gym goers, their primary goal is changing body composition—less fat and more muscle.  For body composition goals, an extremely effective training method that utilizes a circuit style format is peripheral heart action training.

Peripheral Heart Action
In the 1960’s, Dr. Steinhaus coined the term peripheral heart action (PHA) to describe his systematic grouping of exercises to make athletes stronger and improve their anaerobic fitness.  Bob Gajda, a Chicago area strength coach from the 1970’s, popularized this style of training.  He found that PHA training made his athletes leaner, more muscular, and fitter in a shorter period of time than other forms of training.  In high school, I read many of Mr. Gajda’s articles and books on PHA and used these programs in my own training.  PHA training is attractive because it requires minimal equipment and time.  What it does require is a lot of effort.

The theory behind PHA is that you stimulate a strong systemic vascular response by selecting activities that emphasize effort in different parts of the body.  A lower extremity dominant activity is followed by an upper extremity dominant activity.  It is the opposite of bodybuilding style training of working one muscle with multiple sets and exercises.   Recent exercise science on the positive hormonal responses that speed up our metabolism and improve body composition have found the PHA method of training produces ideal results.

My two favorite PHA combinations are listed below.  Pick a weight you can perform for the specified repetitions or distance without reaching failure.  Move through the cycle with minimal rest between exercises.  When you have completed the cycle, rest for two minutes and repeat.  Start with three circuits and, as your fitness level improves, progress to four of five circuits.

PHA Kettlebell Series
1.  Kettlebell Goblet or Barbell Front Squat  x 10
2.  Pull ups, Chin ups, or Inverted rows x 10
3.  Kettlebell Swings x 10
4.  Push ups x 10

PHA Sled Series
1.  Sled Push x 25 yards.
2.  Dumbbell, Barbell, or Cable Rows x 10
3.  Sled Posterior Drag x 25 yards.
4.  Standing Barbell Overhead Press x 8

Michael S. O’Hara, P.T., O.C.S., C.S.C.S.

Toddler Fitness

Why Squatting Properly Makes Everything Better

A healthy squat pattern keeps your lumbar spine happy.  The ability to squat with strong, flexible hamstrings and gluteals keeps you lifting and carrying safely and efficiently.  If you are unable to squat, then every time you move toward the floor, you use your lumbar spine instead of the bigger and more powerful hips.  Just like the tread on a tire, you only have so many cycles of flexion in the lumbar spine.  Once you use those cycles up, the back problems begin.

If you enjoy water skiing, snow skiing, volleyball, or other lower extremity intensive recreational activities, you need a full, solid squat pattern.   If you are unable to efficiently decelerate force across all of the lower extremity joints, you are far more susceptible to injury.  The Functional Movement Screen Overhead Squat Test has become one of the best predictors we have for future injury.  Athletes that score poorly in this test get hurt more often and the injuries are more severe.

For those primarily interested in training for aesthetics, a set of loaded squats will do far more for your lower extremities than nearly any other exercise.  The metabolic boosting response from a set of twenty full depth squats is unbeatable.  Try three sets of twenty kettlebell goblet squats and let me know how you feel.

The squat exercise can be done anywhere and it requires no fancy equipment.  It is not overly complex and can be progressed with different types of exterior loading.   It builds better communication between the feet, legs, and torso than any seated machine based training and has far greater carry over to real life.

Unfortunately, due to deconditioning, injury, or a lifetime of sitting, many of us have lost any degree of squat capacity.  The good news is that regaining this pattern of motion is easy.  Listed below are some methods of retraining your squat.

Start At the Bottom
Babies learn to squat from the floor up.  As adults, we reverse this and try to relearn from the top down.  Lets go back to the baby method.  Try sitting on box or bench about sixteen to eighteen inches high.  Slide the hips to the edge and bring the feet back so the knees are bent.  Place the feet as wide as your shoulders.  Lean forward and push the knees apart as you stand up.  Do not push up with your arms on the bench or legs.

Push the Knees Apart
Many of us have sleepy gluteals (butt muscles) and are unable to push the knees apart effectively.  The knees collapse inward into a damaging valgus position.  Try placing a resistance band around the knees and push out on the band as you rise off the box.  This will reinforce activation of the gluteus medius muscles and improve your performance.

Keep a Long Lumbar Spine
If you slouch forward when you squat, try holding a stick overhead as you rise up off the bench.  Grip the stick like you mean it and pull the shoulder blades tight across the upper back.  This will help activate the muscles surrounding your spine and pelvis that have become disassociated from their isometric stabilization duties during a squat.

Load From the Front
When loading the squat pattern, I believe it is far more beneficial to load from the front.  Front loading will make the pattern stronger and it is far safer.  The sheer force on the lumbar spine is less in a front loaded squat than a back loaded squat.  Front loading does a better job of improving squat mobility, core strength, and functional carry over.

Michael S. O’Hara, P.T., OCS, CSCS

Year 55 Scorecard

Fitness is a motivational mind game.  Setting achievable goals provides the ongoing positive reinforcement needed to keep at the fitness habit.  I no longer set as many performance goals.  As I get older (55), it is more difficult to get stronger, run faster, or jump higher.  I try to set attainable process goals.  I want to stay injury free, metabolically healthy, fight off postural deterioration, and train consistently throughout the year.  If I happen to lose some fat, get stronger or faster, it is a happy by product.  Every birthday, I do a fitness goal review and this is my year 55 fitness scorecard.

Two Hundred Training Sessions a Year
My goal is to get in 200 training sessions in a year.  I managed to fit in 212 sessions for the past year.  Setting specific attendance goals is critical.  In fitness, all of the significant long-term benefits happen when you show up on a consistent basis.

Maintain Proper Movement
This is how the downward spiral starts.  You lose some mobility in your lunge, squat, or overhead reach.  Limited mobility means you no longer can work the muscles through a full functional range of motion.  The muscles move less, atrophy takes hold, and the metabolism slows.  You gain fat more readily, and because you are weaker and heavier, you move less.  Less total movement activity leads to even less mobility.  Less muscle mass leads to far less stored glycogen and insulin sensitivity suffers.  Insulin sensitivity problems lead to diabetes, obesity, metabolic syndrome……. You get the idea.  Mobility is a key component to remaining injury free and staying metabolically healthy.  This past year finds me better in all lunge patterns, and my sprint strides no longer look like Barry Sanders on one side and Colonel Sanders on the other.

Better Single Leg Motor Control
This has been the biggest challenge and the biggest change.  My single leg balance is better and the strength in my hips and lower back has improved.  Single leg training becomes more important as you get older or have a history of injuries.  I enjoy the variety that single leg programming brings to my training.

Power Up
In 2012, I did much more power type training.  In athletics and daily survival, power is more important than strength.  As we get older, the ability to fire muscles rapidly recedes.  The last decade of research studies have shown that this trend is reversible.  My scores in the medicine ball throw and the standing long jump both improved.  I believe the drills that helped the most were the hurdle jumps and kettlebell swings.  I became more proficient in both of these exercises.  My vertical leap did not get any better, but it did not get any worse.

No Injuries
I started with a sore shoulder, but some dedicated mobility work and rehab training set that straight.  I made it through the rest of the year with no dings or dents.

No Medications
This is a goal of mine every year.  I consider it a fitness victory if I am able to go another year and not have to take a blood pressure pill, statin drug, or an anti-inflammatory. I can think of no better fitness goal than being able to eliminate medications because your health is better.

Michael S. O’Hara, P.T., O.C.S., C.S.C.S.

Sooner Is Always Better

Recent Research On Early Physical Therapy Intervention For Lower Back Pain

Physical Therapists play a key role in the management of lower back pain.  The lower back pain patient often must travel a long and irregular road on the way to a physical therapist for care.  Patients often have multiple doctor visits, imaging tests, various medications, epidural injections, and worst of all– rest.  So when is the best time for a lower back pain patient to see the physial therapist?  A recent research study has answered that question.

Scheduled to be published in the journal Spine, this study* of over 32,000 patients has concluded “Early physical therapy following a new primary care consultation was associated with a reduced risk of subsequent health care compared with delayed physical therapy”.  Early physical therapy was defined as less than fourteen days.  Early physical therapy lowered costs, reduced the number of visits to the physician and decreased the use of injections, diagnostic imaging tests, and surgery.

Industry and business has figured this out.  Computer chip maker Intel has a program that gets their injured employees with back pain to the physical therapist in 48 hours.  Since utilizing this program, the cost of care has dropped by 30%.  The number of lost workdays has fallen from 52 to 21 days and patient satisfaction with the program is better.  Since 2006, Starbucks has been using a program that gets their employees with back pain to the physical therapist in twenty-four hours.  They have achieved lower costs, earlier return to work, and greater satisfaction from the patients.

In 2009, I spent three days with WorkSmart Solutions in two different industrial plants in Rockton, Illinois.  The physical therapist from WorkSmart visited the plant three days a week and consulted with the employees on any problems with pain.  They provided treatment as needed and assisted with work site ergonomics and activity modification.  The Human Resource departments in both plants remarked on the reduction in administrative hassle and the lowering of work compensation claims for lower back and neck pain.  The employees raved about the care for from the physical therapist and the ease of access to ongoing help.

The earlier we can intervene with physical therapy treatment the more likely we are to prevent the deconditioning that occurs with rest, the development of hypersensitive pathways, and fear of activity.  Lower back pain is a mechanical injury that requires the management of all mechanical forces in the patient’s life.  Education on proper posture, body mechanics, and fitness activities as well as modification of the work site are all part of comprehensive physical therapy intervention.

*Spine, Fritz JM, Childs JD, Wainner RS, Flynn TW. Primary car referral of patients with low back pain to physical therapy: Impact on future health care utilization and costs.

Michael S. O’Hara, P.T., O.C.S., C.S.C.S.