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Foot and Ankle

Turkish Get Ups and Waiters Walks

When designing programs for rehabilitation patients and fitness clients, I often pair up exercises.  This practice is commonly called super-setting and it has multiple benefits:
Train efficiently—You get much more work done during your training time.  
Abolish performance deficits—Most physical therapy and fitness clients need to work on glaring right vs. left movement asymmetries, postural restrictions, and stability limitations.  
Lose weight—Fat loss is a primary goal of most fitness clients.  Pairing exercises ramps up exercise intensity and creates the hormonal response that improves body composition.  
Move better—Training neurologically related movement patterns improves motor control.   

Turkish Get Up and Waiter Walk Complex

How you move says more about your fitness than how you look.  The pairing of the Turkish Get Up (TGU) and Waiter Walk is an exercise complex that improves gait mechanics and the survival skill of getting up and down off the ground.  You will be performing a TGU and immediately move into a Waiter Walk so you need twenty yards of open space.  As you get stronger at this complex and use a heavier implement, some interesting things start to happen.  You get better at controlling respiration and have an intense focus on how your body moves during the TGU and Waiter Walk.  My yoga friends tell me this is the focus of their practice sessions: better respiration, improved motor control, and increased strength.

Turkish Get Up

t_get_upsThe Turkish Get Up (TGU) is generally performed with a kettlebell, but you can use a dumbbell.  A medicine ball can help teach body alignment to beginners.

Exercise activities that produce the greatest rewards are the ones that take the most time to master.  You can learn a barbell curl in five seconds but a TGU can take weeks to master.  Developing proficiency with the Turkish Get Up will require some patience and instruction, but for the time spent, the pay off is tremendous.  Complete instruction on the TGU is not possible in this short article.  Watch the accompanying video and work with a qualified trainer on this exercise.  Steve Cotter and Gray Cook both have excellent YouTube tutorials on the TGU.

Waiter Walk

You must have adequate shoulder range of motion and good balance to perform this exercise safely.  Hold the kettlebell overhead like a waiter carrying a tray.  Keep the chest proud and the neck relaxed.  The upper arm should be adjacent to the head and your walk should be smooth and free of any lean or limp.

Complex
I like to train TGU rookies with a soft Dynamax ball.  If they drop the ball it will not damage any aspect of their anatomy.  Balancing the ball on the hand tends to teach proper alignment.  Progress to a kettlebell as you become more proficient.  Start on the floor and perform the TGU ascent.  Once at the top of the TGU, perform a Waiter Walk for twenty yards and then lower back down to the floor with a TGU descent.  Switch the implement to the other side and repeat.  Perform two trips on each side.

When you perform this complex, strive to move more gracefully before adding more resistance.   Get up and down off the floor and walk in a coordinated and efficient manner.  Only then increase the load of the ‘bell.

View video of Mike performing these exercises herehttps://www.youtube.com/watch?v=s0U9GWMI4bU&t=8s

-Michael S. O’Hara, P.T., OCS, CSCS

Hip Lifts and Roll Outs

When designing programs for rehabilitation patients and fitness clients, I often pair up exercises.  This practice is commonly called super-setting and it has multiple benefits:
Train efficiently—You get much more work done during your training time.  
Abolish performance deficits—Most physical therapy and fitness clients need to work on glaring right vs. left movement asymmetries, postural restrictions, and stability limitations.  
Lose weight—Fat loss is a primary goal of most fitness clients.  Pairing exercises ramps up exercise intensity and creates the hormonal response that improves body composition.  
Move better—Training neurologically related movement patterns improves motor control.  

Hip Lifts and Roll Outs

An intricate system of muscles holds the spine upright over the top of the pelvis.  This pair of exercises coordinates and strengthens this support system.  If you sit all day long, have postural problems, or a history of lower back pain this pair of exercises is worthy of your training time.

Hip Lifts
hip_liftThis drill coordinates hip extension and lumbar spine stability.  It is very beneficial when progressed to the single leg version.  Lay with your shoulders across a bench with the head supported.  Place your arms out to the sides.  Plant the feet on the ground with the knees bent 90 degrees and the shins perpendicular to the floor.  Drop the hips to the floor and then push back up with the gluteals and hamstring muscles.  Hold at the top for two counts and repeat.

Roll Outs
The roll out can be scaled to serve any fitness level.  Beginners can start with a large 65 centimeter physioball, and as they become more proficient, progress to a smaller 55 centimeter ball.  The closer the hands get to the floor the more challenging the exercise becomes.  If you get strong enough, you can perform the forward roll out with a Power Wheel or Sorinex roller.

Kneel on a mat to keep the pressure off your knees.  Your femur (thigh bone) is positioned perpendicular to the floor and the hips are hinged at 45 degrees.  Place the hands on the front of the ball and the elbows directly under the chin.  Brace the abdominal muscles and roll out onto the ball until you feel a challenge through your midsection.  Hold in the challenging position for three counts and then return to the starting position.
Perform twelve repetitions of the hip lifts, rest 30 seconds, and then perform ten roll outs.  Rest and repeat the cycle.  Work up to three sets through this exercise combination.

View video of Mike performing these exercises here: https://youtu.be/Xf08rFU7A4w.

-Michael S. O’Hara, P.T., OCS, CSCS

Crawl and Bearhug Sandbag Carry

When designing programs for rehabilitation patients and fitness clients, I often pair up exercises.  This practice is commonly called super-setting and it has multiple benefits:
Train efficiently—You get much more work done during your training time.  
Abolish performance deficits—Most physical therapy and fitness clients need to work on glaring right vs. left movement asymmetries, postural restrictions, and stability limitations.  
Lose weight—Fat loss is a primary goal of most fitness clients.  Pairing exercises ramps up exercise intensity and creates the hormonal response that improves body composition.  
Move better—Training neurologically related movement patterns improves motor control.   

Crawl and Bearhug Sandbag Carry

A finisher is a short but intense, high metabolic cost, training event performed at the end of an exercise session.  The best finishers create carry over to real life activities and can be made more challenging as you become more fit.  When linked to proper diet, finishers produce the “metabolic hit” that stimulates fat loss.  As the name implies, you always perform finishers at the end of your workout because, afterwards, you will not want to do anything else.

Crawl
Crawling is all about the spiral, diagonal force connection that happens through the middle of the body.  Crawling is the primal exercise that enabled us to stand and walk.  The “core muscles” neurologically connect the left hip with the right shoulder and the right hip with the left shoulder.  They stabilize the pelvis and spine so you can transfer force from the hips to the shoulders.  Crawling keeps that connection healthy and strong.

Bear Hug Sandbag Carry

sandbagThe bear hug sandbag carry is the cure for the epidemic of device disability syndrome (DDS).  This exercise reverses all of the weakness that is created by endless hours planted in a chair, staring into a screen.  Sandbag carries are functional core stability work.  The abdominal muscles interact with the muscles in the legs and shoulder girdle to hold a stable upright position.  Walking with a sandbag kicks starts your postural reflexes, the neural feedback mechanism that holds us up against gravity.  Do not go too heavy on the sandbag.  You should be able to stay tall and not stagger or lean forward.

The routine is simple:  Crawl for twenty yards—ten yards down and ten yards back.  Try to keep the knees close to the floor and the back flat.  Immediately after finishing the crawl, pick up the sandbag with a bear hug hold- no hands linked- and carry it for twenty yards.  Rest as needed and repeat.  Start out with three circuits and increase to five.  Try to keep the rest periods under thirty seconds.  Once you get up to five circuits, add a weight vest and then a heavier sandbag.  Modify the distance, load, and cycles to suit your needs.  Give the crawl/bear hug carry combo finisher a try and let me know how it goes.

View video of Mike performing sandbag carries here: https://youtu.be/Ygg2vbf-Uoo

-Michael S. O’Hara, P.T., OCS, CSCS

 

Three Gifts I Would Give And Three I Would Take Away

Santa Gives You Gluteal Activation
You need a responsive and strong set of butt muscles to function at optimal levels. Many gym goers have gluteal muscles that are neurologically disconnected.  The term physical therapists and strength coaches use is “gluteal amnesia.”  Our sedentary lifestyle involves very little of the glute recruiting sprinting, deep squatting, and climbing that activates the butt muscles.  We mistreat our gluteal muscles with hours of compressive sitting and little in the way of full range hip movement.  Most fitness clients are in need of some intensive gluteal training.  The hip lift is a simple exercise activity that produces a superior response.  See the attached video for a demonstration.

Scrooge the Lumbar Spine Flexion
Drop the sit ups, stop doing crunches, ditch the glute ham developer sit ups, and forgo the toes to bar competitions.  Father time, gravity, and the stress of prolonged sitting are already bending our lumbar spines forward all day long.  The last thing you need to do is accelerate degenerative breakdown of the lumbar segments with more repetitions of spine flexion.  Please forget about isolating abdominal muscles.  Instead learn how to control the team of muscles that hold the lumbar spine stable.  It is a neural event that is worthy of all your efforts.

Santa Gives You Medicine Ball Throws
medballLife is an up tempo game.  What you do in the gym is reflected in how well you can move during activities of daily living.  If you continually exercise at slow tempos you will get better at moving slowly.  The capacity to decelerate a fall requires fast reactions.  Gracefully traveling up the stairs and getting out of the car are only improved with exercise that enhances power and speed of movement.  Medicine ball throws are the easiest way to improve power.  Medicine ball throws can be scaled to all fitness levels and are safe as long as you use a properly sized and weighted ball.  The large, soft Dynamax balls are a good choice for beginners.  They rebound well off of the block walls in the gym and are easy to catch.  Do not overload your medicine ball throws, a two to eight pound ball is best for most gym goers.  Get with one of the trainers for instruction on adding medicine ball throws to your training program.

Scrooge Sitting Down in the Gym
Movement happens in an upright, standing position.  “Seated exercise” is an oxymoron.  If you want to improve how your body functions, you must stand up and defy gravity. Every athletic endeavor is performed in a standing position. Seated exercise reinforces poor postural habits and diminishes your capacity to move.  I call it the “illusion of exercise” and it will always be highly visible in commercial gyms because it is easy to sell.

Santa Gives You Four-Point Training
Crawling is the neurological training tool an infant uses to develop the capacity to stand and walk.  It is the pathway to better motor control and less pain.  Nearly every physical therapy patient and most fitness clients benefit from a healthy dose of four-point position exercise.  In your fitness program, reinforce the patterns of spinal stability and reboot the postural reflexes with some horse stance horizontal, crawling, and Jacobs Ladder training.   Four-point training can be scaled to any fitness level.  Watch the attached video for some examples.

Scrooge Elliptical Training
I know you love the elliptical.  It is the no impact, cardio darling of the gym but it should be used as a fitness dessert and not a main course.  Elliptical training has multiple drawbacks.  Ergonomically, it is a one size for everyone apparatus that does not work well for taller or shorter people.  When you walk or run, you improve the important skill of stabilizing your body over one leg.  An elliptical keeps both feet stapled to the machine and deadens any neural enhancement of balance or single leg stability.  Hip extension keeps our back healthy and our body athletic.  Maintaining or improving hip extension should be part of every training session.  There is no hip extension produced when you train on an elliptical.  Many people maintain a flexed spine when they use an elliptical.  Sitting produces the flexed forward spine we all need to work against in our fitness programs.  The repetitive use of the shoulder girdle is a frequent generator of referrals to physical therapy for head and neck pain.  Metabolic adaptation to elliptical training happens fairly quickly.  In January, a 30 minute session burns 330 calories, but by June, your body becomes more efficient and that same routine creates only a 240 calorie deficit.  The low impact, reduced weight bearing nature of an elliptical makes it a poor choice in your fight against osteoporosis.

I am happy when people are more active.  Patients and fitness clients love the elliptical and they believe it helps.  Use that belief to keep you motivated and training.  I just want everyone to manage the drawbacks of this type of training.  Injured people always say “Why didn’t someone tell me?”  Before you jump on the elliptical, take ten minutes and improve your core stability and hip function with some four-point exercises and hip lifts.  Learn how to throw a medicine ball and stay standing through the rest of your training program.  Next Christmas you will thank me.

Merry Christmas and a Humbug to you.

See video of Mike in the gym demonstrating these exercises here: https://youtu.be/H0my94BPHNQ

Michael S. O’Hara, PT, OCS, CSCS

Goblet Squats and Pull Ups

When designing programs for rehabilitation patients and fitness clients, I often pair up exercises.  This practice is commonly called super-setting and it has multiple benefits:

Train efficiently—You get much more work done during your training time. 

Abolish performance deficits—Most physical therapy and fitness clients need to work on glaring right vs. left movement asymmetries, postural restrictions, and stability limitations. 

Lose weight—Fat loss is a primary goal of most fitness clients.  Pairing exercises ramps up exercise intensity and creates the hormonal response that improves body composition. 

Move better—Training neurologically related movement patterns improves motor control.  

Goblet Squats and Pull Ups

The more inefficient you are when performing an exercise activity the greater the metabolic demand.  Inefficient exercise is the key to fat loss.  Most gym goers become efficient in their selected exercise activities and body composition improvement comes to a standstill.  This pair of exercises creates a systemic response that ramps up the metabolism and drives the hormonal response that creates better body composition numbers.

Goblet Squats
toes_to_fingertipsHold a kettlebell by the horns, with the elbows down and the kettlebell held against the sternum.  Keep the chest proud and relax the neck.  Place the feet at shoulder width and initiate the squat by pushing back the hips.  Keep the torso tall and descend to at least a thigh parallel to the floor position.  Let your pelvis fall between the legs. The elbows should drop down between the knees.  As you get stronger, use two kettlebells held in the double rack position.

Pull Ups
If you are unable to perform a pull up with your own bodyweight, use a band for assist or better yet, one of the machines that assists a pull up.  Use a pronated grip (hands facing away) or a neutral grip (hands facing one another).  I like a set of rings as it affords the shoulders more freedom of movement.  Attempt to get your elbows tight to your side at the top of the pull up.

Perform ten goblet squats, then perform six pull ups, rest sixty seconds, and then cycle back through.  Perform four total trips through this pair of exercises and you will have completed 40 goblet squats and 24 pull ups.  There is something about the pull ups that makes my upper back feel more stable and I move through the goblet squats with greater ease.  As your body composition improves, the pull ups get easier.

View video of these exercises here: https://youtu.be/3L13W9VpqXk

-Michael S. O’Hara, P.T., OCS, CSCS

PDFThe September 2016 newsletter contains information on preventing ankle sprains.  Mike O’Hara, PT demonstrates exercises to prevent ankle inversion.  Meet Fenton Fitness member Gay Adams and read her story on staying strong during a difficult time, and learn about the suitcase carry–a better alternative to weighted sidebends.

Download Here

Bear_PawGetting up and down off the ground is a movement skill we need to maintain.  It is the functional exercise activity that keeps us safe and independent for a lifetime. Developing proficiency in getting up and down off the ground has multiple benefits.  It takes away fear, builds confidence, and increases activity in other areas of life.  Your fitness training should involve activity that makes you better at moving gracefully in and out of the positions necessary to get up and down off the ground. 

Getting up and down off the ground is largely a neural activity.  Nearly everyone has enough strength, range of motion, and balance—you just need some practice.  Physiologically, we know that movement practice makes transmission of neural signals more efficient.  Research on motor learning has taught us that repetition, ascending challenge levels, and coaching produces the best results.  The bear paw exercise is a good starting point for improving from the ground up movement skills.

Bear Paw Performance

You need a medicine ball and some open space.  Get down on the ground in an all four stance with the medicine ball under the left hand.  Brace the abdominal muscles and lift the knees up off the ground about six inches.  Maintain that suspended position and roll the ball forward and backward with the left hand, like a bear pawing the ground.  Keep the right shoulder blade down the back and the neck free of tension.  Perform ten repetitions, lower down, and rest.  Switch to the right hand and repeat the drill.  Perform three times on each side.

View video explanation of the bear paw exercises here: https://www.youtube.com/watch?v=gGcsbv-BqfU

Michael S. O’Hara, PT, OCS, CSCS

Fitness training for those of us past 40 years of age is more complicated.  Physical performance and recovery capacity is dramatically different.  If you need proof, look around for the forty year olds in the NBA or NFL.  The good news is that with proper planning, consistent performance, and the wisdom that comes with age, we can stay fit and active for a lifetime.  I have compiled a collection of tips for the forty plus fitness client. 

Manage Eccentric Muscle Loading

sledDuring the concentric portion of a lift, the muscles shorten as the load is moved.  In the eccentric phase, the muscles gradually lengthen as the load is lowered in a controlled manner.  Eccentric muscle activity (lengthening under tension) produces more muscle micro trauma and, therefore, requires more recuperation time.  It is the eccentric aspect of a resistance exercise that creates delayed onset muscle soreness.

Older fitness clients do not possess the same recovery capacity as younger individuals.  Utilizing exercise activities that reduce eccentric stress is a valuable training tactic.  Concentric biased training allows older trainees to perform a greater volume of work and be ready a day or two later for the next training session.
Sled work is my favorite “concentric only” fitness activity.  The muscles shorten to propel the sled and never have to lengthen against resistance.  You can push, pull, row, and press a sled at fairly high levels of exertion and still sufficiently recover between training sessions.

Loaded step ups are a predominantly concentric contraction, lower extremity strengthening exercise.  It teaches balance, core control, and improves single leg strength. The eccentric aspect of a loaded step up is minimal and this makes it an essential exercise for older fitness clients.

My favorite upper extremity eccentric only training device is the Surge 360.  The Surge provides resistance through a series of multi-directional pistons.  All exercise activities on the Surge are concentric only.

Resistance tubing is another tool that can help manage eccentric muscle activity.  The force curve (increased load as the tubing is lengthened and decreased as it gets shorter) helps reduce muscle activity during the eccentric aspect of many exercises.
-Michael S. O’Hara, P.T., OCS, CSCS

In an effort to get back into shape, Monica added some stadium step running to her fitness program.  She went to the high school stadium and made twenty trips up and down the bleachers.  The initial sessions went well but after the first few weeks her knees started aching and the pain began to interfere with activities of daily living.  Monica tried some anti- inflammatory medications and ice but neither produced any relief.  She recently arrived at our physical therapy clinic for some help with her knee pain.

Running stadium steps is a demanding exercise activity that will produce a strong metabolic response.  Unfortunately, stadium steps are too stressful for most people.

Risk/Reward Ratio of the Stadium Steps
shutterstock_385922764For deconditioned individuals, stadium steps fall on the risk side of the risk reward ratio.  Most overweight and “out of shape” fitness clients have tight and weak hips.  They are inefficient in the skill of decelerating their body down the stairs and that skill deteriorates as they fatigue.  They need to use training methods that reduce orthopedic stress and limit biomechanical overload.

Stadium steps are a high level fitness activity.  It is the calculus of mathematical learning.   Deconditioned and overweight individuals need to start with basic algebra before venturing into quantum physics.  The better approach is to get fit first and then add stadium steps to your workout after you have improved strength, body composition, and mobility.

Run hills instead.  I have switched many stadium stepping physical therapy patients to running up and walking down hills.  It is a more forgiving form of fitness training than stadium steps and the benefits are superior.

Your Inner Gladiator
If you insist on stadium step training, I have some suggestions.  Spend six weeks strengthening your hips.  Most deconditioned folks, sit all day and have poor strength/strength endurance in the hips.  Weakness in the hips permits the knees to collapse inward on your downward bound through the steps.  I like bridges, hip lifts, mini band squats, and walking lunges.  See my recent article and video on my favorite gluteal strengthening exercises.

Foam roll the outside, inside, back, and front of your hips, thighs, and hip rotators.  Most stadium stepping pain patients are a big basket of myofacial restrictions.  They writhe around on a soft roller and look at me like I am crazy.  Restoring the mobility of the fascia that encapsulates the deceleration muscles of the hip will help improve performance.

Run up and walk down, softly.  It is the step descent that causes the biomechanical stress on the muscles and joints.  As you travel down the steps, think about actively engaging the gluteal muscles and decelerating with the hips and not the knee.  The louder the impact on the descent the more likely you are an inefficient decelerator.  Have someone watch you as you travel down the steps.  If your knee collapses inward, you need to get off the steps.
Build up slowly.  Do not start with twenty flights.  Start with three trips and gradually build up your work capacity–once a week is more than enough for most folks.  Find other training modalities that are less stressful.  Being too aggressive with a training program is one of the big reasons people fail with fitness, and it keeps me busy in the clinic.

Monica was, by her own account, twenty pounds overweight.  Her hip mobility was less than ideal and she had prior history of hip pain problems.  She had diminished hip range of motion and limited strength in her hamstrings and glutes.  During assessment of her deceleration skills, Monica tended to land in a collapsed inward knee position.  We had Monica perform a program of mobility and strengthening exercises for both hips and rest from all “cardio” activities.  Her knee pain resolved and she was able to return to a program of fitness training.
-Michael O’Hara, P.T., OCS, CSCS

A physician friend sent me this recently released research article on the benefits of maintaining strength and muscle mass as we age.  I think everyone should take the time to read this article.  We are keeping people alive for longer periods of time, but how well are they living?  The discussion of the extension of life span compared to enhancement of health span is worthy of consideration.  Improving muscle mass and strength dramatically improves quality of life, a factor often not given enough consideration.

10522_2015_9631_Fig1_HTMLAge-related sarcopenia is the loss of muscle mass as we age.  Sarcopenia and functional disability travel hand in hand.  Combating sarcopenia has become a hot research topic as greater numbers of the American population pass through old age and the cost of their care becomes an issue.  The good news is that age-related sarcopenia is a very treatable condition.  The bad news is that it takes some education and effort.   When discussing the need for strength training, these are the top questions/concerns I get from physical therapy patients and fitness clients:

OK, how much, how difficult, and how often?
After the eye rolling, this is the question I get from most of my sarcopenic patients.  The research training programs that successfully reversed age-related sarcopenia involved four to seven progressive resistance exercises performed for a total of twelve to twenty sets.  The participants trained two or three times a week and the level of perceived exertion fell into the mild to moderate regions.  You are looking at 90 – 150 minutes a week of mild to moderate exercise.  The important, and often completely missed, aspect of progressive resistance training is that you increase the resistance or load lifted as you become stronger.

Can’t I just do yoga, golf, tennis, hot yoga, swim, walk, chair yoga, tiddly-wink, Pilates, underwater yoga?
I am sorry but the research studies have not found that these training modalities produce the necessary stimulus to combat age-related sarcopenia.  You can still perform all of these activities– just include a consistent program of progressive resistance strength training.

I don’t know what to do…
Poor exercise selection and beginner’s enthusiasm are the biggest reasons people fail with progressive resistance strength training.  Exercise is like medicine, administer the correct prescription at the proper dose and the results will be good.  Just like a visit to your physician, it all starts with an evaluation.  You need to start at a level that makes you better and not broken.  Get instruction from a qualified coach and follow his/her plan.  A big warning- the world of fitness is filled with many “certified experts” -–it took them a full weekend to complete their training.  These experts keep us busy in the physical therapy clinic.

You can view the research article here: http://link.springer.com/article/10.1007%2Fs10522-015-9631-7
-Michael O’Hara, P.T., OCS, CSCS

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