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Learn more about Rehab, Sports Medicine & Performance

Knee

Fitness Reinforcement

An Olympic Quest

As a society, we do not do enough to reward positive fitness habits.  I think the Russians are on to something with this novel method of earning a subway ticket.  As a country, we need to get into the fitness incentive technological race and expand on this advancement.  We aren’t going to let the Russians beat us.

I am sure Google has the software and hardware that would permit us to record our exercise activity and earn fitness credits.  Americans could use their earned credits to purchase health care, reduce income taxes, or bank them in their health care accounts.  This would be a non-mandatory incentive that would do more to lower health care costs than putting trans fats under FDA control or minimizing the size of our soft drinks.  It would reward good fitness behavior.  We could even link the program to the government Affordable Care web site…

Michael S. O’Hara, P.T., OCS, CSCS

What Women Need

Needs Are Different Than Wants

Rosei The RiveterI get to discuss fitness goals with women nearly every day.  They want to lose weight, get rid of musculoskeletal pain problems, have more energy, and “get arms like that girl”.  Many of them have been doing their favorite exercise activity for years and have been unsuccessful at achieving any of their stated fitness goals.  What they tell me they want to do is yoga, elliptical training, and Pilates.   What they need to do is start on a program of strength training.  

Ramping Up Your Metabolism
We all know that a body with more muscle burns more calories all day long.  You can get away with eating more food and not develop greater fat deposits.  Much more significantly, greater muscle mass positively influences fat metabolism, insulin levels, glucose processing, hormone profiles, and disease resilience.  These changes influence the “more energy” feeling you develop with strength training.  

Training To Abolish Pain
Nearly every patient that comes to physical therapy with a chronic pain problem has a glaring strength deficit that is perpetuating the pain.  They have gluteals, scapula retractors, or cervical stabilizers that are not functioning at a level that permit them to perform normal activities of daily living and remain free of pain.  What makes these patients better is a program of targeted strength training.  If you have chronic hip, knee, lower back, or neck pain, your best method of permanently resolving the problem is strength training.  

Bone Health
All of the current research says you need bone jarring, compressive, and aggressive loading of your skeleton to enhance or prevent further loss of bone density.  Over the last year, two government panels of experts have told us that taking more vitamin D and calcium does not appear to make any difference in bone density.  Better bone biology requires that the exercise stimulus be strong and consistent.  Low skeletal stress activities such as yoga, Pilates, and elliptical training do not create the forces needed to have a positive effect on bone density.  Read Bending the Aging Curve by Dr. Joseph Signorile.

Staying Independent
I am sorry Ladies, but muscle mass, strength, and power production all leave you at a far faster rate than your male counterparts.  It is not fair, but it is the truth.  As you age, training to restore these physical capacities becomes much more important if you wish to remain independent for a lifetime.  Ask any physical therapist who works with geriatric clients and they will tell you that weakness is the driver of debility.  The good news is that a properly designed program of strength training can work wonders.  

Motivational Goal Setting
Strength training provides motivation by having clear goals.  “I want to tone up” is not a clear goal.  Any psychology major will tell you that reaching defined goals reinforces positive behavior.  You improve from three to eight solid push ups, carry ten more pounds for fifty yards, press twenty pound dumbbells instead of tens, and it motivates you to stay with the program.  Numerous psychological studies have found that a lack of goal achievement is the number one reason people fail to succeed in staying consistent with an exercise program.  The girl with the arms you like has strength goals.  

Michael S. O’Hara, P.T., OCS, CSCS

The Lunge Matrix

Three Dimensional Leg Training

Twenty-five years ago, I participated in a three day “functional movement” seminar given by physical therapist, Gary Gray.  Gary got the entire class involved in a morning exercise class he called Pump and Praise.   One of the activities he taught was the lunge matrix.  I was 30 years old and had been exercising fairly regularly, yet I found the lunge matrix much more challenging than expected.  Since that time, I have used the lunge matrix with physical therapy patients, fitness clients, and in nearly every session of my own training.  Almost everyone can benefit from a little lunge matrix training.

The muscles in our trunk and hips are inter-twined, aligned in a spiral and diagonal fashion.  They are neurologically connected and work as a team to drive movement in three dimensional patterns.  The lunge matrix neurologically activates all of the muscles in all of the possible movement patterns.

The lunge matrix is ideal for anyone involved in a multi-directional sport.  Tennis, volleyball, basketball, soccer, and football require efficient transition in all directions. Injury prevention is the most important aspect of any athletic training program.  Your gym program should make you more bullet proof on the field of play.

The lunge matrix can be used as a movement preparation activity with just bodyweight (my favorite) or as a stand-alone strengthening exercise.  When performed as a strengthening exercise, use functional level loads, dumbbells, or medicine balls that equal the weight of the bag of groceries or the grandchild you are going to lift.  The loads should not alter the quality of movement or shorten the range of your lunges.  Choose shoes with flatter soles as some of the more cushioned running shoes can make lateral and rotational movement patterns difficult.

Lunge Matrix Series
1. Anterior lunge R / L
2. Lateral lunge R / L
3. Rotational lunge R / L
4. Posterior lunge R / L

Watch the attached video, and then give the lunge matrix a try.

Michael S. O’Hara, P.T. OCS, CSCS

Stripe Hype

The Good And Bad Of Kinesio Taping

In 2008, Kinesio tape (KT) was donated to 58 countries for use during the Olympic games.  Since that marketing effort, its presence in televised sports has exploded.  The athletic fashion statement found at many competitions is the brightly colored strips of tape across elbows, knees, shoulders, and hips.  At Wimbeldon, Novak Djokovic had green tape on his elbow.  Many of the soccer players at the last Euro competitions had tape on shoulders and hips.  Female beach volleyball players seem to be wearing more tape than clothes.

Kinesio tape was invented by chiropractor Dr. Kenzo Kase in the 1970s.  KT is made of cotton with an acrylic adhesive that permits it to stretch 40-50% of its resting length.  The website for Kinesio tape claims that it can alleviate pain, reduce inflammation, relax muscles, enhance performance, and help with rehabilitation.  Rock tape, a competing product, makes similar claims and uses the slogan Go Stronger, Longer.

Does Kinesio Taping work?
Serena Williams with Kinesio TapeA meta analysis performed by Wilson in 2011 looked at all of the studies performed with KT and found some evidence that it helped improve range of motion, but no evidence that it helped reduce inflammation, relax/activate muscles, or improve performance.  There is no evidence that it “off loads sensitive tissues” or improves “lymph drainage”.  The number of high quality studies was small.

How Might Kinesio Taping Work?
What we do know is that the elastic, compressive nature of any band, brace, or tape placed on the body stimulates receptors in the skin.  The receptors modulate the perception of pain and as a result, pain decreases.  An example is a research study in which the patients that wore a neoprene sleeve during a series of tests 12 months post anterior cruciate repair produced significantly more force and had better balance than without the neoprene sleeve.  The sleeve created a constant pressure on the skin surrounding the knee.

Should You Use Kinesio Tape?
If you have a minor ache or pain and no structural musculoskeletal damage, then go ahead.  The KT can make you feel better, and this will make exercise and activities of daily living easier.  The tape can provide some control over the symptoms, and it has no side effects other than occasional skin irritation.

Remember that your body sends pain signals for a reason.  Any type of musuloskeletal damage should be dealt with more comprehensively than just KT.  It is a bad idea to use KT to reduce pain and then participate in activities that create even greater tissue trauma.  A small and easy to rehab rotator cuff tear can become a big, full thickness, surgical repair tear if you tape it up and practice your tennis serves.

We do lots of things in medicine that have no solid, double blind research that proves efficacy.  The manufacturers of KT products need to spend more money on research and less on marketing.  I am hopeful that in time, more evidence will develop for the use of KT.  If some strips of KT make you feel better, go ahead and use it.  The best approach is to get to the cause of the problem and enact a treatment plan that resolves the pain or functional limitation.

Michael S. O’Hara, P.T., OCS, CSCS

If Frankenstein Had Glutes, He Could Have Run Away

Get Fit With Monster Walks

Frankenstein in chainsMost of the exercises performed in the gym emphasize the sagittal (front/back) plane of motion.  Squat, lunge, elliptical, and treadmill are all sagittal plane activities.  In athletics and life, we must be able to move efficiently in all planes of motion.  Our gluteal muscles are the primary producers of lateral and rotational movement in the lower extremities.  Strong and responsive gluteals keep your knees and lower back safe from injury during athletic activities.  A simple exercise to improve gluteal function and move better in the often-neglected frontal plane is a band monster walk.

You will need a mini resistance band or a lateral resistor.  Place a mini band loop around your ankles.  Assume an athletic stance with the feet straight ahead, knees bent, and hips flexed.  The band should be held taught throughout the exercise.  Try to keep the hips and shoulders level throughout the exercise.  Your torso and pelvis should not wobble side to side.  Move the right foot 12 to 18 inches to the right, and after planting the right foot, follow with the left.  Remember to keep some tension on the band.  When you have completed the prescribed number of repetitions, rest and then lateral step back to the left.

As you get better at this exercise, try performing the drill moving forward and backward.  The backward monster walk is an excellent gluteal activation exercise for runners.  Try performing one or two sets of eight to ten repetitions.

Michael S. O’Hara, P.T., OCS, CSCS

Front Squats

Stability, Mobility, And Better Posture

The squat has been described as the king of all exercises.  The large amount of muscle recruited during squatting makes it a very metabolically demanding exercise.  In athletics, the capacity to perform a full squat with proper torso, hip, and knee position has been correlated with greater durability–fewer injuries.  The overhead squat test is one of the patterns assessed in the Functional Movement Screen and is used in physical therapy and athletic training.  Squatting with the load placed on the front of the body is an excellent way to enhance mobility, stability, and strength.  Compared to leg presses, seated leg curls, and knee extension, front squatting creates much more carry over to activities of daily living and athletics.  The problem is most people do not know how to get started with front squats.

When you squat with the load across the front of the body instead of on the upper part of the back, the stress on the spine is reduced.  You can “cheat” a back loaded squat by leaning forward, but you cannot lean forward with a front squat.  Leaning forward on the front squat causes the load to fall from your shoulders or hands.  Front squatting creates a greater core stability demand and reduces shear force on the lower back.  Full depth front squatting will improve your posture and restore mobility in the hips, shoulders, and thoracic spine.

Front squatting is an exercise that is more equivalent to daily tasks and athletics.  Lifts in real life rarely place the load across your shoulders.  When you lift the grandchild, carry the groceries, or hoist the wheelbarrow, the load is in front of the body.  During athletics, the opponent is in front of you, and you must stay upright and tall to dominate the activity.

Front Squat 101
Before loading the squat, practice bodyweight squats to a depth target.  I like to use a 12 inch box or a Dynamax ball (12 inches in diameter).  You should be able to perform a body weight squat to a thigh below parallel position with a stable spine before attempting a loaded front squat.  When you perform a loaded front squat, initiate motion from the hips by sitting down and back.  Push the knees out and descend so the thighs travel to below a parallel to the floor position.  Keep the chest up and torso tall as you push back up.  Finish at the top by contracting the gluteal muscles and keeping the front of the rib cage down.

Choose A Proper Implement
While the barbell offers the greatest loading capacity, many individuals do not possess the shoulder mobility to hold the bar on the shoulders.  The Goblet Squat position with a kettlebell or dumbbell works just as well.  A sandbag hugged close to the body in the high Zercher position or bear hug hold has a high degree of athletic carry over.  Avoid the Smith machine variation.  You end up leaning on the machine and this eliminates much of the core stability demands and exposes the spine to greater shear force.

Michael S. O’Hara, P.T., OCS, CSCS

Chicken Run

Viscosupplementation For Your Painful Knees

When the knees start aching, activity levels fall, fitness recedes, weight is gained, and cardiovascular problems follow.  The baby boomers are reaching the time of life when knee joint breakdown begins.  Many patients have knees that show arthritic changes on imaging tests, but they are too young for a knee replacement.  While we know losing weight and improving leg strength and mobility will help decrease knee symptoms, many people have so much knee pain they cannot move enough to exercise.  One of the medical treatments that can help these patients is viscosupplementation.

Viscosupplementation is an intra-articular knee injection of hyaluronic acid administered by a physician.  Hyaluronic acid is a natural substance found in the synovial fluid of our joints.   Its function is to act as a joint lubricant and shock absorber.  Patients with knee arthritis have less hyaluronic acid in their joint.  The idea is that by adding some hyaluronic acid to the knee, the pain will decrease and the body will be stimulated to produce more of its own hyaluronic acid.

chicken 200
The FDA approved viscosupplementation injections as a treatment for knee arthritis in 1997.  These medications are derived from chicken combs and are now available from several pharmaceutical companies.  They are given in a series of three to five injections over a number or weeks and can be repeated every six months.

Viscosupplementation works best on patients with mild to moderate knee arthritis.  It is a treatment and not a cure for the arthritis in your knee.  The injections do not produce an immediate relief of knee pain.   It usually takes three or four weeks and several injections before patients report a decrease in knee pain.  Manufacturers claim six month’s of pain relief.  Clinically, the patients I talk to report three to six months of pain control.

The big benefit of viscosupplementation is that it can reduce knee pain and permit the physical therapy or fitness client the opportunity to begin exercising and work on the fitness goals that reduce stress on the knees.  The three to six month window of pain free knees is enough time to improve strength, restore functional mobility, and decrease bodyweight.  For people with knee arthritis, reducing loading and improving strength is the best life long method of managing knee arthritis.

Michael S. O’Hara, P.T., OCS, CSCS

Heads Up

The Downside Of Upside Down Exercise

H_HoudiniExercise activities that place the head below the heart have become more popular in fitness programs.  In almost every gym you see decline bench pressing, incline sit ups, glute-hamstring developer exercises, and more recently, hand stand push ups as a regular part of many exercise programs.  While these activities may have some value, you might want to reconsider training in an inverted position for some other reasons.

Esophageal Reflux
When you invert your torso, the contents of your stomach can more readily travel back up into your esophagus.  Head below your belly with a hiatal hernia, a little extra mesenteric fat, and some strong contractions from the abdominal muscles, and you have the perfect environment for gastroesophageal reflux disease (GERD).  Millions of Americans (14%-20% depending on the study) take medications to manage the symptoms of GERD—heartburn, chest pain, persistent cough, difficulty swallowing, hoarseness.  Prilosec and Nexium are the biggest moneymakers the pharmaceutical industry ever created.  Many Americans (10%-15%) have GERD, but are unaware of the problem because the tissue damage has not reached symptomatic levels.  Erosive esophagitis or Barrett’s esophagus is a clinical finding of cellular change in the esophagus and a precursor for esophageal cancer.  Esophageal cancer is one of the more deadly types of cancer.

Glaucoma or Retinal Disease  
The head down position raises pressure inside the eyeball.  As little as 30 degrees of decline has been shown to increase intraocular pressures.  It is estimated that 2.2 million Americans have glaucoma, but only half of these know they have the problem.  Individuals with glaucoma already have elevated intraocular pressures and should avoid these positions.  The back of the eye (retina) is susceptible to changes in vascular pressures, so if you have any retina issues, avoid the head down position.

High Blood Pressure / Hypertension
Your heart, lungs, and arteries are conditioned to pump blood with your body in an upright position.  Many vascular alterations occur when we flip into a heads down position.  When you assume the head below your heart position, the arterial pressures inside the skull increase.  Elevated cranial blood pressures can lead to headache and much more severe problems such a stroke.  One in three Americans are walking around with high blood pressure.  Add in an exercise induced elevated heart rate and some less than pliable carotid arteries and you have the ideal environment for a big bad brain event.  If you have hypertension, I would not go about using any inverted positions in the gym.

Bottom Line
Apart from going blind, having a stroke, and developing an incurable cancer, you should be fine.

Michael S. O’Hara, P.T., OCS, CSCS

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

A Step Up In The Right Direction

Anterior Step Ups

Most of the lower extremity training in the gym occurs with both legs working at the same time.  Leg press, leg extensions, squats, and deadlifts all train both lower extremities simultaneously.  In life, we almost always function in a single leg, or predominantly single leg manner.  All athletic activity requires a high degree of single leg control to be proficient and remain free of injury.  Your fitness training should include activities that improve balance, proprioception, core stability, and strength while on one leg.  One of the best single leg exercises to add to your training program is step ups.

Connecting Your Lateral Subsytem
When you stand on one leg, the team of muscles that keep you upright and tall are collectively called the lateral subsystem.  They consist of the groin muscles (muscle on the inside of the thigh), the gluteus medius (outside of the hip), and quadratus lumborum (side of the spine).  These muscles must work in a coordinated fashion to keep you straight and stable.   A step up exercise places a strong demand on the lateral subsytem.  Seated machine based exercises have no effect on this essential neuromuscular interaction.

Keeping You Safe
When I start clients on step ups, the most glaring deficit is almost always single leg stance balance.  Many of these people run, bike, and regularly attend group exercise classes, yet they have very limited control when they stand on one leg.  I do not care how much weight you use on the knee extension machine or how flexible your hamstrings have become; if your balance is poor, you are at a far greater risk for a fall and/or injury.  Anterior step ups will help improve single leg stance balance.

No Squishy
Deadlifts, squats, and leg press all create spinal compression.  The anterior step up exercise creates much less in the way of compressive force on the lumbar spine.  Fitness clients and athletes with a history of lower back pain can strengthen the legs with less spinal stress.

Real Life Carry Over
There is specificity to training.  The exercises you perform in the gym must look and feel like the activities you must perform in real life.  Your performance on a step up is far more likely to carry over to real life than your performance on a leg press or leg curl machine.

Anterior Step Ups
If you perform this at home, make sure you use a stable step up box—I would not use a padded lifting bench, milk crate, or old air conditioner.  A mirror can be very useful in monitoring your performance.  Most people can start with an eight inch household step.

Stand facing the box with one foot completely on the box–from heel to toes.  When you perform a step up, use your gluteals and hamstrings to push through the foot and drive up into single leg stance.  Do not jump up on to the step by leaning over and “popping up” with the rear leg.  Bring the rear leg up to 90 degrees hip flexion, and hold a single leg stance for two counts.  Try to abolish any wobble in your single leg stance position.  Lower back down using the stance leg to control the descent.  Perform all of the repetitions on one leg and then repeat on the other leg.  If you find one leg is significantly weaker, then start with that limb first.  Perform two or three sets of eight to ten repetitions.

Master your bodyweight on the eight inch step first and only then move to a higher box.  A good goal is to move up a box height that places the top of the thigh just below parallel when the leg is placed on the box.

You can load the anterior step up many ways.  I like using a medicine ball held at chest level as the first progression of loading and then progress to using an Iron Grip plate.  For athletes the Barbell Step Up is a great functional exercise.  It is best to perform this exercise in a power rack in case you lose control of the weight.

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

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