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.
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
The Downside Of Upside Down Exercise
Exercise 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.
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.
Apart from going blind, having a stroke, and developing an incurable cancer, you should be fine.
Michael S. O’Hara, P.T., OCS, CSCS
Robin Anthony McKenzie
“My patients taught me all I know.”
On May 13, 2013, world renowned physical therapist, Robin McKenzie died. Robin was an astute observer of his patients’ signs and symptoms. Early in his career, he realized that many of his patients with back or neck pain would get better only to suffer the same problem months or years later. To solve the problem of recurrence, he devised a very successful program of spinal therapy based on patient education and continued self-treatment with daily home exercise. He developed a system of evaluation and treatment of mechanical spinal disorders that has gained a worldwide following. His books, Treat Your Own Back and Treat Your Own Neck have sold over six million copies–more than any other medical self-help books. In 1982, he founded the McKenzie Institute to educate fellow physical therapists on his evaluation and treatment methods. I consider his most recent book, 7 Steps To a Pain-Free Life a must read for anyone who must lift, carry, or sit all day, or for patients with recurrent neck / lower back pain.
Thank You, Robin
Fresh out of college in 1984, I quickly realized that I had no idea how to help patients with lower back and neck pain. Thirty years ago, I completed my first McKenzie course and became a much more effective and confident clinician. Over the next two years, I completed three more of the McKenzie courses and went on to attend three of the McKenzie Institute’s International Symposiums. The education from the McKenzie Institute has been priceless. All of the physical therapists at our clinics have studied Mr. McKenzie’s teachings, and over the years, Fenton Physical Therapy has been fortunate to sponsor several of the McKenzie Institute educational courses. Our entire professional staff is grateful for the insight and knowledge Mr. McKenzie has brought to our profession.
Michael S. O’Hara, P.T., OCS, CSCS
Poor choices in exercise selection are often the cause of injury and pain. Most gym members are unaware of the damage that is created until it is too late. The joint stress produced by activities that manipulate body position in an effort to isolate a certain muscle very often create significant articular irritation. If your fitness goals are to stay strong and injury free for an entire lifetime, I suggest you avoid certain exercise activities.
A staple of Self and Shape magazine, this exercise probably will make your triceps muscle work hard if you possess enough shoulder mobility to drop down and bend the elbow 90 degrees. Unfortunately, bench dips also produce excessive stress on your neck and shoulders. During a bench dip, your neck is forced forward and the shoulder girdle is pushed into extreme positions of extension and internal rotation. Most of us have poor neck and shoulder posture and this activity feeds into the forward head–rounded shoulder posture that is epidemic in today’s computer based world. The movement of the shoulder joint during a bench dip pushes the humeral head forward and makes the long bicep tendon take a severe twist over the front of the humerus. This position stretches the anterior capsule of the glenohumeral joint making you more susceptible to shoulder subluxation or dislocation. Biceps tendonitis, tendonosis, and complete ruptures are one of the more common injuries we see every day in physical therapy. At the top of this exercise (elbows extended), the shoulder is loaded in a manner that compresses the subacromial space, making you more prone to impinge on the superior rotator cuff tendons.
Women typically have less stable shoulder joints and more sensitive necks, yet they seem to gravitate to this drill. MRI imaging tests of non-symptomatic shoulders reveal that many of us are unaware that we are walking around with rotator cuff tears and bone spurs in our shoulders. An exercise that places the shoulder into a stressful position may be all that is needed to make that tear or spur start waking you up at night. For athletic performance purposes, the bench dip movement is worthless as it is not similar to any movement pattern you ever perform on the field of play.
The gym is full of exercises to train triceps that are safer than bench dips. Try getting better at push ups, and remember that you cannot preferentially “burn fat off” the back of your arm with direct triceps training. If you speak with any of the strength and conditioning coaches that make their living getting athletes ready to perform at optimal levels, none of them use the bench dip.
Michael S. O’Hara, P.T., OCS, CSCS
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.
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.
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.
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
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 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
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.
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.
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
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.
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.
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.
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.