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Rehabilitation

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Lumbar Spine Fitness Guidelines

Janet injured her lower back while exercising in her local gym.  She was taking a trip through her favorite “ab ciruit” when she felt a snap in her lumbar spine.  The next day she was unable to stand up straight.  Two weeks later, we met her in physical therapy for her initial evaluation.  She was ready to return to her fitness program three weeks later.  Janet was very concerned she may suffer another exercise induced back injury and requested some advice.  These are the simple guidelines I give to physical therapy low back patients returning to exercise.

Mobilize the Thoracic Spine and Hips

Movement is supposed to happen at the thoracic spine and hips.  Unfortunately, prolonged sitting, deconditioning, and poor training choices tends to restrict mobility in these areas.  If you are unable to rotate and extend at the hips and thoracic spine, your brain will use other joints to make up for the deficit.  Pushing extra rotation and extension forces into your lumbar spine is never a good thing.  Dedicate some training time to improving thoracic spine rotation and hip extension / internal rotation range of motion.  If you sit for a living, work on your mobility everyday.

Make the Lumbar Spine Stable

Most fitness clients believe that more lumbar spine movement is a good thing.  They perform toe touches, back twists, and the many breeds of up and down dogs.  Unfortunately, greater lumbar spine range of motion is positively correlated with a higher incidence of lower back pain.  The incidence of low back pain escalates even further when we move those hypermobile lumbar spine segments against a resistance.  What does keep lumbar spines healthy is high level of lumbar spine strength endurance.  Can you hold the lumbar spine stable and prevent movement from occurring at the pelvis and five lumbar vertebrae.  Your lumbar spine stays happy and healthy when you focus training efforts on planks, roll outs, crawls, carries, and Pallof press exercises.  Avoid the sit ups, crunches, sidebends, toes to bar, and other assorted “ab” exercises that create lots lumbar spine motion.

Avoid Muscle Isolation Exercise Activities

The muscles that support the lumbar spine work together as part of a neurally connected team.  Training activities that support better communication between the team members will create optimal performance.  The neuroanatomy saying is “What fires together, wires together”.  Ditch the “upper abs”, “lower abs” baloney and sprint away from anyone who trys to strap you into a machine in an effort to “isolate your obliques”.

On her discharge from therapy, Janet was unable to perform a single roll out and fatigue fairly quickly with a twelve pound suitcase carry.  For the last three months, she has followed the guidelines and her progress has been excellent.   Janet is currently performing a suitcase carry with fifty pounds and has worked up to ten full reps on an ab wheel roll out.

Michael S. O’Hara, PT, OCS, CSCS

The Cumulative Effect of Activity

Many people are put off from starting an exercise routine because they are overwhelmed by the time commitment they feel is necessary.  Fitness magazines, exercise experts, and everything on youtube preaches–

–30 minutes of cardio three times a week

–45 minutes of strength training twice a week

–150 minutes of exercise per week

Most of this well-intentioned advice is wrong.  Nearly everyone can derive significant benefit from short bouts of fitness activity that are performed on a consistent basis.  Walk for five minutes twice a day.  A simple routine of two strengthening exercises will take no more than five minutes.  Climb the stairs in your home three times once a day.  Practice getting up and down of the floor.  Stay consistent with a routine of short exercise bouts and you will be healthier and stay independent for a lifetime.

More research has demonstrated the beneficial effect of short exercise sessions interspersed throughout the day.  Read the March 28, 2018, New York Times article by Gretchen Reynolds, Those 2-Minute Walk Breaks?  They Add Up.  View the article: https://www.nytimes.com/2018/03/28/well/move/walking-exercise-minutes-death-longevity.html

Mike O’Hara, PT, OCS, CSCS

Spring Trap

Preventing Gardener’s Trauma

After a long, snowy Michigan winter, the first warm and sunny day, we charge outside and clean up the yard.  The months snow bound in the house have made the gardeners eager to start the spring clean up and prepare for the summer to come.  Most of us will spend the winter in a fairly sedentary physical state and with no physical preparation to launch into hours of challenging outdoor work activity.  Every year at our clinics, we treat patients with gardening and yard work induced injuries that could have been prevented with some modifications of activity and preventative exercise.  These are my four hints to help safeguard my gardener friends from an unintended trip to the doctor’s office.

#1: Set a Time Limit.

Most of the patients we see with gardener trauma report that they worked “all afternoon” in the yard.  It is not uncommon to hear patients report they were bending, pushing, or pulling for five or six hours.  Use some caution and limit the duration of your weeding, raking, and shoveling.  Set a time limit of two hours and then stop–the garden will be their tomorrow and you will be less likely to have to undergo a springtime MRI.

#2: Use Proper Ergonomics.

Many gardening tasks place your body in challenging positions.  Ergonomic experts go to great lengths to eliminate forward trunk flexion and sustained knee flexion from industrial work settings.  Pulling weeds and cleaning out flowerbeds combines both of these positions and can create mechanical back and knee pain.  Avoid being in the “hands and knees” position for extended periods of time by changing positions frequently.  Use knee pads to reduce compressive forces on the knee joints and purchase gardening tools with extended handles so that you need not bend as far or as often.

#3: Avoid Lifting Heavy Objects.

After a sedentary winter spent indoors watching television and knitting, the last thing you should attempt is to hoist the 40 lb. bag of fertilizer into the back of the wheelbarrow. Lifting injuries increase dramatically with loads greater than 25 pounds.  Lifting any object from the floor to standing is risky, and carrying unstable loads that can shift around increases stress on the body.  Divide heavy loads into smaller portions and avoid lifting directly off the floor.  Get a bigger, stronger, and fitter neighbor or family member to help with heavy lifting tasks.

#4: Prepare For Battle.

Gardening and yard work are challenging tasks that should be met with a degree of preparation.  If you want to work for five hours in the garden and remain pain free, you must train your body for that level of activity.  I have selected three simple exercises you can do to get yourself ready for action in the yard.  Simple modification of ergonomics, limitations on work duration, and preparatory exercise can prevent a summer of pain.

Getting Ready To Toil In The Soil.

These three exercises can help you avoid injury and make your spring gardening safer and more productive.  Ideally you will perform these drills three times a week for two or three weeks before getting outside and working.

Hip Flexor Stretches

This stretch elongates the large muscle that runs across the front of the hip and attaches to the spine.  This region tends to tighten with prolonged sitting and can restrict hip and spinal motion.  Place one knee up on a cushioned chair and the other foot slightly forward on the floor.  Keep the spine tall and bend the front knee to stretch the hip flexor muscles.  Hold for five to ten seconds and repeat five times.  Perform the stretch on the other side.

Four Point Fold Ups

If you are going to spend time on all fours, it is a good idea to train your body for this task.  Assume a four-point position, knees under the hips and hands under the shoulders.  Keep the hands stationary and drop the hips back toward the heels.  Go back to the point you feel a stretch and hold–do not stretch into pain.  You may feel this in your hips, shoulders, lower back, or upper back.  Hold for five to ten seconds and repeat five times.

Bodyweight Squats

Gardening and yard work involves a lot of squatting.  Being able to safely squat allows you to lift with better body mechanics.  Simple bodyweight squats will strengthen the legs and trunk in preparation for these tasks.  Place your feet at least shoulder width apart.  Check the foot width with a full length mirror– most people squat with the feet too close together.   Keep the heels flat on the floor and squat down by pushing the hips back.  Work on maintaining balance and control during the motion.  Practicing this movement pattern will also improve your flexibility.  Perform a series of ten repetitions and then rest and perform another set of ten.

Michael O’Hara, PT, OCS, CSCS

Training For Less Fat, More Muscle

How To Induce A Growth Hormone Response

Human growth hormone (hGH) has been a newsmaker because of athletes’ illicit use of synthetic versions of this hormone to help them perform better on the baseball diamond, football field, or bicycle race.  Bodybuilders inject synthetic hGH to help sink bodyfat levels to single digits, all the while maintaining optimal muscle mass. The last ten years of exercise science has shown what type of fitness activities induce the greatest natural growth hormone response.  Specific exercise and recovery activities have a positive effect on our body’s daily hGH production.

Human growth hormone (hGH) is secreted in a pulsatile fashion throughout the day.  A number of physiological stimuli can initiate hGH release, the most powerful of which are sleep and exercise.  Human growth hormone has many varied roles throughout your life.  For adult athletes and fitness clients, hGH helps increase fat metabolism–you get leaner, enhance muscle recovery from challenging exercise or injury, you stay stronger, and produce a healthier body composition as you age.

Resistance Training

Resistance training produces a significant exercise-induced growth hormone response (EIGR) that can last for 24 to 36 hours.  The response is greatest with full body training sessions that involve multi joint lifts and carries.  EIGR is not limited to traditional barbell or dumbbell training, but is also produced with the performance of bodyweight resistance training.  The post training hGH response gets better as the trainees became more proficient (gets stronger) with strength training.

Anaerobic Exercise

The exact mechanism that causes EIGR with anaerobic exercise is not known, but it appears to be related to higher lactic acid levels in the blood.  The activities that produce the greatest EIGR are high intensity exercise intervals lasting at least 30 seconds.  The researchers’ current recommendations for optimal EIGR are six to eight 30 second intervals of high intensity activity.  Bicycle sprints have been the most commonly used exercise modality in research studies, but other activities can be used as long as your joints and muscles can tolerate the stress.  Treadmill, stairclimber, rower, as well as track sprints and hill runs are good interval training choices.

Sleep

Human growth hormone is released in response to our natural circadian rhythms.  If your sleep-wake cycle is disturbed, the cyclical release of hGH is blunted.  Maintaining good sleep hygiene is important for optimal hGH production.  Avoid stimulants such as caffeine and alcohol before retiring to sleep.   Falling asleep and waking at consistent times creates more consistent hGH blood levels.  Just a few nights of interrupted or decreased sleep duration have been shown to reduce fat metabolism, slow muscle recovery, reduce insulin sensitivity, and decrease hGH levels.

Natural HGH Production Activity

Inducing optimal human growth hormone production is easy:  Get adequate and consistent sleep.  Every week, perform two or three high intensity interval style training sessions for six to eight sets of 30 seconds duration.  Two or three times a week perform a full body strength training program made up of full body multi joint exercises.

Michael S. O’Hara, PT, OCS, CSCS

Finding Fitness With Lower Back Pain

The number of USA emergency room visits, pain medication orders, injections, imaging studies, and surgical interventions directed at lower back pain continue to rise.  I frequently meet people who report their fitness efforts have been hampered by low back pain.  I have five recommendations that can help fitness clients with lower back pain have more success in the gym.

#1 Do not exercise first thing in the morning:  Ergonomic experts have found that many more industrial lower back injuries happen in the morning.  The theory is that the discs in the lower back imbibe or gain fluid overnight and are more likely to deform with a physical challenge.  Give your lower back one or two hours of walking around time before starting an exercise session.

#2 Isometric strengthening of the spinal stabilizers:  The function of your “core” muscles is to limit movement of the lumbar spine and pelvis.  Stop all crunches, toes to bar, sidebends, sit ups, seated twisting, and learn how to perform bird dogs, side hovers, Pallof press, planks, and carries.  Compliance with this single hint would reduce USA expenditures on lower back pain dramatically.

#3 Enhance the function of your hip flexors and gluteal muscles: Please cease all the forward spine flexion, toe touching, spine twisting activities.  Greater lumbar spine range of motion is associated with more–not less, lower back pain problems.  Learn how to foam roll and mobilize the hip flexors and gluteal muscles.  Prolonged sitting and most popular “cardio training” deadens these muscles.  Properly functioning hip flexors and gluteal muscles keep the pelvis stable and take stress off the lower back.  Reawakening dormant gluteals and hip flexors is the magic that resolves long term lower back pain.

#4 Focus on single leg strength training:  Ditch the front loaded hip hinges–deadlifts, cleans, snatch, and drop the loaded squats.  Swear off the lower lumbar deranging leg press.  Reduce spinal compression and train the legs, one at a time.  Single leg training reveals the right / left side movement asymmetries that drive lower back pain.  Resolving these asymmetries and sparing the spine goes a long way to abolishing back pain.  You will need some guidance on exercise selection and execution- this brings me to #5.

#5 Get some help:  Exercise is the most powerful medication on the planet.  Nothing else comes close.  Take the proper dose of appropriate training and the results will be amazing.  Take the wrong dose of an inappropriate activity and the results can be devastating.  This is especially true for people with a history of lower back pain.  Find a qualified physical therapist to guide you through your fitness journey.  One way or the other, you are going to spend time and money on your health.  Proactive spending is always cheaper and more beneficial than reactive spending.

Michael S. O’Hara, PT, OCS, CSCS

 

The Coldest of Shoulders

Understanding and Not Understanding Adhesive Capsulitis

Marilyn first noticed the right shoulder pain when she was sleeping on her right side.  Over the next month, the pain became more frequent and more intense.  Her shoulder ached in the morning and after any repetitive activity.  Marilyn tried medications and ice, but the pain persisted.  After eight weeks, the pain decreased, but her shoulder movement had become restricted.  Her shoulder became so tight that she developed difficulty with activities of daily living such as fixing her hair, dressing, and bathing.  Marilyn had developed a “frozen shoulder” and the frustrating thing was that she had no idea why it had happened.

No one fully understands why a frozen shoulder develops.  For some reason, the envelope of tissue that surrounds the glenohumeral joint–the joint capsule, shortens and develops thickened adhesions or scar tissue.  The medical term is “Adhesive Capsulitis”.  This tissue restriction limits the ability of the humeral head (upper arm bone) to rotate and glide properly so your shoulder becomes tight and painful.

Most of the time, a frozen shoulder occurs with no associated injury or activity.  Frozen shoulder most commonly affects patients between the ages of 40 and 60 years old.  It is far more common in women than men.  Individuals with diabetes are at far greater risk.  If you have undergone a surgery or sustained a trauma to the shoulder, you can develop a frozen shoulder.  This is especially true if you have held the joint immobile for a period of time.  Several studies have linked Parkinson’s disease, thyroid problems, and heart disease to a greater incidence of frozen shoulder.  Patients that develop a frozen shoulder are more prone to getting it in the opposite shoulder.  Despite all of this knowledge, we continue to see many frozen shoulder patients that have none of these predisposing factors.

I would add another condition to the commonly mentioned predisposing risk factors for frozen shoulder.  In my career as a physical therapist, it has been a rarity to find a frozen shoulder patient who was strong.  From grip strength in the hand to the muscles that hold the shoulder blade on the rib cage, these patients are usually weaker than their same age and sex peers.  The strength in the unaffected arm is often as limited as the arm with the frozen shoulder.  My belief is that the most common risk factor for developing a frozen shoulder is upper body weakness.  The glenohumeral joint is a fairly unstable joint that relies on the integrity of the muscles to kept it free from trauma.  If the shoulder muscles are unable to properly control the joint, then excessive stress is transmitted to the joint capsule and an inflammatory response ensues that scars and tightens the capsule.

Physical therapy for a frozen shoulder consists of manual therapy to stretch out the shortened joint capsule and a program of exercise to restores shoulder range of motion, coordination, and strength.  Most of the time, we get the patient when the shoulder is at its tightest point and recovery takes six to ten weeks.  As with so many conditions, the patients that get to therapy earlier or before the shoulder is fully frozen do better with therapy.

In many ways, Marilyn is the typical frozen shoulder patient.  She is the correct, age, sex, and fitness level.  Further medical work up revealed that she was prediabetic and in need of some ongoing medical attention.  Marilyn was a model physical therapy patient and her shoulder function was restored with six weeks of physical therapy.

Michael S. O’Hara, PT, OCS, CSCS

Be Happy and Feel Good

Watch The Ted Takj by Dr. Stephen Ilardi

The number of Americans with depression has increased dramatically over the last ten years.  Depression is usually managed with medications and at present, one in five Americans is taking an antidepressant medication.  A modality of depression treatment that is often overlooked is exercise.  Daily movement has a restorative effect on brain health.  For decades, we have known that bed rest, induced by illness or injury, can change our physiology in a fairly short amount of time.  A sedentary lifestyle can have just as big an impact on how the brain functions.  Take the time to watch Stephen Ilardi PhD *Ted Talk on the management of depression.  If you have the time read the **article he wrote in the October 26, 2017 issue of the Wall Street Journal.  Dr. Ilardi has some insight on how technology enhancements are making us unhappy.

Consistent exercise restores brain health, immunizes us from depression, and greatly reduces pain.  Physical therapy patients and fitness clients frequently say the most beneficial aspect of a renewed devotion to exercise is the improvement in their mood.  Hundreds of studies have demonstrated the positive effects exercise has on brain chemistry.  All of the happiness and pain suppressing molecules antidepressant medications attempt to increase are developed and maintained sooner and stronger with exercise.  Mood improving serotonin, dopamine, and BDNF–Miracle Gro for you neurons–all increase with exercise.  Some of the most revealing research on pain science has shown that the brains “pain circuitry” changes when a patient is depressed.  Pain is perceived as more intense, widespread, and emotionally challenging.  Now put down your iphone and watch Dr. Ilardi.

Michael S. O’Hara, PT, OCS, CSCS

*TedxEmory, Dr. Stephen Ilardi.  See the ted talk on youtube here: https://www.youtube.com/watch?v=drv3BP0Fdi8

**Wall Street Journal, Why Personal Tech Is Depressing, Dr. Stephen Ilardi, October 26, 2017.

Modern medicine has lengthened our lives, but unfortunately, many older people physically deteriorate to a level that makes them vulnerable to minor health setbacks.  Frailty is a syndrome marked by weakness, poor mobility, a slow gait, and excessive fatigue.  Frail individuals are unable to adequately recover from physical activity or a challenge to their health.  Minor illnesses send them to the hospital, nursing home, or assisted living center.  Frail individuals are often unable to tolerate beneficial medical procedures and must live with pain and physical restrictions.  Frailty is a problem that responds very well to treatment.

In the 65 year old plus population, frailty syndrome is common.  Fifteen percent of the non-nursing home population is frail and forty five percent is pre-frail.  Frail individuals are far more likely to fall.  Forty percent of the frail and twenty two percent of the pre-frail individuals are hospitalized every year.  Frailty is a marker for adverse health outcomes and a means of identifying opportunities for intervention in patient care.

Physical activity has been shown to be the best preventative and treatment for frailty.  Patients bounce back from surgery much better if they under take a program of prehabilitation exercise prior to surgery.  Research on rehabilitation has demonstrated the benefits of exercise to restore strength and mobility in the frail population.  Take the time to read, One Last Question Before the Operation: Just How Frail Are You? by Paula Span in the October 27, 2017 issue of the New York Times.  Read the article here: https://www.nytimes.com/2017/10/27/health/elderly-surgery-frailty.html

In the senior population, fitness activities must focus on training that maintains functional mobility and an independent lifestyle.  You need to stand up and train to be a more graceful and competent walker.  Practice drills that improve your capacity to transfer from the floor to standing.  Always include balance and reaction exercises that keep you free from falls.  Foremost are strengthening activities that maintain bone density and restore capacity to lift, carry, push, and pull.

Michael S. O’Hara, PT, OCS, CSCS

* New York Times, One Last Question Before the Operation: Just How Frail Are You? Paula Span, October 27, 2017

PDFRead about keeping your hip flexors healthy and working well in Mike’s article, Nobody Names Their Child Iliacus.  Video instruction of the exercises in the article is available.  Jeff Tirrell gives five nutrition rules than can be broke.  Find out the correct way to set up your dual action air assault bike.

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PDFFind out if you scalenes are causing problems in Mike’s article, Scalene Salvation.  Read the inspirational stories of some Fenton Fitness members who conquered osteoporosis.

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