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Rehabilitation

Robin Anthony McKenzie

1931-2013

“My patients taught me all I know.”

r_mcknzie_bookOn 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

Bench Dips

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.

BENCH DIPS
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

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

The Incredible Shrinking Man

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

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

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

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

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

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

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

Toddler Fitness

Why Squatting Properly Makes Everything Better

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

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

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

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

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

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

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

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

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


Michael S. O’Hara, P.T., OCS, CSCS

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.

 

Multi Directional Power Training

Surge 180

We have recently added a new training tool to our physical therapy clinics.  The Surge 180 is a simple and incredibly effective training device for rehab patients.  The patient stands on the platform, grasps the handle, and works against resistance provided by three pistons.  The physical therapist can use the Surge 180 to improve many different areas of performance.

Safe and Effective Power Training
Most physical therapy patients are severely underpowered.  Not only do they need to get stronger, they must also get better at creating force quickly.   The patient can accelerate against the handle of the Surge 180, and because the overall mass is so small, there is no damaging inertia to overcome.  The mass of a weight stack, barbell, or dumbbell creates so much inertia that when you attempt to move the load quickly it creates damaging joint stress.

Multi-Directional
In life and athletics, our bodies move in all directions.  The Surge 180 handle moves forward–backward, right–left, diagonally, and into rotational movement patterns.  The handle excursion is big enough to accommodate patients of all heights.

It Demands You Stand
Rehabilitation is all about getting better at functioning in standing positions.  Patients need to learn how to efficiently transfer forces from the ground up through their body.  On the Surge 180 platform, the patient can be positioned in-line, split, straddle, or single leg stance.  Connecting the shoulder to the opposite side hip, through an active core is the essence of rehabilitation training.

Core Coordination
The coordinated performance of the team of muscles that control the hips, pelvis, and spine is more important than simple strength.  Standing, walking, climbing stairs, and carrying all require the synchronous transfer of forces from right to left and back again.  The resistance provided by the Surge 180 creates the neural feedback to fire those reciprocal motor patterns.

Michael S. O’Hara, P.T., OCS, CSCS

Suspended Push Up Animation

Atomic Push Ups Are A Fitness Blast

Your muscles work as a team to carry you through the day.  They never function alone, so training them with isolation exercise will produce less than optimal results.  The muscles over the front of the body are linked together through interwoven layers of fascia to form what Thomas Myers, in his book Anatomy Trains calls the “superficial front line”.  The shoulder girdle is slung onto the body in a basket weave pattern of muscles.  One of the best exercise activities to activate this team of muscles is the Atomic Push Up.

The guys and gals at TRX named this exercise because of the metabolic response it produces.  Although the TRX company popularized the Atomic Push Up, you can use any type of suspension trainer that has foot straps.  This exercise helps build a better connection between your shoulders and hips.  It will strengthen the push pattern and activate the frequently neglected hip flexors.  Unlike a bench press type drill, the Atomic Push Up requires core control and the active participation of your legs.  Atomic Push Ups require a great deal of neural control as you must coordinate muscles from the hands to the feet to properly perform this drill.  The Atomic Push Up is not a bodybuilding type exercise that will “sculpt your outer pectorals” but it will help you move better.

Atomic Push Up Performance
Attach the suspension trainer overhead with the foot straps eight inches off the floor.  Sit on the floor and place the feet in the straps.  Roll over and assume a push up position with the feet suspended off the floor in the straps.  The top of the suspension trainer should be directly over your feet.  Descend toward the floor, and as you push back up, pull the knees up toward your chest.  Use a steady cadence of lower down–push up–knees in–knees out.  Beginners should aim for sets of five repetitions.  Stop before the performance of the drill deteriorates.  Common faults are sagging in the middle, lack of depth during the push up, and poor head position.  For men, twenty repetitions of Atomic Push Ups is a worthy fitness goal.  For women, eight is great.

You generally do not see Atomic Push Ups performed in commercial gyms because suspension trainers are rare and this exercise is difficult.  Beginners may wish to place a mat under the torso and head in case of a sudden face plant.  You can use a pair of parallellettes if you find weight bearing on your hands is difficult.  Moving the body forward so the suspension strap is pulling you backward makes the exercise more challenging.

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

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.

Pushing Through Fitness Barriers

How Sled Pushing Can Produce Big Results

Most of us have busy schedules and limited time to exercise at the gym.  We want the most benefit possible for our time spent working out.  Sled Pushing is a high value activity that can be utilized by almost all fitness clients.

True Core Stability
How our “muscles in the middle” truly work is in a standing position with our legs in contact with the ground.  The legs are usually in an asymmetrical stance, transferring force from the ground through our body into the arms.  Most “core stability” exercise performed in the gym put you in a supine position with no leg to arm connection.  Sled pushing more closely emulates the demands place on our spinal stabilizers during daily activities.

Training Acceleration
In sports performance, the development of acceleration—the first four or five strides– is critical.   Weight room training with box jumps, barbell squatting, and hang cleans has been shown to produce better vertical leap numbers, but not nearly the same gains in 40 yard dash times.  Sled pushing places the body in the forward lean position you need to properly accelerate out of the blocks when sprinting.  It trains the neural pathways that turn on your acceleration muscles.

The Road to Easy Recovery
Sled pushing is all concentric muscle activity and no eccentric.  Eccentric muscle activity, the muscles lengthen against a resistance, creates much of the muscle soreness brought on by exercise.  Your body needs more time to recover from eccentric muscle activity.  You can perform a greater volume of work with a sled, and not be terribly sore the next day.  For older trainees, whose bodies require more recovery time, sled work is a valuable training tool.

The Injured Athletes Rehab Training
If you have a knee, lower back, or hip injury you may not be able to perform squats, lunges, deadlifts, or kettlebell swings.  Sled pushing is an alternative rehabilitation exercise for the lower body.  I have had great success treating runners with knee pain using sled work as a recovery exercise.  The core stability demands of sled pushing are helpful in restoring lumbar function in lower back pain patients.

Scalable to Any Fitness Level
Beginners can start with an empty sled and gradually add weight.  I have been able to progress physical therapy patients from 25 pounds to 125 pounds in as little as four week’s time.  Pushing is a very primal movement pattern, so most people catch on after two or three attempts.

Michael S. O’Hara, P.T., OCS, CSCS

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