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Rehabilitation

LUMBAGO FIASCO

The Top Three Things You Do In The Gym To Screw Up Your Lower Back

Therapeutic exercise has consistently been proven to be the best way to manage lower back pain.  It has a better long-term outcome than injections, medications, and surgery.  Unfortunately, many people end up injuring their lower backs in a well intentioned, but misguided effort to get fit.  Below are the top three lumbar spine mistakes I see people making in the gym.  

You Exercise Sitting Down
The muscles and joints of the lumbar spine, pelvic girdle, hips, and knees are an interconnected team.  To get the team playing more efficiently, your body needs to be challenged by gravity and trained in an upright position.  A basketball team would never get better if they practiced while sitting at a desk.  You should run away from anyone who straps you into a machine in an effort to help you with a back pain problem.  By the way, you already sit way too much.  You drive, computer, television, and sometimes sleep in a seated position.  Prolonged sitting creates much of the tissue shortening and muscle weakness that makes you more prone to lower back pain.  

No Consideration For Compression
This is an issue that is particularly important for individuals with prior episodes of lower back pain.  Most people are unaware of the many gym activities that create compressive forces on the lumbar spine.  Treadmill running (more if you hold on the handles), leg press, crunches, and leg lifts create a compressive loading of the lumbar joints and discs.  Be aware of the cumulative loading on the lumbar spine, and alter your training schedule so that you perform certain exercise activities on different days.  Do not perform squats on the same day you run on the treadmill.  If you are going to perform 50 incline sit ups, do not do it on the same day you deadlift.  If you are uncertain of what activities place a compressive load on the lumbar spine, you need to work with a physical therapist or certified trainer.  

You Are A Flexibility Freak And A Stability Geek
Creating spinal flexibility without the strength to keep your spine stable sets you up for injury.  Many lumbar pain patients I evaluate are able to flex the spine forward and palm the floor.  They can bend their spine like an overcooked noodle, but they are unable to summon the muscle control to hold the lumbar joints in a stable position.  These patients often report a long history of dedicated stretching, yoga, and Pilates training.  They fail the lumbar stability tests, and are often unable to perform the overhead squat or in line lunge functional mobility tests secondary to a lack of core stability strength.  These same patients are often surprised at their poor performance in the core stability tests because they “strengthen their abdominal muscles” with crunches and leg lifts.  Training to improve spinal stability and exercising your abdominal muscles are completely different things.  Every gym goer needs to learn the difference.

Michael S. O’Hara, P.T., OCS, CSCS

 

KICK THE KICKBACK TO THE CURB

In our physical therapy clinics, we get to treat elbow pain every day.  The pain is usually brought on by some kind of repetitive activity.  Tennis players get pain on the outside of the elbow.  Throwers and golfers get pain on the inside of the elbow.  Fitness clients commonly end up in physical therapy with complaints of elbow pain.  The cause of the pain is usually some sort of triceps isolation training, and the biggest offender is the “triceps kickback” exercise.  The kickback is a Shape magazine standard that appears to be a favorite with female gym goers.  The triceps kickback is more likely to give you elbow pain, than to produce thinner and more shapely arms.  

Three things make this exercise problematic for the elbows.  The kickback exercise creates a bad force curve.  The resistance is the strongest when the triceps muscle is at its least advantageous position, and this places the majority of the load on the elbow joint in a fully extended position.  When I see this exercise performed in the gym, it is usually executed with a swinging of the dumbbell.  The momentum of the weight forces the elbow into excessive end range extension.  Kickbacks are often performed for high repetitions.  It is not uncommon to witness someone perform three or four sets of twenty repetitions.  That is sixty to eighty high speed, end range repetitions under a stressful force curve on each elbow.  

From the elbow pain patient I hear, “But I don’t feel any pain when I perform the kickback exercise.”  Most golfers, tennis players, and throwers don’t feel pain during their participation in sports.  The elbow pain usually sets in later that day or the next morning.  Another common concern is that they will not be able to reduce fat on the back of the arm without direct triceps work.  This is the “spot reduction myth” that just won’t die and keeps many a physical therapists employed.  Avoid the trainer that tells you a specific exercise will take subcutaneous fat off an area of your anatomy.  

Elbow irritation that creates scar tissue and inflammation is often difficult to eliminate.  The pain in the elbow can get so bad that it limits other training activities.  The good news is that elbow pain is often self-inflicted, and with a little education, we can avoid the pain.  Watch the video, dump the kickback exercise, and start training your triceps with some push ups and presses.  Your elbows will thank you.  

Michael S. O’Hara, P.T., OCS, CSCS

HIP LIFTS

The Sure Cure for Gluteal Amnesia

Your hamstrings and gluteal muscles always work together as a team.  Strong, coordinated hamstrings and gluteals are your lower back’s best friend.  They anchor the pelvis and hold a stabilized spine in a tight and tall position.  They work with the other posterior chain muscles to keep stress off of the sensitive structures of the lumbar spine.  Patients with chronic lower back pain often have weak and even atrophied gluteal muscles.  Building strength and coordination in the hamstrings and gluteals is often difficult for patients with lumbar spine pain problems.  Hip lifts are lower back friendly exercises that can restore the function of hamstrings and gluteal muscles.  

Hip Lifts
There are many different types of hip lifts and all are beneficial.  The two basic hip lift drills discussed below work well for most fitness clients and physical therapy patients. 

Feet On Ball Hip Lifts
FOB Hip Lifts photo

This exercise will strengthen your posterior leg muscles and spares your spine any stress.  Lay supine with a physioball under your heels.  Place the arms at the sides and push down into the floor with the arms to stabilize the body.  Keep the feet together and aimed up at the ceiling.  Brace your abdominal muscles and squeeze the legs together.  Use the butt muscles (gluteals) and posterior thigh muscles (hamstrings) to lift you up off the floor.  Hold the suspended position, in one long line from ankle to shoulder, for three counts.  Lower with control and repeat for five to fifteen repetitions.   

Bench Hip Lifts
Bench Hip Lifts photoThis drill coordinates hip extension and lumbar spine stability.  It is very beneficial when progressed to the single leg version.  Lay with your shoulders across a bench with the head supported.  Place your arms out to the sides.  Plant the feet on the ground with the knees bent 90 degrees.  Drop the hips to the floor and then push back up with the gluteals and hamstring muscles.  Hold at the top for three seconds and repeat.  Perform five to ten repetitions.  As you get stronger, progress to performing the exercise one leg at a time.  From the same starting position, lift the left leg up off the ground.  Lower slowly and using just the right leg, lift back to the starting position.  Make sure the right foot stays flat on the floor and you push up through the heel.  Perform five to ten repetitions on each leg.  Switch over to the left and repeat.  If you find one side is more difficult, perform an extra set on that side.  Eliminating performance asymmetries in this exercise often resolves long standing back pain. 

Michael S. O’Hara, P.T., OCS, CSCS

 

 

FRACTIONIZED EXERCISE AND HYPERTENSION

Over 60 million Americans have hypertension and another 65 million have prehypertension.   Prehypertension is a series of risk factors that place the patient on the path to the development of hypertension.  Hypertension is a primary risk factor in stroke and heart disease.  Left untreated, it can cause significant disability and early mortality.   The good news is that hypertension and prehypertension respond very well to exercise.  The bad news is most patients are either are unable or unwilling to exercise for any significant duration of time.  

The commonly prescribed dose of exercise to treat hypertension (high blood pressure) is thirty minutes of uninterrupted activity at 65% to 75% of your age adjusted maximal heart rate.  To produce results, the exercise must be performed every day.  Many hypertensive patients also have physical limitations that limit their activity level.  They are overweight, weak, and often have orthopedic problems that make thirty minutes of continuous exercise impossible.  Many patients despise exercise activity and would rather die than spend thirty consecutive minutes walking or riding a bike.  Researchers at Arizona State University recently tested different exercise prescriptions to see if shorter exercise session performed more frequently would produce positive responses in patients with hypertension.

Study participants wore blood pressure monitoring cuffs that took measurements twenty four hours a day.  They walked three times a day for ten minutes on one training day.  On the next day, they performed one thirty minute walking session.  On the third day, they performed no exercise at all.  While both doses of exercise helped control blood pressure, the brief ten minute sessions performed three times a day was significantly more effective than a single half hour session.  

patient on bikeThe “fractionized” exercise produced lower average blood pressure readings and fewer incidences of blood pressure spikes above 140/90.  It turns out that short, cumulative exercise sessions are remarkably beneficial for vascular health.   Compliance is king when it comes to exercise success.  Compliance with three short bouts of exercise a day is more achievable than one thirty minute session.  A ten minute walk at lunchtime.   Ten minutes on the stationary bike after work and a ten minute evening walk can fit into most peoples lives.

One of my personal training clients has hypertension and he has been much more successful at controlling his blood pressure with abbreviated training sessions.  He was running three times a week and doing yoga on the off days and his blood pressure did not improve.  We changed his program so that he strength trains at the gym two days a week and on his off days, he rides a recumbent bike two times a day for only twelve minutes.  The more frequent training has been more effective at lowering his blood pressure numbers, and he has been able to discontinue medications.  

Michael S. O’Hara, P.T., OCS, CSCS

FIGHTING THE EPIDEMIC OF TYPE II DIABETES

Diabetes Assoc Logo25.8 million Americans have diabetes.  More than 90% of those diagnosed with diabetes have the Type 2 variety.  According to the Center for Disease Control and Prevention (CDC), 35% of the adult population are prediabetic, the precursor to Type 2 diabetes, and are at high risk of developing the disease.  That means 79 million Americans are on their way to Type 2 diabetes.  In 2011, 1.9 million adults received a new diagnosis of Type 2 diabetes.

In the most recent comprehensive survey of death certificates, Type 2 diabetes was listed as the underlying cause or contributing factor in 231,404 deaths.  It is the leading cause of blindness among adults age 20-74 years of age.  Your risk of heart disease and stroke is two to four times greater if you have diabetes.  Hypertension or high blood pressure is present in 65% of the diabetic population.  The CDC statistics in 2008 listed diabetes as the cause of kidney failure in 44% of the cases.

70% of the diabetic population will develop some degree of nerve damage.  The damage to the nerves is called neuropathy.  Diabetic neuropathy leads to weakness, sensory loss, and balance deficits.  I have been treating patients in physical therapy since 1984, and diabetic neuropathy problems are far more frequent and severe.

If the current trends continue, more than 50% of Americans will have Type 2 diabetes by 2020.  According to the United Health Center for Health Reform and Modernization, we are on track to spend 10% of our total health care dollars on diabetes care by the end of this decade.  

The good news is that Type 2 diabetes is largely preventable through lifestyle and behavior changes.  Weight loss, exercise, and consistent medical care can alter the impact of diabetes on your health.  Reducing bodyweight by 7% is enough to improve blood sugar levels and reduce the health implications from Type 2 diabetes.  Walking, biking, or lifting some weights every day is the prescribed minimally effective dose to improve insulin sensitivity.  I know many gym members that have been able to control or abolish their Type 2 diabetes with a commitment to exercise, better eating habits, and the maintenance of a reasonable bodyweight.  

Michael S. O’Hara, P.T., OCS, CSCS

GETTING THE ARROW OUT OF YOUR HEEL

Physical Therapy Treatment of Achilles Tendonitis

Tom started having pain in the back of his left heel after working out at the gym.  He had no pain while exercising, running, or water skiing, but symptoms would occur later in the day.  By the end of the summer, he was unable to walk a round of golf secondary to heel and lower leg pain.  Tom was treated by his family physician with medications and rest, but the pain did not go away.  He received two injections in the Achilles tendon that temporarily relieved his pain, but symptoms returned in two or three weeks.   Tom was referred by his podiatrist to Fenton Physical Therapy for treatment of his Achilles tendonitis.  

The left Achilles tendon was sensitive to pressure, and Tom had a build up of scar tissue in the middle of the tendon.  His left ankle dorsiflexion range of motion (ROM) was half that of his right ankle.  He had pain in his heel and the back of his left lower leg with attempting to rise up on his toes and with squatting.  His physical therapy treatment consisted of ASTYM and a program of home stretching drills he performed three times a day.  After six sessions, the pain was gone and left ankle active ROM was full range.  Four months after discharge, Tom reports that he has been pain free and continues with his daily stretching exercises.  

ASTYM photoInflammation and scarring in the Achilles tendon can be a debilitating and difficult problem to deal with.  Over the last few years, aggressive conditioning programs involving repeated box jumps and obstacle course type races have brought more Achilles tendonitis cases to our physical therapy clinics.  Achilles tendon problems often flare up and then go away with rest and icing.   The repeated cycle of trauma and recovery results in a non-flexible scarring of the Achilles tendon.  This is believed to be the precursor to a more traumatic Achilles tendon rupture.  At our physical therapy clinics, we have found great success with the Augmented Soft Tissue Mobilization (ASTYM) method.  ASTYM treatment consists of twice weekly treatment with specialized tools to aggressively mobilize the scar tissue that develops on the Achilles tendon and “kick start” the healing process.  This approach encourages the patient to be active and engage in a functional stretching program instead of immobilizing and resting the lower leg.  The ASTYM tools allow greater intensity and accuracy with manual therapy treatment of the lower extremity.  The patient generally participates in eight sessions of therapy and is instructed on a home regimen of mobility exercises.

Fenton, Linden, and Milford Physical Therapy all utilize the ASTYM treatment technique.  Fenton Physical Therapy was the first clinic in Michigan to offer the ASTYM method.  We continue to bring our patients the most innovative and up to date Physical Therapy care.

Michael S. O’Hara, P.T., OCS, CSCS

CORE-TEX TRAINING PLATFORM

The New Tool In Our Training And Rehabilitation Toolbox

The latest addition to our rehabilitation and training toolbox is the Core-Tex.  This thirty inch round platform floats on three roller bearings that permit it to tilt, translate, and rotate.  The tri planar motion of the Core-Tex creates an ideal environment for us to work on retraining our patients’ balance, coordination, and proprioception.  It can also be used to create challenging core and shoulder girdle stability activities.

One Stop Shopping For Better Proprioception, Balance, and Coordination
You can improve all three of these critical components of function with one or two Core-Tex activities.  Beginners can use the handrail to create a more supportive environment, and as they improve, progress to reducing the assist from the arms.   Integrating head movement, arm reaches, and weight shifts into the drills enables the clinician to design activities specific to the patient’s needs.

Keeping The Loads Level
The Core-Tex reveals any deficits in weight distribution.  If the patient is unconsciously avoiding loading one side the body, the movement of the Core-Tex platform quickly reveals the flaw.  The therapist can then prescribe training to increase tolerance of loading on the affected side and return for re-evaluation on the Core-Tex.

Tuning Up Your Righting Reflexes
Many of the sensors that keep our body in an upright position are located above the neck. I don’t care how strong or flexible you are, if these neural feedback systems do not work properly, you will not move well.  Evaluating and improving the function of righting reflexes centers in the inner ear and the neck is a frequently neglected area of rehabilitation and fitness.  Incorporating activities that involve moving the head and neck while standing on the unstable Core-Tex platform has proven to be very beneficial in patients with slow reflex response times.

Rotation In The Right Places
Being able to rotate through the thoracic spine and hips is an important aspect of optimal function and pain free existence.  Many physical therapy patients have neck and shoulder pain driven by a lack of thoracic spine range of motion in rotation.  Deficits in hip rotation produce undue wear and tear and eventually pain in the knees and lower back.  The Core-Tex turns 360 degrees and allows us to teach transverse plane motions at the hips and thoracic spine in a fully functional upright, weight bearing position.

Michael S. O’Hara, P.T., OCS, CSCS

“SO WHAT ABOUT CRUNCHES?”

Personal Training Question Number One

crunch photoI get this question from many of my fitness clients at the end of their personal training or group coaching sessions.  Somehow crunches are viewed as an essential part of fitness.   Instructional DVDs are sold with an hour of abdominal exercises—I counted 12 different types of crunches and sit ups in one very popular infomercial product.  In physical therapy, I get to treat the patients who in a valiant, but misguided effort to regain fitness launch into a series of crunch / sit up exercises only to wake the next day with searing lower back or neck pain.  I was recently asked to e-mail my no crunches answer–so here we go.

Sensei Slumpo
Most fitness clients are already have earned a black belt in spinal flexion.  Their thoracic and lumbar vertebrae are bent forward for many hours a day– sitting too much, driving too much, television too much.  Most are proud at how easily they can fold the thoracic and lumbar spine over and “palm the floor”.   The last thing they need is to pull the ligaments, discs, and joints of their spine into further flexion with crunches and sit ups.

Your Mother’s Eyes and Your Grandma’s Spine
As we age, our thoracic and lumbar spines tend to fall into a flexed over “crunched” position.  Why would you want to accelerate the pace of this degeneration by performing activities that accentuate the slumped over forward flexed spinal posture of old age.

The Other Spot Reducing Exercise
Your abdominal muscles or “six pack” will not become more visible with lots of crunches, sit ups, rip twists, belly blasters, or any other targeted training.  There is no such thing as spot reducing.  The table push away is the best exercise to improve the visibility of any muscle.  Unfortunately, it is the least utilized exercise in America.

A Little Kinesiology
The function of your abdominal muscles is not to create movement but rather prevent movement.  They work with a team of other muscles to act as anti extensors, anti rotators, and anti flexor muscles.  The six pack muscle or rectus abdominus makes up a portion of the cylinder of muscle that serves to support your spine in tall and stable position–not bend it forward.  Think “movement preventers” and not “movement producers”.  Crunches and sit ups train your abdominal muscles to do the wrong thing.

The Pros Don’t Use Them
I cannot think of any athletic activity that emulates the motion of a crunch or sit up.  It will not improve your ability to run, jump, throw, or compete.  The strength and conditioning coaches that get paid big money to make athletes more successful and keep them injury free do not use crunches or other repeated trunk flexion exercises in their programming.

Maybe Not Now, But Soon And For The Rest Of Your Life
Your lumbar spine hates combined flexion and rotation, and it really hates it if you throw in some compression from an exterior load like a medicine ball, weight plate, or kettlebell.  Lumbar spine injuries are cumulative.  The stresses build up until one day you bend over to pick up a pencil and your back “goes out”.  Crunches and sit ups serve to accelerate the rate of accumulated spinal stress.  I know you have a friend who does one hundred twisting, medicine ball crunches a day and has never had a problem.  I have a friend who has smoked for twenty years and says he feels fine.

Michael S. O’Hara, P.T., OCS, CSCS

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