Why all the exercises?

Why do the patients always get so much homework in form of exercises from us physiotherapists? I mean, they're already in pain, and then we make them work as well...

Well, there’s a pretty simple explanation to that… When somebody seeks the help of a Physio it’s usually one of these three reasons:

Somebody fell and got injured acutely; while doing sports, in everyday life, in traffic etc. I.e. some sort of accident,

Because of surgery to some part of the body due to injury,

Or because of pain, without any trauma.

In the first two cases most people understand that you need exercises to rehabilitate the injured body part due to loss of function, strength and stability (these changes depend of course on the severity of the injury and time spent before rehab is begun). These negative changes (or adaptions) depend on inactivity, time for healing and reduced loading (one protects the injured area by resting and avoidance of using it normally).

But in the third case; you seek help because of pain, for example in the back, without any real reason for the pain. Suddenly you’re in pain, or perhaps the pain has crept on you and slowly increased. Why not just get a treatment that reduces the pain? I mean, there’s obviously nothing wrong since you haven’t experiences an injury, right?

No, that’s not really the case… There’s always a reason for pain, you don’t suddenly experience pain in the back for no reason at all. No matter if the pain is due to a disc or a nerve, or pain without any real anatomical change or degeneration. I’ve tried to explain the concept of imbalance surrounding a joint in previous posts. This concept is true to all joints, even those in the spine. So where does the pain come from? If nothing is really injured – why does it hurt? And why do one have to go through all those exercises? Imbalance in the muscles, or in the range of motion will also result in pain – therefore we have to find the reason for the pain.

Let’s continue using the spine as an example. It consists of 7 cervical vertebras (neck part), 12 thoracical (upper back part) and normally 5 lumbar vertebras (lower back part). All of these vertebras consist of the vertebral body and joints to upper and lower vertebra. These joints enable movement between the vertebras. Now imagine that the mobility is limited between two vertebras for some reason – the body will compensate through using too much mobility (hypermobile) in another level of the spine. What then to do if this is a part of the reason for the pain? The physiotherapist can help you increase the mobility in the stiff part; there are many different techniques for that, but at the same time you have to stabilize the hypermobile part.

Often this kind of thing problem affects many different levels or parts of the spine, not just in one place between two vertebras – although that also happens. When suffering from such an imbalance for a long time, often with a bad posture, static work, maybe also training repetitively without variation, the muscles will become affected with stiffness in the stiff joint-areas, weakness in the hypermobile areas, over activity in some muscles and instability in the smaller deeper muscles. This will lead to pain, and in the future; to degeneration of disks, joints, etc.

What about the exercises then… Well, the physio cannot do all the work for you, unfortunately for you. The therapist helping you stretch 2/week will not give you a permanency in the shortened and tightened muscles – you have to stretch basically daily, atleast 4-5 times/week to achieve a lasting change. The physio cannot strengthen the weak stabilizing or inactive muscles for you – YOU have to activate and train them your self, etc. Therefore, my friends, we physiotherapists will always give you exercises to work on…

Sure, we can help ease the pain – but it doesn’t help in the long run; the reason for the pain is still there. It’ll only lead to the return of the pain within a near future, and you’ll have to start over from scratch. In my opinion, that feels a bit irresponsible and in the end, it's a waste of time, for both of us...
When I finish treating a patient, I usually say; I hope I don't see you again - at least not for same reason... ;)
Take care of your self!

Do you have a good posture? A discussion about postures

My generation wasn’t as nagged at about "straighten up the back" or "walk with a straight back" as previous generations were. On those days children and adolescents were told even in school to correct threir posture. Good or bad to avoid the nagging? Perhaps mostly bad. Why? Because today, I see even worse postures in the next generation youngsters; that might be due to us nagging too little about their postures.

The famous slouchy
posture, check your friends,
family etc, I promise you*ll
see it!

The strange armé 
posture

Oh yes, you've seen a lot of youths sitting like this. Even if I
 have good  mobility, I'll never be able to achieve the same 
degree of flexion of the back as they can after years of 
stretching their ligaments and muscles in this C-shape...

“Straighten up your back!”; is it the right way to express one self? If I have a patient and ask him to straighten up, I see most often a strange form of military posture where people pull in their stomachs, push out their chests and lean the upper body backward. That's not really what we want to achieve when talking about the importance of good posture ... A good posture involves placing the body segments on top of each other in balance with as little energy expenditure as possible, which puts the joints in neutral position, and that means happy and healthy joints. Easy? Yes, for a child of 2-8 years. They are experts at this. Then we go slowly downhill; especially when we hit the teens; because of too much sitting. And usually at this age children begin to specialize in sports and train too much homogeneous patterns of movement, or playing computer games, playing with iPads, smartphones, etc. The worst thing we can do with our bodies in the subject of posture is to sit most of the day.

How do I instruct a patient to correct their posture? I always start from the bottom:

• Feet; rock back and forth on your feet a couple of times, and find the center of gravity directly in front of the ankle of the foot - but make sure you have good contact with the floor in the following three points; the base of the big and little toe and on the middle of the heel.
• Knees; tighten your thighs and push your knees back, then relax and bend your knees very slightly. Repeat a few times, and then find a middle position - where you feel that your knees are loose and thigh rests on the lower leg without having to contract your muscles.
• The pelvis; this is difficult for many! Tilt the pelvis a little backwards (ie round the lower back) and then tilt the pelvis forward (ie, arch your lower back - like a duck). Repeat a few times and then try to find a middle position with a slight lordosis of the lumbar spine without having to press the pelvis in any direction. You should have a neutral lordosis as we call it.
• Rib Cage and shoulders; inhale and push up the chest - breathe out and sink down. Repeat a few times. When you finish try to find a slight lift of the sternum.
• Shoulders; do a couple of big circles with your shoulder – lift up ventrally and down dorsally. Relax your shoulders after finishing down dorsally.
• Neck and head; Elongate your neck from the spine, push the most prominent part of your head upwards without tilting it back - tuck your chin in a bit and keep your eyes on the horisontal level.

See the movie about correcting the posture here!

Once you found the position, imagine that you lift the entire spine from the pelvis. I once heard a yoga teacher instruct the position of the spine in a poetic way; imagine that the spine and its vertebras are like a string with pearls, and that you stretch the string so that the beads are pulled upward. Beautiful way to express posture correction on.

But unfortunately this is not enough for everyone. As I have in previous blog posts pointed out that today's society with certain type of training methods (pumping up certain muscles), the sitting desk work where we have arms in front of us at a desk for several hours / days etc has altered the anatomy around the joints. A pull toward the stronger muscles is now created. It may also be that certain muscles are shortened or too active and it gets too hard to try to keep the joints in neutral position with the fatigued or weak muscle on the other side. A relatively simple example:

Chest muscles have a tendency to become strong, short and overactive compared to the back muscles. Think of all the guys who want to pump up the breasts, you know how their posture looks... But the muscles are not strong, short and overactive just by improper training, but also of our everyday movements and positions; example what we therapists hate – sitting office work. I can try to instruct that person in the correct posture, but if the chest muscles pull the shoulders constant, the person cannot assume a correct posture more than a few minutes, or maybe even less. It’s too much work, hence one must also work on getting the body into balance. And this applies not only to the torso, it’s equally important for the muscles of the trunk, pelvis and hips, as well as around the neck.

Therefore, I cannot in this blog solve the problem for everyone with bad posture, but for those who do not have so many problems with stiffnesses or weaknesses can work on their posture as instructed above.

For the others; for God's sake, start a more balanced life! Book an appointment with a physiotherapist or the likes and work on your physical problems...!

Well, those are my thoughts anyway :)

Jumper's knee, discussion and summary of the causes...

Time for a sports subject again… This post is about pain in the patella tendon, usually known as Jumper’s knee, but the correct medical term is actually Patella tendinitis.

Some background information;

Jumper’s knee is an overuse injury that is common in the sport of volleyball, but also in basketball.

The etiology (reason) for the injury is still not completely analyzed/researched or understood enough, so the reason is not yet known. Earlier studies have shown risk factors like jump height, mobility, age, gender, a high load of game exposure and a lot of jumping.

During last year I did a literature review in a sports medicine course, the purpose of that study was to present the latest evidence within biomechanical risk factors for the development of jumper’s knee. I thought I would try to share the result.

So, what are biomechanical risk factors?

Biomechanics is the science of such a simple thing as how two joint surfaces moving in relation to each other, but it’s also as complex as how the body is used as a whole, and the forces it’s subjected to. Biomechanical risk factors would then be movements in the joints that can cause damage.

Knowledge I want to share with you;

I looked into new research in the subject of jump and landing technique with advanced analysis and descriptions of the forces on the joints and tendons, angles of the feet, knees, hips and back. It was really interesting to read, though it took some time to get into the subject. It’s not so easy to analyze research, as the result is so dependent on the method; is it reliable and are the statistical methods right? When reading research you HAVE TO understand this type of analysis, as there are so much research with interesting and amazing results, but unfortunately they’re not reliable.

In a lot of studies I found that many used analysis of a two legged landing after a jump down from an elevated position. A lot of people would think; yes, why not? It’s the landing they’re interested in analyzing. OK, yes, but the force and the landing technique is totally different depending on how the jump is done, and very seldom athletes land with the force directed strictly downward after a jump as the jump normally isn't directed only straight up. This makes these studies unreliable as to the outcome and explanations for jumper’s knee, since the landing isn’t specific for the sport.

The athletes used for the research were mixed, but mostly volleyball and basketball players, athlete’s with previous history of jumper’s knee, athlete’s suffering from jumper’s knee at the time for the study, and usually a control group with no history of knee injuries.

I found some real interesting results, and not only of the landing, but also when it comes to the take off for a jump, and some other findings...

The result show;

• Range of motion in the ankle for dorsiflexion is very important
• Increased velocity of flexion of the hip and back in landing
• Increased velocity of loading for the quadriceps muscle in the deceleration phase in the countermovement motion preceding a jump
• The angle of the knee and ankle (lesser degree of plantarflexion) in initial ground-foot contact in the landing
• The flexibility of the Quadriceps, tighter muscle means greater risk
• The anatomical position of the feet in standing, neutral position meant smaller risk for jumper’s knee.

Conclusion; Several biomechanical factors in the landing technique and mobility of the joints and anatomical position of the feet affect the load on the patellar tendon and predispose jumper’s knee. 
So to avoid the problem, work against all of these risk factors. Work on jumping and landing technique with the youngsters, work on the mobility in the ankles and the muscles and so on. As usual; there are no shortcuts!

Video: see the movie here.

Landing with plantar flexed foot compared to lesser cushioning and lesser degree of flexion
Long vs short landing

Velocity of flexion of the hips and core in the landing

Countermovement phase in the stop-jump

Please have in mind that when the research was done, they used highly advanced technique to be able to follow the movements and measure exact angles, so it is difficult for the eye to see, but I did my best to try to show it on the video.

Pictures:

Range of motion (ROM) knee over foot

Normal ROM in the ankle; the knee is passed the foot

Stiff ROM in the ankle, the knee can't pass the foot

Foot position

Normal foot position

Foot position with sunken foot arches (inversion)

Research articles for the review

How to start training after a period of physical inactivity

As promised in my last post, I will try to give some general information about how to plan when changing your lifestyle into a more active or, or if you're planning to increase your level of physical activity significantly.

But keep in mind, that when talking to a Personal Trainer (PT) about your training plan, the PT really has to ask about your history when it comes to injuries, otherwise the exercises aren't adapt to your body, and you might even be training it into more problems. A serious PT always knows or makes sure to know what weaknesses or weak spots the client has.

I will divide my guidelines into two parts:
1. For people who haven't been physically active except for maybe walking a bit each day.
2. For people who's been a little active; for example walking, taking the bike to work every now and then, joining a game once a month, or doing some bodyweight training twice a month.

Nr 1...
... Haven't trained the last couple of years, and maybe wasn't that much of an athlete before that either. How does this person start over with physical activity?
The best way is to make sure you have 8-12 weeks of a transition phase. During this phase you train twice a week with the aim of getting your body used to loading, and really just strengthening the tissue. This means that even though you feel that the training is easy after 3 weeks, do not increase the weight of intensity, as the increase of strength you feel is merely the nervous system getting better at corresponding with the muscles and coordinating them. What you could do instead is to add another set. So for example if you start with 2x12/exercise (2 sets of 12 repetitions in each set per exercise), you do 3x12/exercise instead.

What exercises should you do? Well, If you are totally new to this, most people start working out in machines, because they are safe. But if you have a good PT, it would be better for your body to work with functional movements instead.
When you're only training two times a week, you can do whole body exercises, or just use machines for the different parts of the body both times, but maybe change the exercise even though it's still the same body part (if you train more than twice a week, it's better to split the program so the different muscles get enough recovery time).
After 8-12 weeks, that is when you start to increase the load and go for 3x10/exercise. You can also add another day of training per week, progressively up to 4 times/week during a period of 8 weeks.

Nr 2...
... Has done a little bit of training every now and then, probably because of the bad conscience telling this person to do at least something... ;) Which means that once a month or so, this person does something other than walking or biking; for example goes out for a run, or does some bodyweight exercises.
The main difference compared to the example above is that this person can add some aerobic training in the beginning. Although the strength part is still only twice a week with the same plan as above, but add some easy aerobic training as well, for example using the rower, bike, crosstrainer, treadmill and so on, and maybe even switching between these conditioning machines every 5-10 min once a week.

About what weights to start with; make sure that you at the end of the set feel tired in the muscles, but are still able to do at least 5 more repetitions. That's a good weight to start with.

It's very difficult to give specific advice (obviously) when the information isn't to a specific client. Which means the information above is very general, but hopefully it'll give you some idea about how soft the start really needs to be.

However, if you want to start running, then that's a completely different matter, and needs a completely different approach. I will leave that topic for another post in the future.

Stay well!
Sunny regards from Doha!
Shirin
With special guest appearance from Sophia Bassemir (physiotherapist), Stuttgart, Germany

Training with a Personal Trainer? What do you know about his/her knowledge?

As a physical therapist, I am very pleased that most people in the west (and foremost in Sweden) are taking their training seriously, changing their lifestyle, and spend more time on physical activity to improve their health status. However, we should not forget that there are still very many people who with low physical activity level, but that is not the topic for this post. It was training, and in particular exercise with PT (Personal Trainer).

The background to the topic of this post is that a friend after a long period wanted to get started with exercise. He therefore bought a gym membership, and made an appointment with a PT for help to reach his goals. A few days after the meeting with the PT, my friend wanted to discuss how the meeting went and what information he had received. My reaction was; that will never work, you'll just end up with a lot of injuries!
Maybe not the most humble reaction, but the fact remains; going from no physical activity in the form of regular exercise over a period of about 2 years, to train 5 times / week of which 3 workouts are full body exercises and 2 workouts consist of interval training is far from a realistic and manageable start.
This is partly due to the purely physiological side; the body will eventually break due to the high amount of load and lack of recovery. Instead of enjoying regular exercise; you'd spend the time on rehab instead. But there is also a psychological angle to this; behavior change is difficult enough without the extreme load of this start.

So what do I as a physiotherapist have to say about this. There are actually several things I would like to discuss concerning this topic. Let's start from the beginning ...
Who is the typical person to seek help from a PT? In my experience, it's usually people that during a certain period in their lives haven't had time or for other reasons, couldn't maintain a physically active lifestyle - often for several years. This may be due to an emphasis on career, having small children, and so on. Therefore, I conclude that PT costumers probably consist mostly of 30-40 year olds, who want to get their body fit again. And the goals are often set quite high; a person who's barely done more than a few push-ups before want to be able to do pull-ups and chins (both men and women), or run half and full marathons. The goals are sometimes disproportionate to the person's training history.

What is normally the status of people with low physical activity level?
I'll generalize a bit for simplicity, but we can surely agree that it usually means;

• some measure of overweight,
• weakness in muscles, tendons, ligaments, etc,
• imbalance of muscle groups,
• reduced stability of the trunk and joints (weakness of the stabilizing muscles),
• reduced coordination,
• and stiffness in muscles and joints.

How should the start of a more physically active life look like? This is the first challenge. Everybody want results right away, but obviously our bodies don't work that way. If we go ahead and try that, there's no way to avoid overload injuries. A slow start which means habituation of the body, building strength, durability, stability and mobility is the correct way.

Certainly, the PT feels pressure to deliver results, but sometimes I ask my self the question; does the PT have the knowledge to be able to lead the customer on the right path? Including explaining the training plan and what to expect.
I was pleasantly surprised when I saw people working out with PT:s on Muscle Beach in Los Angeles. The PT where really working with their clients in responsible way; focusing on mobility and stability, taking care of the client, teaching them how to use their body and coordinating it.
No customer should be satisfied with training that leads to injury; although I sometimes find that people generally take getting injuries for granted because they train hard, and are even a little proud of these - because then it means they're training hard. Crazy!

There are many very talented PT's and fitness coaches, but you have to find them. Have you checked what background the PT has? What education he/she has? How many years of experience?
In Sweden, for instance, it wasn't until the end of 2012 that discussions about who's qualified to call them selfes a personal trainer. Before that anyone could, but now there are some rules about the education level a PT has to have. But still there are different education levels on the course, some are just 11-12 days, and some are more serious and are even college level educations. Make sure you know what you are paying for!

Obviously, experience, years in the industry and further education play an important role in choosing a personal trainer. But my advice to you as a paying costumer is asking about the personal trainer's education, experience, and always put the well being of your body first. If the plan sounds too good to be true, then it probably is...

YOU are responsible for your body, no one else. And you want your body to be healthy for many wonderful training years to come!

Listen to your body, and good luck!

PS. In a couple of days I will post a short text on how the start of training could look like... 

Just given childbirth? Exercises for new moms!

A close friend had her first child recently, and took the opportunity to ask if I could advise her on exercises she could start with. The midwife had told her that she could start training lightly, but my friend felt a little unsure of what exercises that could fit in the beginning. So, I chose this topic for my next post ...

The information from midwives is that postpartum women should take it easy and let their body heal first few weeks when it comes to exercise, but start pelvic floor exercises as soon as possible after birth, and taking walks from the second week. To do abdominal exercises like sit-ups should be avoided for a few weeks, both because of diastase between the large abdominal muscle Rectus Abdominis two parts (separated abdominal muscles; Diastasis recti), and to avoid increased abdominal pressure in a situation where they are still struggling to get the strength of the pelvic floor back. With caesarean section it's even more important to avoid sit-ups as it takes 6-8 weeks for the tissue to heal properly.

If you are suffering from Diastasis recti, you should hold off on all the exercises for the trunk until you get the green light from a midwife or physiotherapist about the exercises you are allowed to do, in order to avoid aggravating the healing of connective tissue.

Whether your child is born vaginally or by cesarean section, the starting exercises I would give a new mother are the same. However, a woman who underwent cesarean should wait a few weeks longer with certain exercises, as it can stress the wound, but you have to be aware that various exercises could tug at the wound for up to 10-12 weeks in varying degrees. It will be my general advice that you can start with the first supine exercises 2-3 weeks after birth. Use the time before to focus on training the pelvic floor, as it is important to get good function, and you do not want to miss the recovery window in the beginning. Later you can take the opportunity to combine training the pelvic floor and core, as this provides a more efficient muscle training in these muscles.

The exercises I have chosen are effective for trunk stability and posture, without stressing the body with sit-ups. Midwives provide information that you can start with crunches (which is like a little mini sit-up) as soon as it feels good. It's really the only exercise I did not film, as I feel I want to be careful to prescribe that exercise in general to all.
Obviously, one can develop these exercises and program endlessly, but 8-12 weeks postpartum, you should normally gradually get back to your regular workout, if you feel restored.

(Incase the video doesn't work, click here.)

When you exercise, it is important that you listen to your body and stick to what feels good!

Good luck, and congratulations to the parenthood
Shirin Zarur, physiotherapist