Heart Rate and Exercise Intensity
by Jeffrey H. Tucker, DC, DACRB
In part 3 of this article, let’s discuss heart rate and exercise intensity. It’s imperative to have baseline information on your patients to determine how to most efficiently assist them in achieving their fitness goals.
It’s very important you know their resting heart rate and maximum heart rate (MHR). During a workout, their heart rate is a very reliable indicator of their personal performance level or training load – not as absolute numerical values, but in relation to their own heart rate values.
Calculating Maximum Heart Rate
Miller Formula: 217 – (0.85 x age)
(0.85 x 45 = 38.25)
217 – 38 = 189 MHR
Recent research identified the following formula as more accurately reflecting the relationship between MHR and age:1 MHR = 206.9 – (0.67 x age).
It’s relatively easy to measure your heart rate at rest by feeling your radial pulse or by using a heart rate monitor while still in bed after a good night’s sleep. Once trained, our patients easily can determine their resting heart rate. However, a reliable measurement of maximum heart rate often requires a visit to a testing facility or a sports-minded chiropractor.
If you are experienced in fitness training and are enjoying good health, you also can do your own test with a maximum performance session in your favorite sport. After 15-20 minutes of warming up, do two or three maximum intensity work cycles of around 3-4 minutes and recuperate between them for 30 seconds. If it’s difficult to reach high intensity in your favorite sport (e.g., cycling, cross-country skiing, rowing), you can perform the maximum intensity sessions on a steep hill. The highest measured reading you can achieve is a good estimate of your maximum heart rate.
Target Heart Rate Zone
Your target heart rate zone is the number of times per minute your heart needs to beat to achieve a desired workout effect. It’s represented as a percentage of the maximum number of times your heart can beat per minute (MHR). Most research recommends working out at a target heart rate zone between 60 percent and 75 percent of your MHR.
You need to be able to progress a patient to higher levels of fitness and ensure they are sufficiently healthy to exercise at the desired intensity. Tests performed in different sports mostly indicate your maximum heart rate in that given sport, not necessarily an accurate and absolute value. For example, many people’s heart rate is 10-20 beats per minute (BPM) lower when cycling than when running and even lower when swimming; while cross-country skiing often is slightly higher than when running. When you know your resting and maximum heart rates, it’s easier to control your training intensity.
Xavier Jouven, MD, did a study with men and found those whose heart rates increased the least during exercise (less than 89 BPM) were six times more likely to die of sudden death from myocardial infarction than men whose heart rates skyrocketed. More importantly, men whose heart rates didn’t drop by at least 25 BPM within one minute after exercise also had a greater risk of cardiac death. The risk of sudden death from myocardial infarction was increased in subjects with a resting heart rate more than 75 BPM; an increase in heart rate during exercise of less than 89 BPM; and a decrease in heart rate less than 25 BPM, one minute after exercise.
The conclusion is that the heart-rate profile during exercise and recovery is a predictor of sudden death.2
How the Training Effect Works
How can we use this information to design a training session? Using the National Academy of Sports Medicine (NASM) template, we can create an “integrated performance profile.” Establish the patient’s current fitness level (unfit, fit, athlete, etc.) from your general and medical history, exercise history, body fat analysis and circumference measurements. Combine this information with heart rate and progress your patients to develop better results. Understand that different types of workout intensities are needed and have their own important role to play in developing your fitness level and achieving better results. We cannot let our patients do the same 30-minute walk day after day and expect progress. We have a responsibility to progress and challenge them.
Exercising below 60 percent of your maximum heart rate is relatively easy on your system. When it comes to fitness training, intensity this low is significant mainly in restorative training and improving your basic fitness when you are just beginning to exercise or after a long break. Everyday exercise – walking, climbing stairs, cycling, etc. – usually is performed within this intensity zone. These sessions, when lasting more than one hour, can develop endurance, may enhance recovery, but will not likely improve maximum performance.
Exercising at 60-70 percent of your maximum heart rate is considered the fat-burning zone. Peak fat oxidation has been shown to occur during exercise at 63 percent VO2 max. Peak fat oxidation progressively lessens above this point and was minimal at 82 percent VO2 max, which is near the lactate threshold of 87 percent.
The 60 percent to 70 percent zone improves your basic aerobic fitness level effectively. Exercising at this intensity feels easy, but workouts with a long duration can have a very high training effect. The majority of cardiovascular conditioning training should be performed within this zone. Improving this basic fitness builds a foundation for other exercise and prepares your system for more energetic activity. Long-duration workouts at this zone consume a lot of energy, especially from your body’s stored fat.3
Exercising at 70 percent to 80 percent of your maximum heart rate begins to be quite energetic and feels like hard work. This zone will improve your ability to move quickly and economically. In this zone, lactic acid begins to form in your system, but your body still is able to completely flush it out. You should train at this intensity at most a couple of times per week, as it puts your body under a lot of stress.
Exercising at 80 percent to 90 percent of your MHR will prepare your system for competitive and high-speed events. Workouts in this zone can be performed either at constant speed or as interval training (combinations of shorter training phases with intermittent breaks; see my previous article on interval training). High-intensity training develops your fitness level quickly and effectively, but overtraining might result if it’s done too often or at too high an intensity.
Common warning signs of overtraining include:
- feeling washed-out, tired, lack of energy;
- mild, prolonged leg soreness, general aches and pains;
- pain in multiple muscles and joints;
- drop in performance;
- decreased immunity;
- decrease in training capacity/intensity;
- moodiness and irritability;
- loss of enthusiasm for the sport;
- decreased appetite; or
- increased incidence of injuries.
If a patient experiences these symptoms, the best prescription might be to recommend they take a break from their training program.
When your heart rate during a workout reaches 90 percent to 100 percent of the maximum, the training will feel extremely hard. Lactic acid will build up in your system much faster than can be removed, and you will be forced to stop after a few minutes. Athletes include these maximum-intensity workouts in their training program in a very controlled manner; fitness enthusiasts do not require them at all.
It’s important to note that a workout with a lower perceived exertion is not worse or less significant than a workout with a high-intensity value. Both are needed in balanced training. In fact, lower-intensity workouts are most important for endurance. Low-intensity training builds a foundation on which you can safely build workouts with a higher intensity.
Understand your body’s signals and how to react to them. Learn to recognize what the different heart rate zones feel like during your workouts and what kind of feelings different training effects cause in your body (sweating, ability to talk, muscle soreness). I encourage my patients to learn to notice when their heart rate differs from normal and how unusual situations (i.e., lack of sleep, stress, an oncoming flu) also affect their heart rates.
Using the NASM model as taught in the Corrective Exercise Specialist (CES) and Performance Enhancement Specialist (PES) courses, I implement an “Integrated Program Design” for my patients:
- Train them how to perform self-myofascial release using the foam roll.
- Train them how to perform specific stretching maneuvers.
- Discuss how to control heart rate, performance level and exertion during exercise. Take your heart rate and know your desired heart rate limits. Decide on a training effect target for your workout that day.
- Introduce training in the most sensible and result oriented way. This includes training programs that include core work, balance training, plyometrics, speed (straight-ahead speed), agility (lateral speed), quickness (reaction time) and resistance training.
Plan training wisely and with long-term vision. I don’t want my patients to go to a personal trainer for this type of information and intervention. I want to be able to design a training program with a personal trainer that matches my patient’s needs and goals. Most of my patients want to lose weight, “get in shape,” prevent osteoporosis or need to perform corrective exercises for musculoskeletal reasons. The problems I see most often in those who are working out is they have been doing the same workout without variety way too long. It’s worth saying again – help patients plan long-term.
As I work more and more closely with personal trainers, I see my role as helping each of my patients with injury prevention; maintaining a regular training schedule; an upward trend in strength, endurance, balance, etc.; a correct ratio between training and rest; variety; and keeping both of us motivated.
In part 4 of this series, I will discuss functional movement tests and corrective exercise training.
- Gellish RL, Goslin BR, Olson RE, et al. Longitudinal modeling of the relationship between age and maximal heart rate. Med Sci Sports Exerc, May 2007;39(5):822-9.
- Jouven X, Empana JP, Schwartz PJ, et al. Heart-rate profile during exercise as a predictor of sudden death. N Engl J Med, 2005 May 12;352(19):1951-8.
- Achten J, Jeukendrup A. Relation between plasma lactate concentration and fat oxidation rates over a wide range of exercise intensities. Int J Sports Med, January 2004;25(1):32-7.
Metabolism and the Benefits of Interval Training
by Jeffrey H. Tucker, DC, DACRB
In the previous article, I introduced you to Sheldon, who has been diagnosed with a pre-insertional tear of the Achilles tendon. Sheldon is now out of acute pain and has to start his exercise training in preparation for playing basketball in the upcoming Maccabi Games.
Eliminate Conventional Aerobics
What led Sheldon to an ankle injury was his personal choice in preparation for the games. He started spending about an hour on the treadmill three days per week and then played basketball another three times per week. He did not properly stretch or warm up prior to his activities. The probable mechanism of injury to his ankle was repetitive stress and faulty movement patterns. Sheldon’s diagnosis was a pre-insertional tear in the Achilles tendon. Initially, walking and running were painful. However, he could ride a stationary bike.
One of the first changes I make to a cardio program is to have my clients eliminate conventional aerobics. For example, if a client is spending 60 minutes on a treadmill or elliptical machine, I recommend they spend that hour of time performing: 10 minutes on the foam roll; 10 minutes isolated stretching; 20-25 minutes doing a combination of body-weight exercises, resistance exercises and/or lifting free weights; and 15-20 minutes of cardio training, especially using interval training techniques.
The foam roll is used as an inhibitory technique to release tension and/or decrease activity of overactive neuro-myofascial tissues in the body. After using the foam roll, clients are instructed to participate in static stretching of muscles to increase the extensibility, length and range of motion of neuromyofascial tissues in the body.
The next phase of the workout is muscle-activation techniques, often performing body-weight exercises. These exercises are used to increase intramuscular coordination and strength. Squats, lunges, push-ups and step-ups are examples of dynamic movements. When I train my clients to lift free weights, I want them to lift heavy weights. When I teach free-weight training, I recommend creating circuits of five exercises, performing six repetitions of each exercise and then performing the circuit three times. The sixth rep of each set should be difficult to complete if you are using the correct amount of weight.
In three separate half-hour, in-office sessions, (once per week for three weeks) I can teach my clients approximately 15 different resistance, body-weight and/or free-weight exercises. At the end of the three sessions, they have learned and practiced enough to perform a 15-minute, 30-minute or 45-minute whole-body, customized workout routine. The amount of time they work out and spend on the home program depends on the number of sets they perform. They can adjust this to their own schedule.
If clients are not ready to lift free weights, I use a fitness tool that combines a stick and exercise bands into one effective workout. You can do hundreds of different exercises and combination movements to improve strength and flexibility. Every Tuesday and Friday morning, I teach a small-group exercise class. My experience has shown that resistance-band or resistance-bar exercises can be performed for one-minute intervals and then changed to the next exercise for the next minute. This routine can be continued for 20-45 minutes. This provides a great cardio, strength and flexibility workout.
Teach Interval Training
Sheldon needed to get cardio fit and “court ready” for the basketball tournament. The best choice of training for his cardio is interval training. Interval training is broadly defined as alternating brief periods of very high-speed or high-intensity work, followed by periods of rest or very low activity. Simply put, interval training is based around the concept of “Go fast, then go slow, then repeat.” You can perform interval training routines on pretty much any machine you want, such as a treadmill, bike or elliptical machine, and it can apply to almost any sport (swimming, cycling, running).
In interval training, high heart rates during work periods and low heart rates during recovery follow each other. This not only results in increased cardiovascular strengthening, but also increases the energy expended per minute, increasing thermogenesis and thus resulting in increased fat loss. Just remember, the concept of interval training is to go fast and then go slow.
If you are dealing with an unfit client, I don’t recommend they run to get fit. They need to start a walking routine first. Once they are fit, they can run. Typically when a person decides to start an exercise program, they usually think of walking as the major form of exercise. Walking is an ideal place to start. How do you apply interval training? If you’re in good shape, you might incorporate short bursts of jogging into your regular brisk walks.
In my home gym, I have an elliptical machine for my interval training. For example, I warm up at a speed of 5.5 for five minutes and then perform short, fast (speed of 8-10) bursts for 30-60 seconds. I slow down for a minute or two and then repeat the fast burst again. This is performed for 15-20 minutes. If you’re less fit, you might alternate leisurely walking with periods of faster walking. For example, if you’re walking outdoors, you could walk faster between certain landmarks.
Have you ever noticed when people continue to do the same walk, day in and day out, and do not add periods of short bursts to increase metabolic activity to improve their fitness level, they simply stay at the same weight, BMI and body composition? If clients are just beginning an exercise routine, I also suggest they include bicycling in their routine. Since bicycling allows for maximum metabolic disturbance with minimal muscular disruption, metabolic rate and exercise activity efficiency easily can be increased. To apply interval training to cycling, you could pedal all out for 60 seconds and then ride at a slower pace while you catch your breath for the next two to four minutes. Try to keep the bursts of speed at around 90 percent to 100 percent of maximum effort.
An example of an interval routine for runners is to sprint for 20 seconds, rest 10 seconds, repeat four to eight times; or sprint 15 seconds, rest 5 seconds, repeat four to six times.
The Benefits of Interval Training
Major increase in fat loss. In a study done by Tremblay, et al., two groups were assigned different training regimens.1 Group A performed regular moderate intensity cardio (like jogging or bicycling) for 20 weeks and Group B performed interval training routines for 15 weeks. The results of each group were recorded. Group B lost nine times more fat than Group A in five weeks less time.1
Increased lactic acid threshold. Lactic acid threshold indicates how fast your body can remove the lactic acid in your muscles. When your body can remove lactic acid more efficiently, you can work the muscles at a higher intensity for a longer period of time before they become fatigued.
Shorter workouts. If you crank up your exercise intensity using interval training, you can work out in less time and accomplish more compared to performing steady-state cardio. It appears interval training burns more fat than regular moderate-intensity cardio. The rationale is that recovery of metabolic rate back to pre-exercise levels can require several minutes for light exercise and several hours for hard intervals. This phenomenon is called excess post-exercise oxygen consumption (EPOC). Intense exercise of a significant duration may cause EPOC or afterburn. This means extra calories are burned after an intense exercise bout. This indirect expenditure of energy has been shown to last from 30 minutes to many hours post-exercise.
Don’t forget that the training effect increases faster with increased intensity than with increased duration. A long-duration, low-intensity workout will not necessarily result in a high training effect, while a short, high-intensity workout may produce a high value. You need to develop an aerobic base in your fitness clients, but you must progress to intervals if you want real results in both fitness and fat loss. The bottom line is: The higher the intensity, the more calories will be expended. The more energy expended per minute, the more efficient your exercise time will be for fat loss. By the way, Sheldon’s team went on to win the men’s basketball championship.
- Tremblay A, Simoneau JA, Bouchard C. Impact of exercise intensity on body fatness and skeletal muscle metabolism. Metabolism, July1994;43(7):814-8.
by Jeffrey H. Tucker, DC, DACRB
This article is a real story about a client of mine, Sheldon, whom I am proud to call a very good friend. Last year, I was excited to find out that he was invited to play in the 2007 Maccabi Games (www.jccmaccabigames.org).
I want to personally share his story with you while educating you on the principles of rehab at the same time. Sheldon was given an opportunity to live a dream of playing in a basketball competition that few will ever experience. He came to me feeling confident with our past experiences I could help him recover from a serious injury and get him in shape for the tournament in about 12 weeks’ time. Like every client, Sheldon’s recovery and therapy required customization.
In mid-September 2007, Sheldon, a 49-year-old male presented to my office with left lower-posterior leg and ankle pain made worse with walking. He indicated to me that the pain was in the Achilles tendon region and attachments at the calcaneus. He had been recently invited to play for the U.S. basketball team at the 11th Pan American Maccabi Games in Buenos Aires, Argentina, in December 2007. He decided to make the trip to Argentina a family vacation. Sheldon was not unfit, yet he was not in condition for a world-class competition. The ankle injury had occurred as a result of his overexertion in preparing for the tournament.
He came to my office with an immediate goal of pain relief so he could practice basketball again. His bigger goal was a structured exercise program to get him ready for Argentina. The patient was diagnosed with pre-insertional Achilles tendonitis with a partial tear. His past history was remarkable for low back pain and previous diagnosis as a pre-diabetic. The goals of a complete chiropractic/rehabilitation training program for this client were to: decrease pain and body fat, increase strength, endurance, flexibility, lean muscle mass and performance; and prevent injury.
Sheldon’s treatment was guided by measurements such as bioelectrical impedance analysis (BIA), weight loss, heart rate, exercise intensity, ratings of perceived exertion, interval training timing and meal plans. The tools I used to decrease his pain as quickly as possible were a class IV, high-powered warm laser, sound-assisted soft-tissue mobilization (SASTM) as taught by David Graston, joint mobilization/manipulation and myofascial therapy. I had his MD prescribe ketoprofen cream, an anti-inflammatory used to massage into the Achilles area.
As part of his overall program to achieve the above goals, I recommended and initiated food plans, supplementation and a corrective exercise program. Diet is the best tool for fat loss. I have found the Mediterranean diet is easy for clients to follow and offers the best results.
The need for supplements depends upon the individual sitting in front of you. However, there are specific nutrients we can recommend for each individual to take on a daily basis. For example, Sheldon was instructed to take 3 grams of EPA/DHA per day for pain relief and to support joint and bone health, glucose and insulin homeostasis, and the integrity of neurological cells. He was instructed to take daily essential vitamins and minerals, and to increase his protein intake using a bioactive, pure whey protein powder concentrate.
Exercise creates changes in the musculoskeletal system, increasing strength and performance, along with stimulating physiological processes. However, we may not all agree on the best type of exercise to make such changes. In this article and the next, I will discuss these topics and much more, clarifying the connections between fat loss, fat-free mass, exercise and performance.
Measurement and Weight-Loss Basics
Within three weeks, Sheldon was walking without pain. At the end of the third week, he could jog with slight to moderate pain after 10 to 15 minutes of intermittent stops and starts, as in playing basketball. Once his pain diminished enough that he could jog, it was time to get serious and implement a corrective exercise program. We all recognize the value in measuring blood pressure, height and weight. As part of my workup before starting an exercise progression or before starting a weight-loss program, I measure body fat percentage and lean body mass. When I ask a client, “How much do you weigh today?” I often hear remarks such as, “10 pounds too much.” Then I ask, “But how much do you weigh now?” and get the usual response of, “I don’t know, I never weigh myself.”
Maintaining a healthy body weight includes maintaining healthy functioning immune, hormonal and reproductive systems without any traces of an eating disorder. It is also a weight that you can realistically reach and maintain with healthy lifestyle efforts. To effectively manage body weight and body composition, it is important to know your daily caloric requirements. A BIA test can tell us body composition and basal metabolic rate. Accurate assessments using BIA allows me to determine each client’s unique personal caloric requirements and to better plan and evaluate weight management/exercise programs. As mentioned above, I utilize therapeutic lifestyle changes (TLC) including food plans, supplements, exercise and relaxation that can be evaluated using objective measures before and after beginning my nutritional and/or exercise program.
Body Composition Measurements
In my practice, I use a body composition machine, which is a portable, battery-powered bioimpedance analyzer. Patient assessments are conducted using a connection between the analyzer and the wrist and ankle of the patient. Connections to the patient are through standard ECG sensor pad electrodes. Resistance and reactance, the two components of impedance, are measured directly from the body.
On Sheldon’s initial office visit, he was 78 inches tall and weighed 215 pounds. A look at some of the results from Sheldon’s BIA test revealed the following:
|Fat Mass (FM)
|Fat-Free Mass (FFM)
|Body Mass Index (BMI)
|Intracellular Water (ICW)
|Extracellular Water (ECW)
Body weight is the sum of your body fat or fat mass (FM) and your lean body mass or fat-free mass (FFM). FFM consists of dry lean mass and total body water (TBW). TBW is divided into water inside the cells (intracellular water – ICW) and water outside the cells (extracellular water – ECW). TBW is the sum of intracellular water and extracellular water (ICW + ECW = TBW). Keeping these components appropriately balanced is the key to staying fit and healthy. Compositional imbalance in the body is closely related to obesity, malnutrition, edema and osteoporosis. It also will contribute to suboptimal athletic performance.
Body Mass Index
Body mass index (BMI) is a common measure expressing the relationship (or ratio) of your body weight to your height. BMI is more highly correlated with body fat than any other indicator of height and weight, but it is not recommended for use as the sole measurement of your body composition. It does not apply to infants, children, adolescents, pregnant/breastfeeding women or adults over 65 years of age.1
BMI Measurements and Ranges: You can calculate your BMI using the formula: BMI = weight (kg)/[height (m)].2
BMI <18.5: This calculation may indicate an underweight status and may be associated with health problems for some people. This client may need to have a consult regarding diet or other health-related issues.
BMI of 18.5 – 24.9: This zone is the preferred range as it is associated with the lowest risk of illness. The client is living life in a way that improves health.
BMI of 25 – 27: This zone may be fine if you are physically active. You likely have lots of muscle mass and may be overweight but not overly fat. However, a BMI over 25 may be associated with health problems for inactive people. This client will need to consult with a doctor.
BMI of 27 – 29.9: This is a health risk zone and is associated with increased risk of heart disease, high blood pressure and diabetes. At this point diet, nutrition and exercise must be implemented.
BMI > 30: This is obesity. Clients must be provided with a program of balanced eating, supplements, regular exercise and reduction of stress.
Sheldon’s BMI was 25.5, putting him between 25 and 29.9. Although he is only 0.5 over, this still falls within the overweight range. Being overweight increases your risk for heart disease, diabetes and other serious health problems. I was not concerned about Sheldon being overweight, but I was concerned that he would be under stress from the workouts ahead and was on a tight time schedule to get ready for Argentina. Within the first week of treatment, I had discussed the Mediterranean food plan with Sheldon to promote healing and increase strength.
Table 1: Risks of cardiovascular disease relative to body mass index and waist circumference3
|Body Mass Index (BMI)
Men = 102 cm (40 inches)
Women = 88 cm (35 inches)
Men > 102 cm (40 inches)
Women > 88 cm (35 inches)
|Underweight = <18.5
|Normal weight = 18.5-24.9
|Overweight = 25-29.9
|Obese = 30-34.9
||Very High Risk
|Obese = 35-39.9
||Very High Risk
||Very High Risk
|Extremely obese = 40+
||Extremely High Risk
||Extremely High Risk
The BMI ranges are based on the relationship between body weight and disease and death.4 Overweight and obese individuals are at increased risk for many diseases and health conditions, including hypertension, coronary heart disease, stroke, type 2 diabetes, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, some cancers (endometrial, breast and colon), and dyslipidemia (high LDL cholesterol, low HDL cholesterol or high levels of triglycerides).
There are three types of muscle: cardiac, visceral and skeletal muscle. The quantity of skeletal muscle is most affected by exercise, particularly by strength-training programs. By comparing the percentage of body fat mass and skeletal muscle mass in each body component, the level of fatness or obesity can be measured in a more proactive and exact manner. An essential part of my program is to teach my clients how to train and lift free weights. By teaching Sheldon corrective exercises and a free-weight training program, I expect his muscle mass to increase and the body fat to decrease.
We will follow Sheldon’s progress in part 2 of this series and look at metabolism and the benefits of interval training.
- Mei Z, Grummer-Strawn LM, Pietrobelli A, et al. Validity of body mass index compared with other body-composition screening indexes for the assessment of body fatness in children and adolescents. Am J Clin Nutr, 2002; 75(6):978-85.
- Garrow JS, Webster J. Quetelet’s index (W/H2) as a measure of fatness. Int J Obesity, 1985;9:147-53.
- Gallager DG, Heymsfield SB, Heo M, et al. Healthy percentage body fat ranges: an approach for developing guidelines based on body mass index. Am J Clin Nutr, 2000;72(3):694-701.
- Prentice AM, Jebb SA. Beyond body mass index. Obesity Rev, August 2001;2(3):141-7.
- Gallagher D, Visser M, Sepúlveda D, et al. How useful is BMI for comparison of body fatness across age, sex and ethnic groups? Am J Epidemiol, 1996;143(3):228-39.
- World Health Organization. Physical Status: The Use and Interpretation of Anthropometry. WHO Technical Report Series. Geneva: World Health Organization, 1995.
by Jeffrey H. Tucker, DC, DACRB
Thoracic kyphosis associated with myofascial pain syndrome is a common clinical complaint. The objective of this article is to describe and discuss management of patients with thoracic kyphosis and associated myofasical pain syndrome using the Deep Muscle Stimulator device and exercise. Thoracic kyphosis is a very common dysfunction, especially as we get older. Sitting in a slumped posture coupled with a sedentary lifestyle can cause and perpetuate kyphosis and myofascial pain. As with most health conditions, prevention of kyphosis is easier than reversing the condition.
Problems occur when the kyphotic curve becomes increased and is associated with stiffness. The thoracic spine is naturally the stiffest section of the spine, because of the rib attachments forming the costotransverse and costovertebral joints. The two main planes of movement are flexion/extension and rotation. The upper thoracic spine has a very important relationship to the neck, scapula and shoulders. The mid thoracic spine has an important relationship with the diaphragm. The costal part of the diaphragm has slips of muscle arising from the internal surfaces of the inferior six ribs and their costal cartilages, interdigitating with the slips of the transverse abdominus.
The thoracolumbar junction has a very important relationship to the lower back. It is important to assess exactly where in the thoracic spine stiffness is taking place. Stiffness in the upper back with a rounded shoulder appearance is often associated with myofascial pain syndrome in the upper and middle trapezius, rhomboids, pectorals, and levator scapulae muscles. These muscles often feel very tight and overactive. Muscle dysfunction in this area can be from lower trapezius and/or serratus anterior muscle deficiency, muscle tension, muscle inhibition and myofascial trigger points.
The Deep Muscle Stimulator (DMS) developed by Dr. Jake Pivaroff, a chiropractor, (DrJake@D-M-S.com) is a hand held electric motorized device that provides brisk vibration and percussion in rapid succession. To the client it feels like strong vibration. Like manipulation, the DMS influences mechanoreceptor stimulation which may inhibit pain, relax hypertonic muscles, and restore proper motion to restricted spinal joints. The DMS can be used as a stand alone treatment or in conjunction with any other modality or mobilization/manipulation technique. It is especially useful for neuro-myofascial techniques, and pre- or post-manipulation therapy.
The author is currently using the DMS in conjunction with Neuromobilization Techniques as well. The DMS technique causes mechanical contraction of muscle and is performed to treat neuromusculoskeletal conditions. The DMS device is especially useful for covering the entire surface of the back. The brisk vibration and percussion delivered by the device provides pressure and force to overcome the density of the erector muscles, spinous ligaments and thoracolumbar fascia.
I can cover more surface area using the DMS, be more thorough and faster, than using hands alone. Although the patient usually reports feeling relaxed, the device has a stimulating effect upon the nerve receptors. A vibratory sensation is conveyed from the site of application on the body that travels outward for 2-4 inches or further, depending on the patients’ density. Latent trigger points, taut bands and/or tender spots that were not felt by the patient will often be revealed with a sensation when stimulated by the DMS, thus allowing these spots to be worked out.
The body tissues directly influenced by the Deep Muscle Stimulator (DMS) are the skin, the fascia, the muscular system, lymphatic system, and the nervous system. The glandular, digestive, and bony systems are indirectly influenced. In cases of numbness or tingling, this vibration will have a benumbing effect which will react in a sedative manner. Like ischemic compression techniques, the DMS will reduce trigger point sensitivity found in muscle, tendon, periosteum, ligament and skin.
By reflex action through the sensory nerves in the skin a sedative effect is produced by DMS. The muscles and soft tissues are bound together by the deep and superficial fascia, the viscous, gel-like ground substance, and layers of many large and small blood vessels. Metabolites and toxins can become stored in the connective tissues and the DMS will increase vasodilation, allowing tissues to receive adequate fresh amounts of oxygen and nutrients. This process will remove waste byproducts to facilitate tissue recovery and repair. DMS can be lightly used over swollen joints in order to send on through the blood stream the broken down products of inflammation.
Specific treatment for thoracic kyphosis will include manipulation of hypomobile joints and DMS used over the soft tissues. Using the device can be performed in a stroking nature, in which the surface of the device is used lightly or with deeper stroking over the paraspinal musculature. The device provides a deep kneading as well as stroking. Holding the device slightly off the skin to provide light stroking is used in the early stages of treatment or when deeper stroking cannot be tolerated by the client. Light stroking, even in its lightest form, has definite therapeutic effects.
The device is used with a firm, even pressure either in a transverse or circular manner. A definite amount of body surface should be decided upon by the operator before using the DMS. For example, thorough stroking of the gastrocnemius/Achilles tendon and/or the hamstring muscle may be required to release tension that is causing a patient to curl forward contributing to thoracic kyphosis .
Deep Muscle Stimulator Technique for Kyphosis
Changing the relationships among the bones in an abnormal kyphotic spine requires changing the tensional balance through the soft tissues and actively moving the spine. To perform this procedure, the doctor will use the DMS device along the erector spinae muscles while the client performs active motion. Ask your client to stand close to a counter top so their hands can easily rest on the counter top and be used as a support. An alternate position is to have the client sit on a stool or the edge of a treatment table making sure the feet are grounded on the floor.
Have the client assume a “tall spine” posture. Instruct your client to drop the chin toward the chest until a comfortable stretch is felt. Allow the weight of the forehead to carry the thoracic spine into flexion one vertebrae at a time. Complete thoracic flexion and simultaneously treat the paraspinal muscles with the DMS. Instruct the client to curve in the opposite direction, maintain moving the DMS along the paraspinal muscles. Maintain the pressure of the DMS as the client opens into hyperextension at the thoracic spine.
Different forms of mobilization can be used with the DMS, coupled with passive and or active movements to joints. Manual stretching of myofascial trigger points, manual stretching of tissue and muscle fascia, and manual separation of connective tissue can be performed while the operator is using the DMS over the involved tissue.
An office visit using the DMS device can include both manipulation of the joints and soft tissues, or without movements to the joints as a stand alone treatment with its own physiologic effects to the soft tissues. The DMS prevents or breaks down adhesions if tissues are bruised, matted, or thickened. DMS has a reflex action upon the nervous system by affecting the peripheral sensory nerves. The dry rubbing over the back extensors is often associated with muscular contractions and when the treatment is stopped there is an obvious elevation of the local skin temperature. Patients appreciate that oil or lotion does not have to be applied.
The types of exercises can be broken up into two categories.
First, range of movement exercises aimed at increasing movement of the many joints that make-up the thoracic spine. Flexibility exercises into rotation, flexion and particularly extension are essential. I find the most useful exercise, is to use a high density foam roller, laying it cross the spine in the stiff hypomobile areas, knees bent up and then arching back over it as the most useful flexibility exercise.
The foam roll is used as an inhibitory technique to release tension and/or decrease activity of overactive neuro-myofascial tissues in the thoracic spine. The foam roll provides a very good maintenance flexibility routine and is best performed before stretching as a way to mobilize the joints. Other flexibility exercises that are important are stretches for the pectorals and latissimus dorsi. The static latissimus stretch is accomplished with the client on all fours with one arm outstretched, the hand and forearm on a stability ball. Tightness through here can often pull the shoulders forward and increase the kyphosis.
If someone is stiff and rounded through the thoracic spine, the upper trapezius, rhomboids and levator scapulae muscles are often very tight and overactive. The DMS can be used over these muscles as well as over the latz and pectoralis muscles.
The second group of exercises are to improve muscle tone and endurance and thus posture. The better the muscles are at holding the thoracic spine in correct posture, the less stiff the thoracic spine will become. Key muscle groups are the lower trapezius, serratus anterior and thoracic erector spinae.
Gym based exercises that improve kyphosis are back extension, bent over row and diagonal cable pulls. Performing isolated strengthening is a technique used to increase intramuscular coordination of specific muscles. With the chest on a stability ball and both toes touching the ground, the letters ‘Y’, ‘T’, ‘W’ and ‘L’ can be performed with the arms. Make sure you have your feet on the ground and if required have the feet up against a wall, lay face down with the swiss ball positioned under your chest and stomach. You have to hold your thoracic spine extended while feeling like you are pushing your chest out, pulling the shoulders and scapulae away from your ears (“down and back”). Then make the letters with your arms and hold each position for two breaths. These postural stabilization exercises on the ball can be performed 3-5 days per week. One to two sets of 10-15 repetitions is suitable.
Abnormal kyphosis treatment objectives are: to decrease pain, strengthen weak muscles, decrease mechanical stress on spinal structures, improve fitness levels, induce intersegmental motion, improve posture and improve overall mobility.
In summary, assess the client’s posture for dorsal kyphosis. Observe the thoracic spine during arm raising and lowering. Does the spine straighten or not? Apply manipulation to fixed segments, provide Deep Muscle Stimulator device over thoracic paraspinal muscles with active range of motion, instruct client in corrective exercises.
Example Exercise Prescription for Kyphosis
- Give patient advise on proper posture while sitting and standing. Teach clients to perform a sternal lift and “tall spine”.
- Train proper respiration.
- Deep Muscle Stimulator over the entire back.
- Mobilization/manipulation of hypomomobile/fixed joints in the thoracic spine and ribs.
- Foam roll at home (daily).
- Stretch/lengthen the latissimus dorsi, upper trapezius, subscapularis, pectoralis (daily).
- Perform isolated exercises to the lower trapezius and serratus anterior.
- Perform integrated exercises: lunge to overhead press with free weights in the hands.
by Jeffrey H. Tucker, DC, DACRB
Judith is a 59-year-old female who consistently comes to my twice-weekly exercise classes. I train and teach clients in everything from low-load exercises to multiplanar lunges; from bands to balance training; from exercise sticks to Swiss balls; and from plyos to kettlebells.
Jude, as I affectionately like to call her, also occasionally chooses to come to my office for a session when she is in pain. Her usual areas of discomfort are in the upper back/lower neck area or the lumbopelvic region. Jude also comes to see me when she feels like she is “off” regarding her posture or her workouts. Sometimes she comes to me because something in her workout hurts her, or because she notices after sitting for long periods during the day (hunched over a computer) or in a vehicle, that she has become really stiff and tight. On this particular day, it was Jude’s lumbopelvic region that bothered her.
Jude is no ordinary lady. She is health conscious, a savvy business woman, a smart consumer, and appreciates that specialization of treatment for care is the key to progress. Jude likes what I have to offer (and is willing to pay out of pocket): small-group exercise classes, diet and nutrition recommendations, soft-tissue and joint-therapy choices, cutting-edge knowledge and experience.
I have taught Jude how to use the foam roll for self myofascial release, how and what muscles to stretch for her overactive muscles, and drilled technical proficiency in all of her exercises. So I was surprised when Jude presented to my office and I discovered she had the same tightness in her calves and hamstrings (biceps femoris) that I noticed in her previous treatment three months earlier. I thought I had given her the recipe for relief on the prior visit: daily use of the foam roll at home, stretching, specific low-load exercises, and continuation of my exercise class, in which I have been teaching kettlebell training (high-load, whole-body exercises).
If I could interview the calf and hamstring muscles what would they say? Why was Jude experiencing overactive calf and hamstring muscles despite the fact that she told me she was using the foam roll, and stretching her calves and hamstrings. I was certain she was doing whole-body exercises because I was there to instruct her.
The “muscle whisperer” in me knew something was wrong or missing here. I did a checkup of her feet and gait analysis. Nothing obvious jumped out at me. I had her perform the “arms overhead” squat test. This movement observation revealed the feet turning outward very slightly as she descended into the squat. The second toe had moved outward about 20 degrees from a line drawn straight down from the center of the tibia. I also observed the heels rise during the squat decent. The “arms overhead” squat evaluation confirmed overactivity of the soleus and gastrocnemius muscles.
I also observed that her low back was rounding very slightly when she performed the “arms overhead” squat. This indicates overactivity of the hamstrings, especially of biceps femoris muscle.
Why were her same muscles still tight? I was concerned because I know that if your calves or hamstrings are in the “on” position all the time (meaning they don’t know when to lengthen) and they don’t allow the ankles to dorsiflex, or the hips to hinge properly, you will bend from the back instead, and eventually develop other compensations that lead to discomfort, pain or injury. Jude was paying me to figure this stuff out and help keep her injury free.
I reviewed the corrective exercise treatment strategy equation:
- Inhibit the overactive muscles.
- Lengthen the overactive muscles.
- Isolate and activate the underactive muscles.
- Perform whole-body integrated exercises.
For the inhibition part of the equation, muscles can to be treated using foam roll, ischemic compression, instrument-assisted soft-tissue techniques, deep muscle stimulator or any other technique. For each muscle that requires inhibition and lengthening, there is often an opposing muscle that needs specific low-load isolated exercises to activate it. Activation refers to the stimulation (or re-education) of underactive myofascial tissue.
Here lies the explanation for what I did that made a change in Judith’s recurrent muscle overactivity: Not all muscles have a clear singular role. But all muscles have both slow (tonic) and fast (phasic) motor units. Certain muscles are more tonic and respond to too much loading or too much inactivity by getting and staying shorter. The National Academy of Sports Medicine (NASM) refers to this condition as “overactive.” Examples of tonic muscles are the hamstrings, the adductors and the hip flexors. The phasic muscles such as the middle/lower trapezius, gluteus medius and anterior tibialis are prone to getting weak and stretched out with too much or too little use. The NASM calls these muscles “underactive.” Altered muscle lengths go back to the length-tension relationship.
If the calves (soleus, gastrocnemius) are overactive, it is likely that their functional antagonist muscles (posterior tibialis) are underactive. If the biceps femoris are overactive, it is likely that the gluteus maximus/minimus is underactive.
Judith was doing everything right except she was missing one important part of the equation. A corrective exercise program that stretches the short muscle, such as the hamstring, does not concurrently shorten the lengthened muscle, such as the lumbar back extensors. Corrective exercise therapy needs to shorten the elongated muscle while simultaneously stretching the short muscle.
The keys to preventing and alleviating spinal dysfunction are: have the trunk muscles hold the vertebral column and pelvis in their optimal alignments; and prevent unnecessary movement. To achieve these goals, the muscles must be the correct length and strength and be able to produce the correct pattern of activity. The new treatment plan for Jude was to perform everything she was doing, with the addition of the following:
- specific exercises to isolate the anterior/posterior tibialis muscles;
- low-load exercise retraining the hip extension pattern;
- single-leg Romanian dead lifts for the gluteus maximus/minimus muscles; and
- prisoner squats for ankle mobility, calf lengthening, hip flexion, and gluteal strength.
- After only three weeks of care, Jude showed tremendous improvement.
- Comerford M. Lumbo-Pelvic Stability. Course notes.
- National Academy of Sports Medicine. Corrective Exercise Specialist. Course notes.
by Jeffrey H. Tucker, DC, DACRB
*This article was submitted to DC on 1-20-07. Accepted for publication 2-27-07. Printed May 2007.
Movement assessments have become a clear and comprehensive evaluation and approach to my Chiropractic therapy. It begins with me looking at each clients standing posture. I then ask my client to perform a series of postures. You know this portion as ‘range of motion’ evaluation. For example, I say to the client, “Bring your chin to your chest”, etc., or “bend forward to touch your fingers to the floor” or “raise both arms over your head” bla bla bla! It is old school, but I realize I need to document how far they move and if any sensations present themselves. I have become a keen observer of these movements, one who is not just interested in how far they move, but more interested in the way they move and what there movement pattern can tell me. The evaluation continues with a series of dynamic and static postures to observe how the muscles and joints move. Through this process I generate a sequence of home exercise programs for my clients. Please realize, the movement assessments can be performed prior to any hands on work that you do, or the assessments can conclude with a mobilization or manipulation that you feel is necessary.
If you have read my previous articles you will know that I start with the squat assessment. Observe the client perform a squat several times. Simple say “Let me see you do a squat with your arms out in front of you.” The benchmarks that I look for on this evaluation are that the:
- Upper torso is parallel with the tibia or toward vertical (back is relatively upright).
- Femur below horizontal.
- Knees aligned over feet.
- Toes point forward.
- Knees don’t turn in.
If they cannot accomplish the above criteria I start the correction process with the following training: I call this the supine120 degree knee to chest maneuver. Client lays supine in the 90/90 position. The knees are over the hips and the legs are parallel to the floor. Doctor stands at the feet of the client and uses a knife edge contact along the clients ankle crease. The Doctor resists at the ankle crease while the client is instructed to “pull your knees to your chest.” The Doctor allows the client to move into a knee to chest position. The doctor is providing resistance, not overpowering the client. The client’s lumbar region should remain in the neutral spine. Instruct the client to focus using the lower abdominals, especially the area slightly above and below the inguinal region. Allow the hips to get to at least 120 degrees. This maneuver is a great way to get clients to re-awaken this area. Bring awareness of tightness to this area while you tell the client to release tension or resistance in other areas such as the neck or shoulders that are not needed for this maneuver. Repeat this maneuver as many times to client tolerance.
The next progression is a pose called ‘Find your stance’. This is used as a foundation of all standing postures and movements. I want this to become the natural way to stand. It cultivates a sense of strength and stability. Begin with your feet (shoes off) between your hips and shoulders – go with what feels natural and comfortable. Slightly angle your feet outwards with your weight evenly spread through the balls, lateral edge and heel. Avoid your arches collapsing inwards. Try to feel the medial and longitudinal arches lift up.
Assisted Squats: Doctor and client face each other. ‘Find your stance’, or spread feet to shoulder width or slightly wider if needed; client holds arms and hands out in front of there body; Doctor holds hands with client and assists client to squat. The command is “pull your butt down.” The Doctor is providing assistance so the client doesn’t fall down. However, the client may fall to the floor the first or second time and that is perfectly normal and O.K. to do. Simple get back up and attempt it again. The idea is to allow them to go as deep as possible. Get the client to engage the groin crease muscles to pull them down. The goal of doing this squat is to reach back with the buttocks and down, ex. Sit back on a chair with control. If you have a rope or Theraband (at least the strength of a black theraband), you can wrap it around the clients back and underarms while you hold the ends in the front of the client and ask then to “sit down against” that resistance. Doctor coaches the client to keep the back straight, in this case as vertical as possible. FIGURE 1 Rubber tubing under the arm pits and you assist client to sit down against this resistance. The knee should not bow inward.
“Pull the hips out of the socket” routine to squat. This maneuver requires two assistant partners (the doctor plus an assistant). The client is instructed to squat down in a wider than shoulder stance. The Doctor is to the left of the client and the assistant on the right side. Each assistant places one flat hand behind the posterior leg just below the knee crease. The other hand is placed in the inguinal fossa/ligament crease with a knife edge contact. Assistants use enough pressure to guide the client into a deeper squat. Ask the client to feel like they are pulling the hips out of the socket as they descend. This allows the client to understand and feel the proper joints and muscles to use to accomplish this squat. Allow the client to learn in a wide stance and go as low as they can. As they improve strength they can get into a more narrow stance. Less core muscle is required in a wide stance than a narrow stance. Repeat this maneuver several times. Do a simple test on yourself. Stand in a wide stance and go narrower and narrower until you are in a one legged stance. Feel how the core is participating. Eventually we will get clients to have there feet closer and closer together and this will demand greater core strength.
Right after this maneuver, it will help your client if the Doctor rubs his/her index fingers along the spinous processes while the client does several more squats. This is performed starting at approximately the middle of the back with both index fingers. At the same time rub one finger headward and the other caudal along the spinous process while the client squats down and up. While you rub the spine, instruct the client to stay in a “tall spine” posture. They need to imagine creating more room in the hip socket. Tell the client to think of one thing and only one thing on the way up and that is “gluteals.” You don’t need to suck the stomach in if you elongate the spine, it will automatically come in if they are working to resist extension.
Squat against the wall. This is such a new take on the old school method of a wall squat. Once a person can accomplish the “static wall squat” also known as the “wall sit”, “wall chair,” “airbench” or “back against the ball squat” for one minute, they are ready for this maneuver. Find the distance away from the wall so that when you squat down your sacrum stays in contact with the wall. The key is to keep the sacrum touching the wall. Squat down with arms on the inside of the thighs until the elbows can push against the inner thighs. Put your hands in a prayer pose and push the elbows against the inner thighs. Pry the hips apart as you wiggle side to side going lower and lower. Continue this gentle rocking side to side and attempt to go lower and lower opening the hips. You should feel this in the most proximal attachments of the adductor muscles and hamstrings. Hold this pose for as long as you can and then concentrate on getting back up using the gluteals and keeping the sacrum in contact with the wall. Try this maneuver several times. One minute in this pose really gets you feeling warm. Attempt this with a narrow stance compared to when you are away from the wall. The next progression is to repeat the squat away from the wall.
PIVOTS: These help open the hips. Standing with your feet more than 3 feet apart, with outstretched arms (abduction) to your sides away from the body (the feet should be under the wrists distance). The feet will need to be angled slightly outward approximately 15 degrees. Keep the torso facing forward. Lunge gentle to the left until your knee is bent in a right angle above your left foot. Lengthen the spine upward (“tall spine” concept). Move side to side going more and more lateral (lower). The opposing forces of your legs provide balanced stability. Don’t lean the body towards the bent knee, try to keep the torso upright as much as possible. Imagine the hands pulling further side to side. Allow the sitting bone to be pulled backwards. The legs, both pushing forwards and pulling backwards, allow the hip to hinge and become stable at the same time, two opposing forces balancing one another. Shoulder blades should be kept down.
I recommend clients practice these maneuvers daily. I want my clients to observe subtle changes in posture, decreased pain, increased range of motion, feelings of stability, and a greater capacity for work and sport. As individuals vary in strength, flexibility, and coordination so the practice of functional exercises will be unique to each individual. Using progressive movement as assessments in your practice will tell you where the client is strong or weak, symmetrical or asymmetrical, balanced or imbalanced, coordinated or incoordinated, and which areas need more practice.
- Bergmark A 1989 Stability of the lumbar spine. A study in mechanical engineering. Acta Orthopaedica Scandinavia 230(60):20-24.
- Caterisano A, Moss RF, Pellinger TK, Woodruff K, Lewis VC, Booth W, Khadra T. The effect of back squat depth on the EMG activity of 4 superficial hip and thigh muscles. J Strength Cond Res 2002 Aug; 16(30: 428-32
- Comerford M 2003 and 2006 Lumbo-pelvic Stability. Course notes. Copyright Comerford.
- Tsatsouline, Pavel 2007 Stretch Course. Copyright Tsatsouline.
- Vermeil A 2005 Sports & Fitness. Course notes. Copyright Vermeil.
- All the coaches, sports medicine, and sports scientists who have shared their knowledge with me.
by Jeffrey H. Tucker, DC, DACRB
Neuromobilization is a technique that details the assessment and analysis of radiculopathy. It involves specific maneuvers for upper and lower extremity sensory disturbances.1 Most musculoskeletal pain and dysfunction represents the result of a failure of adaptation.
It is easy to imagine that nerves can become stuck from disc pathology, lateral canal stenosis, fascial glue or any other structure that wraps, invests, supports, separates, connects, divides or may become sticky. The ground substance can become thick and sticky. It is likely that a nerve can become “held” or “stuck” in an area of ground substance that has become viscous or gel-like, or in areas of inflammation.
Neuromobilization is one of the least invasive therapeutic interventions that can start the healing and repair of radiculopathy. The femoral nerve, sciatic nerve, median nerve, radial nerve and ulnar nerve have lines of pull. Neuromobilization procedures are directed at multiple joints, and it is difficult to determine exactly where the nerve may be stuck.
The techniques are taught with two people simultaneously making the correction on the patient. Since it is not always possible for practitioners to have an assistant available to aid in the correction, I have found that a deep muscle stimulator (DMS) device is extremely useful. The hand-held device provides percussion and concussion vibration that allows specific point pressure to increase circulation and oxygenation to the tissues. The stimulator device will allow the muscle to achieve a new resting length. Fascia is stretched and will change length and hold the new form. The stimulator device also relieves joint irritation and inflammation to the surrounding area and nerve; a fixation or joint stiffness may cause a nerve to be hypomobile and irritated every time it is pulled.
Once the patient is comfortable doing at-home stabilization protocol exercises for the neck and back, it is time for them to progress to more advanced corrective exercises. For example, with the patient relaxed in the centrated side-lying posture, you can use a stimulator device in the sciatic-notch region for sciatic-nerve radiculopathy while the patient is talked through actively moving the top leg into abduction, hip flexion, and foot dorsiflexion/plantarflexion.
Advanced Exercises for the Femoral Nerve
Reverse lunge: Stand with feet hip-width apart in front of a mirror with a resistance band wrapped/tied around the knees. Ensure your lumbar spine is in neutral and your back is tall, with your shoulders back and head up. Slide backward with your right leg and bend your left knee only halfway down. Ensure that your front knee is in line with your toes and your back has remained upright, with your lumbar spine in neutral and your hips level. Allow a stretch in the right iliopsoas muscle region. Push back up with the right leg. Your back should remain totally still and your hips level as you performed the push-back. The idea is to slide your right foot back until your left leg bends at 90 degrees. Slide your right foot up to start position, pulling up with the glute of your left leg. Keeping your abs tight will help you keep balance. Finish all reps on one side and then switch sides. Perform 10-15 reps per side.
Prone hip flexor stretch: Lie prone on the floor with the involved-side knee flexed to 90 degrees. The opposite leg is straight on the floor with both ASIS pressed into the floor. Wrap a resistance band around the bent-knee ankle and grab the other end with both hands. Actively extend the hip and pull on the band so the thigh is raised off the floor. Make sure the ASIS stay in contact with the floor. Hold this for a 30-second count while performing diaphragm breathing. Perform three to five reps.
Resistance-band side walk: Place a resistance band around your ankles. Stand with your feet hip-width apart and get into a small knee-bend position. Step to the side with your left leg, then bring your right leg toward the left leg, but not all the way, so you keep some tension on the band. Continue across the room, stepping out with your left leg. Return to the other side of the room, facing the same way stepping out with your right foot. Make sure the foot doesn’t get out from under the knee. Move five steps to the right and five steps to the left. This can be repeated until felt in the gluteus medius.
- Based on a technique course taught by Dr. Kim Christensen.
by Jeffrey H. Tucker, DC, DACRB
In my experience, I have found it useful to measure internal and external hip rotation in a prone rather than a supine position. I was taught this technique by Mark Comerford in 2006 and use it on a daily basis.
In the prone position with the client on the table or floor, grasp the foot gently, maintain the knee at 90 degrees, and slowly rotate the hip internal and external until you feel resistance. Make sure you are isolating the hip and not allowing pelvic rotation to occur. Take measurement of either excessive or decreased motion. (In Part 1 of this article (Jan. 15, 2009 issue), you will find the description and interpretation of the tests for medial and lateral hip rotation.)
If you find an asymmetry in internal hip rotation in the prone position, you can demonstrate the asymmetry in internal rotation by having the patient perform the “windshield-wiper position” in the supine position. Patient is supine lying in the 90/90 pose with both fists together (thumbs touching each other) between the knees. Slowly move the feet outward while maintaining pressure between the knees. Compare left and right internal rotation. This method should confirm what you find in the prone position, and allows the patient to see and feel any discrepancy.
The importance of proper hip range of motion and motor control is that the hip muscles either stabilize or produce power. During gait, the glutes and hamstrings produce hip extension. When the hamstring muscle is more dominant than the glutes during hip extension, the proximal femur / greater trochanter can create stress on the anterior joint capsule by anteriorly gliding during the hip extension movement. Ideally, the greater trochanter is maintained in the acetabulum by coordination and fine control of the surrounding muscles. Anterior gliding of the proximal femur / greater trochanter is a form of “uncontrolled translation” that can create a friction rub or repetitive microtrauma.
Many structures pass over the anterior femur head, such as the labrum, capsular fibers, bursa and soft tissues. It is reasonable to imagine that dysfunctional muscle control at the hip can cause synovitis, bursitis and soft-tissue contracture. If the iliopsoas is stretched or weak, and is not providing normal restraint on the femur head, the anterior gliding will be worse.
Reviewing the anatomical attachments of the hamstrings provides a plausible reason why hip joint motion becomes altered. The hamstring muscles, with the exception of the short head, do not attach into the femur. They attach to the ischial tuberosity. Because the hamstrings do not attach directly into the proximal femur, they cannot provide precise control of the movement of the proximal end of the femur during hip extension.
The short head of the biceps femoris starts at about the mid femur. It has a continuous origin from the lateral lip of the linea aspera on the posterior surface of the femoral shaft, the upper half of the lateral supracondylar line and from the lateral intermuscular septum. Distally, the long and short head of the biceps femoris give rise to a tendon that inserts into the lateral surface of the fibular head. In my experience, the short head of the biceps femoris is consistently one of the most overactive muscles in the body. The hamstrings simply cannot provide local fine motor control of the femur head.
There is another side to this whole hip movement pattern story. When the gluteus max and piriformis muscles are the prime movers for hip extension, the greater trochanter will either maintain a constant position or move slightly posteriorly.
If your patients experience cramps in the hamstrings during the bridge maneuver, they are overutilizing the hamstring muscle and not firing the glutes properly. If the patient has anterior hip pain while performing the bridge exercise up and down, they may not be controlling the proximal femur / greater trochanter.
Hip/pelvic complex dysfunction, especially the gluteal/hamstring relationship, can further impact the kinetic chain distally, such as excessive femoral medial rotation with respect to the tibia. The knee often gets caught between a dysfunctional hip and/or a dysfunctional ankle. The knee can easily become the site of greater flexibility between the ankle, hip and knee joints. Excessive uncontrolled motion is instability. The ankle has a tendency to lose dorsiflexion, while the hip loses extension.
A likely source of muscle impairment is the concept of relative stiffness/flexibility. One structure increases its flexibility to accommodate the relatively stiffer structure. We don’t always know how the muscular impairment begins, but compensation is normal. The nature of our society forces long-term habitual use patterns. A common muscular impairment starts with recruitment issues of the hip lateral rotators. A weakness or recruitment problem of the hip lateral rotators can lead to the short head of the biceps femoris becoming overactive.
Here is how you check the length of the short head of the biceps femoris: Visual postural analysis will reveal a prominence of the biceps femoris muscle. It will simply look bulged behind the knee. To check the length of the right short head of the biceps femoris muscle, put the client’s right leg in the supine 90/90 position. The left leg is held straight and resting on the table. Try to straighten the right leg. Normal for women is a “straight” raised leg (no bend at the knee). Normal length for men is within 10 degrees of a raised straight leg (10 degrees at the knee). If it is short, they may be using the biceps femoris as the primary lateral rotator of the hip instead of the intrinsic hip lateral rotators – the gemelli, obturators, piriformis and quadratus femoris.
The obvious problem with the biceps femoris muscle becoming the dominant muscle is that it attaches to the mid femur proximally and to the fibula distally, allowing the femur to rotate inward and the tibia/fibula to rotate outward. By eccentrically controlling femoral internal rotation, the hip abductors and external rotators are maintaining stability not only at the hip, but also at the patellofemoral region. Weakness of the hip abductors and external rotators may allow increased femoral medial rotation and valgus knee moments, putting excessive compressive forces on the patellofemoral joint and leading to a diagnosis of patellofemoral pain syndrome.
How many of your patients have had knee surgery without any trauma to the knee? Can you see how this knee problem began from the hip and caused a repetitive microtrauma to the knee? Hip abduction strength is key to movement control.
In order to activate the key stabilizers and prime movers of the hip (glute max, posterior glute med, deep-six rotators), I recommend you train your clients in both low-load exercises and high-load exercises. This will improve the performance of the glute medius and maximus, piriformis, obturator externus and internus, gemellus and quadratus femoris. Here is an example of a hip stability exercise prescription progression:
Side-lying clam progressing to side-lying straight-leg hip abduction (going from short- to long-lever exercises). The hip and knee of the bottom leg should be flexed. The top leg should be in the same alignment, supported on a pillow placed between the knees. The patient slowly rotates the hip of the top leg laterally, being sure not to allow the pelvis to rotate, holds this position for 10 seconds and then returns to the starting position. Repeat for 10 reps. Once the exercise looks and feels easy, progress to the long-lever exercise and repeat the same 10-second holds for 10 reps.
Glute max bridges. Starting with double-feet-on-floor glute raises, progressing to one-leg-at-a-time bridges. For single-leg raises, assume the bridge position, lock the right hip into flexion (knee-chest position, holding the knee inward with both hands); this makes it hard for the patient to hyperextend the lumbar spine, so they use the glutes. Bridge up and down 20 times per side. Keep the hips level and isolate the glutes.
Band walk. Begin with tubing at knees, progress to tubing at ankles. Wrap a band around both knees, slightly externally rotate the hip and walk sideways one leg at a time. Walk six steps left and six steps right. Perform as many sets of six reps per side until the patient feels the targeted glute muscle fatigue.
Single-leg bend-over. This is a deadlift hinging at the hip. Begin with hands on hips, progress to a reach with the hand opposite of stance leg. Progress further to use a dowel or a bar across the shoulders or held horizontal along the spine. Perform 10 reps per side.
- Van Dillen LR, Sahrmann SA, Norton BJ, et al. Reliability of physical examination items used for classification of patients with low back pain. Phys Ther, 1998;78:979.
- Brody LT, Thein JM. Non-operative treatment for patellofemoral pain. J Orthop Sports Phys Ther, 1998;28:336-44.
- Witvrouw E, Lysens R, Bellemans J, et al. Intrinsic risk factors for the development of anterior knee pain in an athletic population. A two-year prospective study. Am J Sports Med, 2000;28:480-9.
- Cesarelli M, Bifulco P, Bracale M. Study of the control strategy of the quadriceps muscles in anterior knee pain. IEEE Trans Rehabil Eng, 2000;8:330-41.
- Fredericson M, Cookingham CL, Chaudhari AM, et al. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med, 2000;10:169-75.
- Comerford M. Lumbo-Pelvic Stability. Course notes.
- NASM Corrective Exercise Specialist (CES) course notes.
by Jeffrey H. Tucker, DC, DACRB
This article explains the importance and purpose of measuring medial and lateral rotation of the hips with the patient in the prone position. Insufficient hip rotation control can cause local hip pain, a pain-producing compensation in the lumbopelvic region or the knees. The ideal range of medial hip rotation motion is approximately 35 degrees (without pelvic rotation). The ideal range of lateral hip rotation is approximately 35 degrees from neutral without pelvic motion.1
I am not as interested in the exact number of degrees of rotation as I am interested in testing for excessive or decreased degrees of the range of rotation. In Shirley Sahrmann’s book Diagnosis and Treatment of Movement Impairment Syndromes, she notes less than 30 degrees of lateral or medial rotation is movement impairment. I am also looking for symmetry or asymmetry of these movements. Evaluating excessive motion and/or decreased range of movement will provide information about the quality of movement at the hips. This is sometimes referred to as neuromotor control or movement coordination.
This evaluation will add another piece of the puzzle to understanding the biomechanics of the lower extremities during physical activities such as gait. It has been my experience that altered movement patterns in the hips may result in alterations of the load distribution across the patellofemoral joint2,3,4 and lumbosacral region,5 causing pain and dysfunction in these areas.
Gathering information about movements is part of a functional examination. Poor quality or altered movement patterns are usually more easily detected when we break down a component of the overall movement (e.g., gait). Recognizing poor hip rotation in the prone position may be easier than recognizing a faulty gait pattern during physical activities. Measuring the hips in a supine position with the hips flexed 90 degrees does not seem as functional as measuring the hips in a prone position with the knees together.
The patient should be in the prone position on a flat table. Stand to the contralateral side of the table, to the side of the hip being examined (stand on the left side of the patient while testing the right hip). Grasp the patient’s foot and passively bend (flex) the knee to 90 degrees. Make sure the knees are together and the thigh is in the neutral position. Slowly move the foot away from you, causing medial rotation of the hip. Evaluate how far the hip moves without moving the pelvis. Is it more than 35 degrees? Is it less than 30-35 degrees? Slowly move the foot toward your body, producing lateral rotation of the hip. Is it more than 35 degrees? Is it less than 30-35 degrees?
Excessive medial rotation of the hip (common): This indicates poor stability (ability to maintain a stabile core and move the extremities) function or excessive length of the hip joint capsule and the lateral rotator stability muscles, posterior gluteus medius and intrinsic hip lateral rotators (piriformis, gemellus superior, obturator internus, gemellus inferior, obturator externus, quadratus femoris).
The gluteus medius arise from the outer surface of the ilium, anterior to the TFL. The muscle converges to form a tendon that attaches to the lateral surface of the greater trochanter. The gluteus medius has fibers that attach forward and posterior of the greater trochanter. The posterior border of the gluteus medius may blend with the piriformis. Together with the glute minimus, the glute medius abducts and medially rotates the hip joint.
Therefore, if the G med is not firing properly, there will be excessive medial rotation at the hip. The glute minimus and medius are fundamental in keeping the trunk in an upright position when the contralateral foot is raised during walking. The hip joint capsule surrounds the acetabulum and neck of the femur. A number of ligament bands help keep the femur and acetabulum in check. The capsule can get tight or become loose.
Excessive lateral rotation of the hip: This indicates either poor stability function or excessive length of the medial rotator stability muscles (anterior gluteus medius and minimus).
Decreased lateral rotation of the hip (common): This includes shortening of capsule and shortening of myofascial structures (TFL/ITB). To differentiate between capsule or TFL, examine the end feel. Take the leg into abduction by 1 inch and if decreased restriction occurs, the TFL/ITB is limiting the movement. If there is no change, the capsule is causing the decreased lateral rotation.
The tensor fascia lata arises from the anterior part of the outer lip of the iliac crest, the lateral aspect of the anterior superior iliac spine and the upper part of the anterior border of the iliac wing. You should keep in mind that in addition to arising from the iliac crest, the iliotibial band (ITB) attaches into the posterior gluteus maximus muscle in the back. The gluteus maximus through the ITB also attaches on the tibia distally.
This is an important point to remember because the TFL/ITB muscle is producing movement of both the proximal and distal aspects of the thigh, which reinforces the maintenance of a relatively constant position of the femoral head in the acetabulum during hip extension. The TFL assists in the flexion, abduction and medial rotation of the hip joint and extension of the knee joint. Use specific muscle length tests to confirm myofascial shortening.
Decreased medial rotation of the hip: This includes shortening of the capsule and myofascial structures (piriformis or superficial fibers of gluteus maximus). The superficial fibers of the gluteus maximus attach proximally to four structures: the thoracolumbar fascia, the iliac crest, the sacrum and the coccyx. They travel distally to the deep part of the muscle and end in a tendinous sheet, which passes lateral to the greater trochanter and is attached to the iliotibial tract of the fascia lata. The iliotibial tract runs down the anterior lateral side of the thigh. It blends with the capsule of the knee joint to attach to Gerdy’s tubercle, the lateral condyle of the tibia and the head of the fibula. Again, poor control at the hip does cause knee dysfunction.
The piriformis arises from the anterior aspect of the second to fourth segment of the sacrum between and lateral to the sacral foramina. Its tendon is attached to the upper border and medial aspect of the greater trochanter. The piriformis laterally rotates the extended hip joint and abducts the flexed hip joint. Differentiate by end feel. Assess specific muscle-length tests to confirm myofascial shortening.
When the glute maximus and piriformis are the dominant muscles producing hip extension, their proximal attachments provide more optimal control of the femur in the acetabulum than do the hamstring muscles. If the attachments of the piriformis and glute maximus muscles are overactive at the femur, they will not provide proper control of the proximal femur during hip extension.
- Van Dillen LR, Sahrmann SA, Norton BJ et al. Reliability of physical examination items used for classification of patients with low back pain. Phys Ther 19998;78:979.
- Brody LT, Thein JM. Nonoperative treatment for patellofemoral pain. J Orthop Sports Phys Ther 1998;28:336-44.
- Witvrouw E, Lysens R, Bellemans J, Cambier D, Vanderstraeten G. Intrinsic risk factors for the development of anterior knee pain in an athletic population. A two-year prospective study. Am J Sports Med 2000;28:480-9.
- Cesarelli M, Bifulco P, Bracale M. Study of the control strategy of the quadriceps muscles in anterior knee pain. IEEE Trans Rehabil Eng 2000;8:330-41.
- Fredericson M, Cookingham CL, Chaudhari AM, Dowdell BC, Oestreicher N, Sahrmann SA. Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med 2000;10:169-75.
Part 2 of this article, will focus on specific corrective exercises for the hip.
by Jeffrey H. Tucker, DC, DACRB
There is a lot of excitement and “buzz” about kettlebells in the weight room and the rehab setting these days, so I want to make sure everyone is familiar with this valuable piece of fitness equipment. A “kettlebell” or girya is a traditional Russian cast-iron weight that looks like a cannonball or bowling ball with a handle. The kettlebell goes way back: The term first appeared in a Russian dictionary in 1704. So popular were kettlebells in Tsarist Russia that any strongman or weight-lifter was referred to as a girevik or “kettlebell man.”
Kettlebells come in several sizes/weights, from 5 lbs all the way up to 105 lbs. You can do standard weight-training exercises with kettlebells, including bench presses, overhead presses, curls, squats and rows. However, the unique value of kettlebells is derived from ballistic (fast exercise) work such as snatches, swings, cleans and jerks.
For those of you who don’t know me, I really do prescribe exercise in my practice. Exercise is a natural drug. We need to deliver the right drug, at the right dose, at the right frequency to get the right result. Learning to make good exercise selections is purposeful and designed to decrease pain, prevent injury, decrease body fat, and increase lean muscle mass, strength, endurance, flexibility and overall athletic performance. Currently, I am using kettlebells in my small-group exercise classes to achieve the above goals.
I became intrigued by the claims of the advantages of kettlebells, so I decided I wanted to learn how to use them. I met a well-known kettlebell expert and took workshops from him. I also met with Pavel Tsatsouline, the person responsible for popularizing kettlebells in the U.S. He taught me some of his stretching routines. Once I learned about kettlebells, I immediately realized the benefits to my rehab practice.
The All-in-One Workout Tool
Kettlebells develop all-round fitness and teach kinetic linking. For example, the kettlebell “swings” makes the deadlift functional. It gets you connected to the ground, draws energy from the ground and transfers energy through the shoulder. Kettlebells enhance awareness of posture, position, breath and grip.
Here is a short list of workout equipment the kettlebell replaces: barbells, dumbbells, belts for weighted pull-ups and dips, thick bars, lever bars, medicine balls, grip devices and cardio equipment. The good news is you don’t need to spend thousands of dollars on expensive equipment. For most of your clients, all you need are two or three kettlebells of varying weights. They do not take up much space, so you can train in a small area. In the office, you can get a great workout in a limited space while improving strength, agility and stamina.
I especially like the cardio benefits clients can get from kettlebells. It’s easy to use interval training principles (go slow, go fast, repeat). I have been teaching a twice-weekly exercise class for the past four years. When I first started the class, we used body-weight exercises, balance balls and bands. Each year since starting the class, I’ve introduced a more challenging tool or device. Last year I added telescopic stick/band training to the class, which provided great variety and core work with bands. In January 2008, I started using kettlebells. The participants in my class are noticing more dramatic changes in body composition from kettlebell training than from anything else we’ve done in the past. Kettlebells develop shoulders, back muscles, arms, forearms, a cut-up midsection and strong legs.
Ballistic kettlebell drills involve a snapping action of the hips, and I have found this movement targets the gluteals better than bridges and are as good as squats. Once my clients can perform 50 consecutive bridges in a variety of poses, they are ready for the kettlebell swings. Whatever rehab techniques you use in your office, I always teach and recommend that you start and concentrate on functional asymmetries (right/left differences). Accumulation of asymmetries over time can lead to significant injury.
Most of us have learned something from the Janda method of movement pattern analysis. Kettlebell exercises are movement-based, not just lifting-based. You’re getting movement training with weight instead of weight training with single-plane movement. We’re not just trying to hypertrophy muscles like a bodybuilder; we’re trying to groove movement patterns throughout the body that are both strong and stable.
For sports, you need explosive hips, stable joints and quick hands. Kettlebell training develops those attributes. Most of the moves are done standing (bilateral or single-leg stance), and many moves are done lying supine. Multi-joint movements comprise most of the drills. Kettlebells complement core stabilization, body-weight exercises and telescopic stick/band exercises. Many are characteristic of work, sports, and activities of daily living. With kettlebells, we don’t need machines, so we have more room in our workout areas!
Building Muscle, Losing Fat
With kettlebells, your clients will build muscular endurance when performing high repetitions, and with proper nutrition they will lose fat. Ballistic exercises are not the only exercises to help accomplish this; the Turkish get-up, press and windmill will develop hard midsections and increase shoulder flexibility and stability. Some of my favorite kettlebell exercises include the clean and press, front squat, renegade row, swings and the double clean (holding a kettlebell in each hand).
I love free weights and try to get most of my clients on a free-weight program, but you really can’t do the above exercises with dumbbells. I think kettlebells are actually more challenging than dumbbells. Kettlebell handles are much thicker and will give you a vice grip in no time. Also, the off-centered weight of a kettlebell will force you to use more stabilizer muscles and work the targeted muscles through a longer range of motion.
Progressive, Whole-Body Training
Kettlebell rehab exercise progressions are the same as with other exercise programs. Progress from slow to fast – start a skill at a speed that allows success. Slow down to gain control, and then once it can be mastered, progress to explosive speed. Progress from simple to complex. Finally, build from stable to unstable: a client does not belong in single-leg stance, on a ball or on any unstable surface if they cannot stabilize on the ground with both feet first. Only progress to a less stable environment when the initial exercise is completely mastered and no longer provides a training effect.
I want my clients to get out of pain as quickly as possible so I can begin to train them for fitness. Being fit is a means toward an end, not an end in itself. I use kettlebells to develop complementary motor skills and abilities, and couple effort with execution. Power, flexibility, agility, speed and endurance are the elements of athleticism. Each is trainable, but they must be trained collectively because they are parts of a larger whole. None is a separate entity or more important than another. Sometimes we need to train isolated muscles, but most of the time we train movement patterns, not individual muscles. Kettlebells help achieve this.