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Squats: A Functional Assessment of Movement

by Jeffrey H. Tucker, DC, DACRB

Editor’s note: The following article expands upon concepts introduced in “Overhead Deep Squats: Understanding Movement and Function,” which appeared in the Sept. 28, 2006 issue of DC.

What do you do when your patient with musculoskeletal pain gets 80 percent better and progress seems to be stalled? What’s missing to help this patient gain further progress and relief? The answer is in the human movement system. What information are we missing that will allow us to evaluate the human movement system? We can look at how the kinetic chain operates as an integrated functional unit. We need to take a closer look at what our muscles do when we move in everyday life. Functional movements are multidimensional and multiplanar in nature. I find that the deep overhead squat is a useful functional biomechanical analysis.

Current concepts in human movement science provide a useful framework to classify muscle function. We have two distinct yet interdependent muscle systems: the stabilization system (stabilizers or local muscles) and the movement system (mobilizers or global muscles). The local and global muscle systems must integrate for efficient, normal function. Neither system in isolation can control the functional stability of body motion segments. In the presence of chronic or recurrent musculoskeletal pain, patients employ strategies or patterns of muscle recruitment that are normally reserved for high-load function. Pain and pathology do not have to be present concurrently with local muscle dysfunction.

In the presence of pathology and/or pain, a variety of different dysfunctions may present (related to the weak link) in an individual’s integrated stability system. Identifying the dysfunction is a priority of treatment. Musculoskeletal pathology can heal and the symptoms may subside; however, the dysfunction does not always automatically return to a normal baseline. The clinical challenge is how to identify the weak link. Commonly accepted methods of identifying the weak link include posture analysis, gait analysis, flexibility assessment, neuromuscular assessment, single-leg balance excursion, multiplanar lunge test, multiplanar step-up test, push-up test, multiplanar vertical jump/hop, multiplanar horizontal jump/hop, shark skill test, multiplanar cone jump/hop test, and speed tests. Other functional tests to assess core stability, strength, and sequencing include the hurdle step and the wall sit with overhead reach. We can divide these assessments for stability and sequencing into static tests, such as drawing-in maneuvers, plank postures, and holding postures in different planes; and dynamic tests, such as Janda’s movement patterns. The important thing is to not take out the static tests, but to add dynamic testing to understand the human movement system!

As mentioned in my previous article, the overhead deep squat is a valuable dynamic assessment and exercise. If you wish to exercise the glutes, a full-depth squat is highly recommended. I start my evaluation by saying to the patient, “Just do a squat for me” or “Squat down for me.” Observe the patient’s natural or normal pattern of movement. Note the feet, knees, hips (lumbar spine), shoulders and the head while the patient performs the squat. After I observe several squats, I ask the patient to squat down while holding the dowel or a barbell over their head. Both elbows should be in the extended position.

To reiterate, the ideal criteria for a well-performed overhead deep squat are as follows:

  1. upper torso parallel with the tibia or toward vertical;
  2. femur below horizontal;
  3. knees aligned over feet;
  4. dowel aligned over feet;
  5. toes pointed forward;
  6. knees not turned in or out.

Observe: The foot turns outward (externally rotates) while the patient descends. Relate: This implicates a short soleus and gastrocnemius; and long posterior tibialis and medial gastrocnemius. Assess: If the there is excessive outward foot rotation and the hip adducts and/or internally rotates during the descent and/or ascent, this indicates restricted adductors. Rehab solution: Mobilize the external hip rotators; have the patient squat with a spacer between the knees. Place a foam roll or a ball between the patient’s knees and have them squeeze the object as they squat. The size of the ball or roll should place the knees approximately shoulder-width apart.

The question often comes up, “Should the knees go over the toes?” The answer is not that it is necessarily wrong, but that it tends to be the way weak people squat. Weak people will exhaust ankle range of motion first and then begin to flex the knee. This results in excessive knee angles or hitting 90 degrees sooner. Think 4:1 knee-to-ankle movement: 4 degrees of knee movement for every 1 degree of ankle movement. If a patient experiences knee pain while doing a squat, they do not necessarily have to be discouraged from performing them. Teach the movement so they are doing the proper technique, loading the correct muscles and joints and not overloading the knees.

The rehab regression for knee pain while squatting is to perform the “airbench” exercise. Have the patient stand against a wall with their feet facing straight ahead; their hips, upper back and head should be against the wall. The patient should walk their feet away from the wall approximately one foot-length; bend their knees and start sliding down the wall until the knees cover the toes as they look down at their feet. Instruct the patient to hold this position and lift the toes upward to keep the weight in their heels; the lower back should be flush up against the wall. Make sure they hold this pose for one to two minutes.

If you have a patient whose chief complaint is low back pain, yet they can do the deep overhead squat and achieve the benchmark of having the upper torso parallel with the tibia or toward the vertical and the femur below horizontal – but the foot flattens, turns outward and the hip abducts – they must stretch the gastrocsoleus complex for improvement within the kinetic chain. This patient can use the overhead deep squat as therapy to correct the tightness in the calf. For rehab, have the patient perform squats with a 1- to 2-inch board under the heels while squatting. Gradually (over many weeks) lower the board until the patient can achieve the benchmark of keeping the feet flat on the ground. Squat repetitions will stretch the tight tissue out.

A method to help stretch tight tissue is postfacilitation technique (PFS) over the gastrocsoleus complex. This is indicated for chronically shortened muscles. The patient performs a maximal contraction with the tight muscle from a midrange position. On relaxation, the doctor quickly stretches the muscle, taking out all the slack. The exact steps for PFS are:

    1. apply strong force against resistance for approximately seven to 10 seconds;
    2. instruct the patient to relax immediately;
    3. elongate the muscle fast and maintain muscle in stretched position (10 to 15 seconds);
    4. wait approximately 20 seconds before the next resistance, allowing the muscle to regain normal irritability threshold;
    5. repeat three to five times.

Note: Never stretch if the patient is unable to relax.

A question that often comes up in rehab is, “What should this patient do first, stabilize or mobilize?” Both have significant positive clinical benefits, and it is often advantageous to do both at the same time. The overhead deep squat allows the body to integrate both stability and mobility into function.

If your patient does not meet the benchmark criteria for the overhead deep squat evaluation, you should ask yourself, “Do they need mobilization or stabilization to improve the movement pattern?” The following functional knee-to-chest test will help you sort out this question. Have your patient lie down in the supine position and ask them to “bring the knees to the chest.” If they can bring the knees to the chest and maintain a flat back on the floor, they do not have a mobility problem. If you stood them upright on their feet while in the knee-chest position, they should be in the ideal posture for the squat.

Observe: Patient supine – raises arms overhead and performs knee-to-chest. Assess and relate: If the patient has increased ROM, they can do a full squat. It’s not a ROM issue. Retest: Challenge the patient for stability versus mobility. Stability is reliably tested under low-load situations. Patient position: Supine; perform bilateral knee-to-chest. Doctor notes the distance and location of the thighs on the torso. Patient’s arms are outstretched in front of the body. The practitioner resists bilateral arm flexion. Reassess: Can the patient bring the knees closer to the chest?

Indicates: Increased ROM or decreased pain indicates patient cannot perform the deep overhead squat due to poor stability. Relate: The patient will benefit from a stabilization program. Observe and test: Perform the overhead deep squat with resistance to abduction at the knees (with a band or belt around the knees). Reassess: This leads to increased ROM, but the patient still has pain. Indicates: This is not a gluteus medius issue.

Functional child’s pose. Ideally, there should be even flexion throughout the lumbar and thoracic regions. Observe and test: The patient performs a yoga-type child’s pose with outstretched arms over the head. Instruct the patient to perform posterior rocking such that the posterior glutes touch the heels. Visually observe the spinal contours. Assess: If a patient has an area of increased kyphosis and is unable to get the spine in a natural curved posture, it is likely a hypomobile or stiff area. The purpose is to assess patients who may be hypomobile. It is important to identify stiff or restricted segments, because these may be a cause of compensatory hypermobility or “give” at an adjacent joint. The site of the “give” or compensation can be the site of the pathology and pain. The stiff area will need to be mobilized with manual techniques and/or the patient can be instructed in the use of a foam roll for self-mobilization.
Improving the quality of the deep overhead squat: Here are four specific progressions and sequences that will improve the deep overhead squat:

Toe-Touch Progression #1:

    • Stand erect with feet side by side, heels and toes touching.
    • Elevate balls of the feet onto a 1- to 2- inch platform.
    • Insert a towel roll or foam roll between the knees.
    • Reach for the ceiling, stretching the arms as high as possible with palms facing forward.
    • Touch fingertips to toes.
    • Repeat for 10 to 12 reps.

Toe-Touch Progression #2:

    • Stand erect with feet side by side, heels and toes touching.
    • Elevate the heels on a 1- to 2-inch platform; toes on ground.
    • Insert a towel roll or foam roll between the knees.
    • Reach for the ceiling, stretching the arms as high as possible with palms facing forward.
    • Touch fingertips to toes.
    • Repeat for 10 to 12 reps.

Reverse Squat Sequence:

    • Stand with the heels on a 1- to 2-inch platform, feet spread shoulder-width apart or wider.
    • Bend forward until the entire palm can be laid flat on the floor or on a 2-, 4- or 6-inch platform. The entire palm must be flat.
    • Lower the body, knees outside of elbows; keep the feet straight.
    • Sit deeply into the squat.
    • Stretch for 20 seconds.

Deep Squat to a “Y” Position Sequence:

    • Start from a deep squat position with the hands on the platform.
    • Raise the right arm over the head. Follow the hand with the eyes.
    • Raise the left arm over the head. Follow the hand with the eyes.
    • With both hands in a “Y” position, extend the spine as much as possible.
    • Stand up.
    • Repeat for 10 to 12 reps.

How to identify impairment in the overhead deep squat. Observation: The patient complains of flexion-related symptoms in the lumbar spine. The lumbar spine flexes during the descent. Relate: The lumbar spine has greater motion into flexion relative to the hips under flexion load. Rehab: The patient needs to learn to forward lean with a straight back and independent hip flexion, but only as far as the neutral lumbopelvic position can be maintained. Observation: Abnormal lumbar extension during the descent/ascent. Relate: This implicates short illiopsoas, lumbar erectors, quadratus lumborum and latissimus dorsi muscles. Rehab: The patient performs a “single-leg forward bend” with the foot of the tight side on a stool. This puts the knee and hip into slight flexion. Put the foot of the tight side flat on a stationary stool approximately 12 inches high. Ask the patient to bend forward and touch the fingertips to the floor. Repeat this 10-12 times.

Functional stability grip assist. Observe: During the overhead deep squat, the doctor observes that the heel of foot rises while descending from the neutral starting position. Retest: Ask the patient to keep their feet flat. If you notice a lack of depth with the heels flat on the ground, this may be from a lack of stability and/or a short soleus muscle. Retest: Have the patient perform the “functional stability grip assist deep squat: – the patient grips each hand to a door knob, a bar or the back of a chair. Perform the deep squat. Depth should improve; then stretch the Achilles, gastrocnemius, quadriceps and gluteals. Holding onto a rail or bar will enhance stability that provides active control of the local or global muscle’s ability to control motion. Relate: Lack of depth indicates restricted Achilles, gastroc, quads and superficial glut max. Observation: There is a lack of depth and the knees drift internally during descent and/or ascent. Assess: Lack of depth indicates dysfunction of the adductors, gluteals and proximal hamstring. Rehab solution: Lie on your back with your feet up on the wall. As you get more functional, your hips will sit closer to the wall and be flat on the floor at the same time. When you get your legs up on the wall, allow them to spread apart to stretch the adductors. Tighten the thighs and pull your toes back toward your knees and hold for one to four minutes. Your feet must be pointed straight behind you for your hips to be doing the work needed to stabilize the spine. Progression: Perform the above with a foam roll under the lumbar spine to enhance the lordosis. Spread eagle with the legs and feet up along the side of a wall. This will simultaneously stretch the adductors and hamstrings. Observation: The low back goes into flexion during the overhead deep squat. Assess: If the low back goes into flexion to get depth, this implicates the iliotibial band that inserts into the glut max or lack of lumbar control. Solution: Stretch the gluteus and iliotibial region.

Overhead deep squat asymmetry. Observe: Lack of depth or asymmetry occurs during the range of descent motion. Assess: Does the pelvis shift? The pelvis will shift away from restriction. Relate: Asymmetry when squatting indicates restriction in the hip rotators. Rehab: Stretch or mobilize hip rotators. Instruct the patient to lie on their back with both knees bent and their feet flat on the floor, pointed straight ahead. The patient should place their arms out to the side at shoulder level, cross their right ankle over the left knee and rotate the ankle/knee junction in that same direction to the floor. Instruct them to press the right knee away from their body with the right hip musculature; repeat the exercise on the opposite side.

Dysfunction: Asymmetry when squatting shifting to a side. To determine what hip may be causing the dysfunction, check hip height in prone position. Rehab: Stretch and mobilize hips. The prone anterior hip stretch is performed. With the patient in the prone position, place one ankle under the opposite patella. Ideally, the hips should be symmetrical and the height of the anterior hips should be equal distance from the table top. Observe and assess: Asymmetry when squatting shifting to a side indicates weak abductors. Rehab solution: Strengthen the abductors. Perform an abductor exercise by having the patient stand sideways next to the wall. The leg that is closest to the wall should be placed in 90 degrees at the hip and knee. Push with the outside leg into the wall. Progress to wall ball exercises.

Tucker test. As noted in my previous article, the purpose of this test is to help recruit a deeper and stronger contraction of the gluteal group. Test: Place a quarter on the outside of the clothes between the buttocks at the level of the anus and have the patient hold it in place with a strong gluteal contraction. Assess: Can the patient contract the gluteals strong enough and continuously while performing the bridge exercise up and down so the quarter does not drop to the floor? Relate: In order to hold the quarter in place, the patient must concentrate on performing a strong gluteal contraction. This forces the continuous contraction of the gluteus and initiates a co-contraction of the abdominals. Progression: Have the patient perform the overhead deep squat with the quarter held in the buttocks.

Resources

  1. Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthopaedica Scandinavia 1989;230(60):20-24.
  2. 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 August 2002;16(30:428-32
  3. Cholewicki and McGill. Mechanical stability in the vivo lumbar spine: implications for injury and chronic low back pain. Clinical Biomechanics 1996;11(1):1-15.
  4. Clark M. “Introduction to Kinetic Chain Dysfunction.” Course notes, 2005. Copyright NASM.
  5. Comerford M. “Lumbo-Pelvic Stability.” Course notes, 2003. Copyright M. Comerford.
  6. Vermeil A. “Sports & Fitness.” Course notes, 2005. Copyright A. Vermeil.
  7. All the coaches, sports medicine specialists and sports scientists who have shared their knowledge with me.
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Overhead Deep Squats: Understanding Movement & Function

by Jeffrey H. Tucker, DC, DACRB

What are the most common imbalances patients present with? The obvious answer is musculoskeletal imbalances. This article discusses the functional assessment of stability and mobility to movement re-education. Assessment of the overhead deep squat for stability and mobility imbalances will improve your awareness of the patient’s movement dysfunction. Training stability and providing manual mobilization and/or self mobilization are current concepts of movement dysfunction.

A restricted segment can cause a compensation that leads to uncontrolled and increased motion. The uncontrolled segment or region is the most likely site of the source of pathology and symptoms of mechanical origin. Common dysfunctions within the movement system occur when the ankle, hip or thoracic spine needs mobilization, or when the knee, lumbar spine or glenohumeral joint needs stabilization.

There is plenty of evidence to support the link between uncontrolled intersegmental translation or uncontrolled range of motion and the development of musculoskeletal pain and degenerative pathology. Motor control dysfunction within the ankle, knee, hips, lumbar region, thoracic region and shoulder contribute to insidious onset, chronicity and recurrence of pain.

We need to restore ankle dorsiflexion, hip flexion/extension and/or hip adduction/abduction, and thoracic flexion and extension, because there is a frequent relationship between the loss of range of motion at one or more motion segments, and the development of compensatory excessive movement at adjacent segments. Learning to refine mobility and stability will reduce asymmetries and limitations as a means of injury prevention. It is important to establish stabilization prior to strengthening. Evaluate flexibility limitations and asymmetries between the left and right sides of the body. An individual conceivably could overcome a deficit in range of motion in one joint by using more ROM at another joint to achieve the specified goal.

The body is a “kinetic chain” of interconnected parts. I recommend overhead deep squatting as the primary assessment to evaluate whether mobility or stability is required.

The overhead deep squat: The ideal criteria for a well-performed overhead deep squat are:

    1. upper torso parallel with the tibia or toward vertical (back is relatively upright);
    2. femur below horizontal;
    3. knees aligned over feet;
    4. both arms overhead with the dowel aligned over feet;
    5. toes pointed forward; and
    6. knees don’t turn in or out.

Hypomobility at any joint in the lower extremity kinetic chain can challenge the motor-control mechanisms of the patient and lead to joint instability. Joint hypomobility can present as dysfunction of intra-articular motion, producing limitations of the accessory movements of roll and glide between the joint surfaces. Limited range of motion also can occur in the myofascial system (extra-articular in nature). These two components are interrelated and often occur together. The abnormal displacement or restrictive barrier to movement changes the normal pattern of movement of the instantaneous axis of rotation (IAR). Movement around an abnormal axis of rotation imposes abnormal compression or impingement on some aspect of the joint tissues and produces altered proprioceptive input to the central nervous system. The motor-control system must adapt to maintain function. These faulty movements increase microtrauma in the tissues around the joint, which, if accumulative, lead to dysfunction and pain.

After an ankle sprain, hypomobility may occur at the subtalar joint, talocrural joint, distal tibiofibular joint, or proximal tibiofibular joint. Limited dorsiflexion after lateral ankle sprain has been attributed to tightness in the gastrocnemius-soleus complex, capsular adhesions developed during immobilization, and subluxations or any combination.

Ankle: The hypomobility of the ankle or tissue tightness can be observed during the overhead deep squat if the heel of the foot rises while descending from a neutral starting position. This is the result of limited soleus muscle motion (e.g., ankle dorsiflexion). Motion can be restored and maintained despite restricted arthrokinematic motion. Restoration of dorsiflexion and normal gait patterns occurs after anterior-to-posterior (manual or self) mobilizations of the talus in the mortise.

If the patient’s toes turn outward while descending from the starting position, it means he or she may have weak, tight lateral gastrocnemius, hamstrings, weak inner thighs, and is at risk for Achilles tendonitis.

The progression of rehab to improve the foot dysfunction is to start the patient with ankle self-mobilization. The patient starts out in the double-leg stance. Take a single step forward onto a stool with the right foot. Ask the patient to flex the ankle and knee over the stool as far as they can go. Compare to the left side. The restricted side can be stretched and mobilized while on the stool by repetitively moving the knee over the foot. Altered movement of the subtalar joints and soft tissue tightness can be restored through self repetitive range of motion maneuvers. Next, have the patient perform a wall stretch. With their hands against a wall, feet flat on the ground and one foot at least 18 to 20 inches behind the other, have them bend the front knee. Hold the static stretch for at least 30 seconds. Do this at least two times per leg. The next exercise involves standing on one foot, turned in 45 degrees with the heel hanging off a step. The patient’s body’weight is on the forefoot. Have them hold onto a wall or rail handle and let their body weight drop down. Instruct the patient to hold this stretch for at least 60 seconds.

Knee: If the knees drift inward while descending from the start position of the overhead deep squat it may mean the patient has weak glutes, tight inner thighs, and is prone to knee and low back problems. The patellofemoral joint may be influenced by the segmental interactions of the lower extremity. Abnormal motions of the tibia and femur in the transverse and frontal planes are believed to have an effect on the patellofemoral joint. The first progression for the knee is to use a foam roll on the adductor and abductor muscles. Firmly press and roll along the tight tissue for several minutes or until you feel a release of tight tissue. Have the patient perform a lunge at a 2 o’clock or 3 o’clock pose with the right leg and a 10 o’clock to 11 o’clock pose with the left leg. The patient should next perform side-lying leg raises. Do not allow the quadratus lumborum muscle to activate early. Raise and lower the top leg, keeping it straight. Isolate the TFL and glute medius. Only perform this on the side that drifts.

Hip: If the patient can keep the feet straight ahead or have only slight external rotation, plus the heels stay flat on the floor while squatting, but they cannot achieve the depth of getting the femurs below the horizontal, they may have tightness where the TFL attach into the glutes. The hip joints may be restricted. The rehab progression is to start with manual mobilization of the hips. Teach the patient how to perform hip range of motion on their own. Part of this solution is simply to do repetitive squats. Over time and many repetitions, the patient will break up the tissue tightness and be able to squat lower and lower.

If you suspect a patient is having a hip extension firing problem during gait, with the hamstrings dominating the movement pattern, rocker sandals can help retrain the gluteus maximus. There are a number of ways to “wake up” the gluts while squatting: for example, weight shift toward the heels, bridges up and down with a therapy band around knees to provide resistance to abduction; side steps with a band around the ankles; or bridges on a gym ball with alternate heel raises. Tight hip flexors will inhibit the gluteus, so these need to be evaluated for length.

For a stronger gluteal contraction, perform the Tucker test, the purpose of which is to help recruit a deeper and stronger contraction of the gluteal group. Test: Place a quarter on the outside of the patient’s clothes between the buttocks at the level of the anus, and have the client hold it in place with a strong gluteal contraction. Assess: Can the patient contract the gluteals strong enough and continuously while performing the bridge exercise up and down so the quarter does not drop to the floor? Relate: In order to hold the quarter in place, the patient must concentrate on performing a strong gluteal contraction. This forces the continuous contraction of the gluteus and initiates a co-contraction of the abdominals. Progression: Have the patient perform the overhead deep squat with the quarter held in the buttocks.

Lumbar: If the patient’s back bends into flexion while performing the overhead deep squat, it may mean they have tight hip flexors, a weak core and poor posture. This is such an important diagnostic tool. Why is this point so important? The lumbar spine may be more flexible relative to the hips in flexion due to lengthened erector spinae and shortened hamstrings. This can lead to a hamstring strain, but more importantly, the muscles that control excessive lumbar flexion (lumbar erector spinae) have more “give” than the muscles that limit hip flexion (hamstrings). Consequently, during trunk flexion the lumbar spine gives more easily than the hips and excessive flexion occurs in the lumbar spine relative to the amount and time of flexion at the hip joints, resulting in compensatory lumbar flexion and a potential lumbar flexion stability dysfunction. The patient complains of flexion-related symptoms in the lumbar spine. You can see how this will translate to their everyday life. See if you can detect the following possible flexion movement dysfunctions in the low back when the patient forward leans while performing the overhead deep squat:

    1. Shortened back extensor mobilizer muscles (longissimus and iliocostalis): The pelvis shifts more than 4 to 5 inches posteriorly during forward bending and the spine demonstrates limited flexion.
    2. Shortened hamstrings: The hips demonstrate less than 70 degrees of hip flexion during forward bending.
    3. Lengthened gluteus maximus: The hips demonstrate more than 90 degrees of hip flexion during forward bending.
    4. Lengthened back extensor stabilizer muscles (superficial multifidus and spinalis): The spine demonstrates excessive flexion during forward bending.

The progression of rehab is to use the foam roll on the anterior and lateral sides of the hips. Work out as much tissue tightness as you can on the foam roll. To stretch the hip flexors, teach your patient to do a lunge with an arm raised overhead. The precise steps are as follows: Leading with the right foot, the patient performs a lunge while raising the left arm overhead and rotating the upper body to the left. Instruct the patient to hold this pose for 30 seconds and to perform at least two stretches on each side. The most important solution for this movement dysfunction is to control movement at the site of the instability. This concept is a process of sensory-motor re-programming to regain proprioceptive awareness of joint position, muscle activation and movement coordination. This training is beyond the scope of this article. However, you can start by teaching clients to co-contract the mutifidus and transverse abdominus muscles.

Thoracic: During the overhead deep squat, the patient presentation of lack of mobility in the thoracic spine may include the inability to get the dowel directly over the feet. I usually find the arms way out in front of the feet. These patients lack thoracic extension. You will feel restricted motion on palpation of the thoracic spine into extension. The patient may have an obvious forward-drawn posture, anterior head and shoulder carriage (slumping) and/or an increased kyphosis. The rehab solution for this dysfunction is mobilization. The foam roll will allow for self mobilization into extension. The repetition of performing self-mobilization of the thoracic spine into extension, while the patient performs the overhead deep squats, is an exercise in and of itself. Another self-mobilization maneuver involves asking the patient to sit on a chair facing the wall, leaning the forehead on crossed arms against the wall. The patient’s knees and toes touch the wall. Taking deep breaths in and out, on the exhalation the patient forces thoracic extension movement, repeating the process about 10 times. I often find the thoracolumbar junction, T6 and above, as the key joints to manipulate to create flexibility.

Shoulder: The gleno-humeral functions. Stability is sacrificed to a large degree to achieve this mobility. During the overhead deep squat you will observe the patient pushing the dowel behind their back instead of over the head. To correct the instability in the shoulder we need to correct the length-tension relationship, improve muscle endurance and coordination of the rotator cuff muscles. These muscles act in a manner to generate a force balance to maintain centering of the joint throughout the range of motion.

Assessment of the overhead deep squat provides analysis of stability and mobility. An exercise program based on the assessment can be implemented to achieve stability and mobility. Stability is only tested reliably under low-load situations. Mobility is based on the ability to pass or fail the ideal criteria of the overhead deep-squat posture. The benefits of having good stability function of both the local and global stabilizer muscles, as well as good joint flexibility, are improved low-threshold motor control and reduced mechanical musculoskeletal pain.


Resources

  1. Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthopaedica Scandinavia 1989;230(60):20-24.
  2. 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 August 2002;16(30:428-32
  3. Cholewicki and McGill. Mechanical stability in the vivo lumbar spine: implications for injury and chronic low back pain. Clinical Biomechanics 1996;11(1):1-15.
  4. Clark M. “Introduction to Kinetic Chain Dysfunction.” Course notes, 2005. Copyright NASM.
  5. Comerford M. “Lumbo-Pelvic Stability.” Course notes, 2003. Copyright M. Comerford.
  6. Vermeil A. “Sports & Fitness.” Course notes, 2005. Copyright A. Vermeil.

Dr. Jeffrey H. Tucker graduated from Los Angeles College of Chiropractic in 1982. He is a diplomate of the American Chiropractic Rehabilitation Board and teaches a 14-hour postgraduate diplomate series on cervical and TMD rehab and lumbar spine biomechanics and rehab. Dr. Tucker practices in West Los Angeles and Encino, Calif.

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Thera-Band Training

by Jeffrey H. Tucker, DC, DACRB

The product is great for rehabilitation, functional movement training, sport-specific conditioning and group classes.

Sometimes patients have to take a step backward to move forward, and sometimes their voyage is not so much about discovery as rediscovery.

Stiffness is not the major chief complaint I hear from clients, but it is often checked off on their intake forms. Stiffness can be associated with pain, inflammation, fatigue, and any other complaint that bring clients in my office. The most common reason for stiffness is the effects of immobilization of the joints and muscles. The spinal joints, hip joints, knee joints, shoulder joints, and ankle joints are the most commonly involved. Muscle and joint pain commonly originates from bad habits of sitting, standing, sleeping, and walking. Stiffness has real consequences if ignored.

A Functional Workout

It doesn’t matter if my client is young, middle-aged, or a senior citizen; I use the functional training approach as part of my treatment, especially for relief of stiffness. I start my rehab recovery teaching patients body-weight maneuvers and floor exercises. Then, I progress patients to use bands. I incorporate resistance bands from Thera-Band for rehabilitation, functional movement training, sport-specific conditioning, and group classes. The next progression I use is to free weights and Kettlebells. Last year, our profession was inundated with laser therapy and decompression tables, while the strength-training world was invaded by Kettlebells. I like to think that I have access to every kind of equipment, but through it all, I am still a proponent of the minimal and inexpensive need for equipment in “authentic” functional training, like the bands.

The bands can provide the basis for an authentic functional workout limited only by the imagination and knowledge of the practitioner. Functional exercise is based on its outcome, not how the exercise looks. Don’t ask me how to activate specific muscles (that question was answered years ago). Instead, ask: “Why did this person lose the movement pattern in the first place?” The bands help me get rid of stiffness and improve functional strength, which is usable strength. Functional strength is hard to measure. That’s why I attempt to identify it by using many unorthodox movements, such as assisted posterior reaches.

This exercise is one of the best methods of developing functional abdominal strength in overhead athletes, or athletes in sports that bring the arms overhead, such as tennis and basketball. Stand on both legs (eventually progress to one-legged stands) facing away from a band firmly held in place. Hold the band in both hands, and extend your arms straight up above your head. Bring the hips forward and the hands back. Lean backward as far as you can without feeling pressure in your lower back. Engage the lower abdominals to return to the starting position.

Using the bands, I teach movements that train the body to do what it was meant to do. These can simply be broken down into four pillars:

    1. Standing and locomotion (gait). One of my favorite exercises that improve the hip rotator stabilizers (gluteus) is to have clients wrap the Thera-Band (usually the green band) around the ankles and walk sideways across the room or down a hall to activate the gluteus. This one maneuver alone has helped more patients improve altered gait than any other.
    2. Movements that lower or raise the body’s center of mass, such as squatting, lunging, and climbing. I have clients stand on a band and hold the ends of the band in their hands while doing squats, and perform an overhead press on the way up.
    3. Pushing and pulling, such as standing rows and pressing maneuvers.
    4. Rotation. These are changes in direction. For example, torso rotation and proprioceptive neuromuscular facilitation (PNF) band chops are a functional way to train the abdominals. Everyone talks about the core, which includes the major muscles attached to the trunk, above the ischial tuberosity, and below the superior aspect of the sternum. Approximately 87% of the core muscles are oriented either diagonally or horizontally and have rotation as one of their actions. Our bodies were made for rotation, yet very little rotational training is addressed in today’s standard training protocols. The bands make rotational training easy.

The most annoying things about the bands is getting the latex powder on your clothes and occasionally the bands break while you are in the middle of a set. An advantage to band assessing and training is the observation of symmetrical or asymmetrical movements. The link between uncontrolled spinal and joint intersegmental translation or uncontrolled range of motion, and the development of musculoskeletal pain and degenerative pathology, is well-known. Often, patients are not even aware of the bad movement pattern that they are doing over and over that is causing the stiffness. Sometimes, it is only clearly seen when the muscles fatigue and pain sets in.

The inefficient control of muscles and bones, poor movement habits, and poor posture give rise to very subtle and unique imbalances in the body-stability system. This puts mechanical stress and strain on the joints; and the muscular, neurological, and connective tissue systems of the body. This leads to cumulative microinflammation, which leads to pain and pathology. This predisposes joints to early aging and stiffness. A significant amount of injuries and stiffness occurs in clients with right- to left-sided strength and flexibility imbalances. My recommendations with the Thera-Band are to put the core first and to look for the following asymmetries:

Core Stability

Everyone has heard about core stability and realizes how critical it is for the inner core of the body, namely, those joints closer to the spine, to be supported by the postural muscles designed to do so. Core stabilization was originally referred to as “low load motor control training of the trunk while progressively adding a limb load and proprioceptive challenge while maintaining a neutral spine.”

Assisted posterior reaches using the Thera-Band develop functional abdominal strength in overhead athletes.

It’s more about learning to move than about strength. Stability is about keeping the spine still while you move the arms or legs. For example, can you independently move the hip and not the lumbar spine while on your hands and knees, and raise a single leg out behind you (with the band wrapped around the bottom of the foot and the ends held in your hand)?

Flexibility

The purpose of flexibility varies for the different muscles around the joints. For the major power muscles, it is important that flexibility allows freedom of movement for the pelvis, hips, trunk, scapula, and humerus. Freedom of movement needs to be symmetrical.

General Muscle Strength

Once the foundational issues of consistency, core stability, flexibility, and balance control are being implemented, I then look at the bigger picture of the “outer core.” The rest of your body will need strength to carry you into your 80s and 90s. Performance as you age will be improved with strength. You can create strength using the tubing made by Thera-Band. If you don’t tend to strengthen, the natural progression is for the body to lose it.

Stretching

I usually recommend that stretching is the last thing a person does once he or she is pain-free. I see many patients that injure themselves from overstretching in yoga class and with Pilates. Stretch to increase flexibility, but don’t overdo it. I encourage patients to feel the muscle barrier and don’t go past that point. Otherwise, you start pulling on the ligaments, and these were not meant to be pulled apart.

Neuromusculoskeletal function involves a complex integration of proprioceptors facilitating; muscles reacting and joints moving simultaneously in sagital, frontal, and transverse planes of motion in a ground-force kinetic chain-reaction response.

This is facilitated by the moving body in relation to the ground and gravity. Use the bands to put patients through movements that let you see how an individual can control outside forces that are irregular in intensity, speed, load, symmetry, and direction, like sports and real life.

The factors that may play a role in avoiding overtraining are variety and the integrated manner of training. Since there is no isolation of muscle, no one particular muscle gets an inordinate amount of volume. So less recovery time is needed. Start clients on the four pillars and stabilization training as soon as they can.

Is having the bands useful? You bet. Even though I had to get used to how to give directions to patients, and sometimes it takes a while for patients to get the movement pattern correct, bands are still more versatile than machines.

Jeffrey Tucker, DC, DACRB, has been in continuous private practice for 24 years in Los Angeles. His practice includes yoga, Pilates, and Gymstick training. He teaches courses in rehabilitation.

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Functional Exercises: Hamstring Stretching for Low Back Pain

by Jeffrey H. Tucker, DC, DACRB

The sun salutation in yoga is where you begin by standing on your mat with your feet together (toes and ankles touching) and your arms by your sides. Lengthen your spine upwards from the tip of the tailbone to the crown of your head. Inhale deeply. Exhale and bring the hands together in the prayer position. Inhale as you stretch your arms up beside your head, lengthening and arching your spine. Exhale and bend forward, hinging from the hips, with your arms stretched out in front. Place your hands flat on the mat beside each foot, bending your knees if you have to. Try to bring your forehead to your knees. STOP right here. The sun salutation continues on with other maneuvers, but I want to talk about the toe-touching portion. It’s this maneuver, whether during a yoga class, bending over in the shower or picking up an object on the floor that can cause so much trouble for our lower backs.

A forward bend does not require straight legs. The key is to aim for a perfect hinge from your hips no matter how straight you can press your legs. If you can touch the floor but the spine is bowing to achieve this, you leave the hip hinge open and the stress is carried in the back and knees. Short hamstrings are common and the body compensates for this restriction by increasing motion in the lumbar spine. In normal functional movement, the brain and central nervous system (CNS) have a variety of strategies available to perform any functional task or movement. During functional bending-forward movements, a relatively stiffer hamstring muscle tends to resist ideal movement, but function is maintained by excessively increasing lumbar spine flexion range. This is what is called “compensation.”

It’s not unusual for a person with tight hamstrings to compensate with resultant lengthening or overstrain of the lower lumbar spinal extensor muscles (lumbar spinalis and superficial multifidus). Once the lumbar spine has developed abnormal compensatory motion, the stabilizing muscles and supporting structures (e.g., ligaments) around the lumbar joints become too flexible, more lax or provide insufficient stiffness or resistance to motion. These joints are now poorly controlled by the muscles. This can cause pain in the low back region with daily activities and unguarded movements, as well as sitting, standing and lying postures.

The lumbar spine may be more flexible relative to the hips in flexion due to lengthened erector spinae and shortened hamstrings. The muscles that control excessive lumbar flexion (lumbar erector spinae) have more give than the muscles that limit hip flexion (hamstrings). In summary, if you repeatedly bend forward with tight hamstrings, the lumbar spine may give more easily than the hips. Excessive flexion will occur in the lumbar spine relative to the amount and timing of flexion at the hip joints. This results in compensatory lumbar flexion and potential lumbar spine instability.

A lumbar flexion instability does not require that muscle or connective-tissue structures are tight or short (e.g., hamstrings in the lumbar flexion dysfunction), although you may have a sense of the hamstrings being tight. It does matter that the hamstrings are less flexible and have less give than the muscles at the site of greater relative flexibility or those designed to control dysfunction (erector spinae). Likewise, it does not require that muscle or connective- tissue structures be weak at the site of greatest relative flexibility or overstrain (e.g., abdominals in the lumbar extension dysfunction). It only requires that they have more give or are functionally longer than the muscles at the adjacent segment (hip flexors), which may be very strong or short.

The hamstrings seem to have a clear function. They produce range-of-joint movement (flex the knee joint and extend the hip). The hamstrings are an eccentric resistor of knee extension in sprinting. Correcting the length of the hamstring may be important while simultaneously strengthening the lumbar region. The following procedures are not to be done if your low back is in the inflammatory stage.

Self Test: Bend over and try to place fingers or palms to the floor. Measure the distance of the middle fingers from the floor. Benchmark is the ability to have palms flat on the floor.

Dysfunction: Not able to touch fingers to the floor; you feel discomfort or pain in the low back; or your thoracic spine or lumbar spine are bowing, with the hip hinge wide open.

Solution: Think of a belt lifting the hips up and elongating the spine. Push your heels down and push your bottom up. Stretch the hamstrings with the back locked. Practice separating the tailbone from the chin while hinging at the hips.

Self Test: Bend over and try to place fingers or palms on the floor.

Dysfunction: The thoracic spine and the hamstrings feel tight.

Solution: Practice bending over at the hip hinge with outstretched arms over your head while simultaneously maximally tightening and squeezing the buttocks (gluteals) and fists (keep the arms outstretched). Continue bending over at the hip hinge, fists and buttocks as tight as possible, for eight seconds. Release the tension but don’t come back up yet. Repeat the squeezing of the glutes and fists for eight seconds. Practice this maneuver with your buttocks against a wall and then continue to get lower and farther away from the wall. Try to isolate the hamstring muscle and belly, not the attachments behind the knees. Repeat this maneuver five to seven times.

Self Test: You look at your posture and see that the thoracic spine is rounded. Your normal posture has rounded shoulders.

Dysfunction: You have restricted thoracic spine motion or you have kyphosis (loss of the normal spinal curvature).

Solution #1: Release the knotted tight tissue, joints or adhesions along the spine by lying on a foam roller and putting pressure on the knots for 20-30 seconds while breathing. Do this daily for five to 10 minutes.

After this, lie down on your stomach with your hands and arms along the sides of your body (palms up). Lift up the head, shoulders and torso as high as you can toward the ceiling. Build up to the same number of repetitions as your age.

Solution #2: Practice squats while facing a wall. Stand close to the wall so your nose almost touches it; try to move your feet closer and closer to the wall. Keep the feet straight forward, allowing the movement to occur in the hips and lengthening the spine.

To stretch the back and the hamstring: Use the bow maneuver. While the back is at 90 degrees, pry one hand to the opposite heel; keep prying side to side. An important principle of stretch is to spread the load. You can go further with less stress. Repeat the original toe-touch test.

Still can’t put your palms on the floor?

Solution #1: Thoracolumbar spine post-isometric relaxation (PIR): This definitely will allow the client to bend further in the toe touch. This maneuver requires two people.

  • The client bends over with proper mechanics at the hips (push the heels down and the bottom up). Remind the person to “spread the load.”
  • Tell them to keep their weight even from the toes to the heels.
  • Place both flat palms on the client’s lower thoracic spine.
  • Ask the client to lift the thoracolumbar region, initiating from the hips and elongating the spine (think tailbone-to-chin). Resist the client’s upward movement for approximately eight seconds. You are not pushing down; you are resisting their upward movement. You do not have to be heavy-handed to give the client’s back a nice release and stretch.
  • Have the client release the upward push and simply follow them downward (lower).
  • The client stays in the new lower position and repeats the process three to five times.

Solution #2: Long-sitting partner stretch with post-isometric relaxation (PIR) technique: This maneuver requires three people. One is the person being stretched and two assistants. Two people face each other on the floor. The third person is sitting back-to-back with the person being stretched. The client’s legs are straight in the long-sitting pose. The client must hinge in the middle. The first assistant’s legs are straddled to the outside of the client’s legs. The second assistant is gently leaning against the client’s back to prevent them from leaning backward.

The first assistant takes hold of the client’s wrists in a monkey grip. The client leans forward as if they were folding, hinging from the hips, lengthening the lower spine out of the hips, making the stomach as long as possible and bringing the back as close to parallel to the floor as possible. The first assistant leans backward taking out the slack in the arms. The client is using muscles to actively extend the spine and lengthen the back of the legs, moving them forward. Remind the client to keep the arms straight and “stretch the back, breathing into the tailbone.” Keep the head in alignment with the spine. The weight of both assistants supports the stretch. Repeat this maneuver three to five times, using the principles of PIR. To come out of the stretch, the client can bend their knees slightly as they come upright.

Resources

  1. Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthopaedica Scandinavia, 1989;230(60):20-4.
  2. Cholewicki J, McGill S. Mechanical stability in the vivo lumbar spine: implications for injury and chronic low back pain. Clinical Biomechanics, 1996;11(1):1-15.
  3. Comerford M. Lumbo-pelvic Stability. Course notes. 2003 and 2006 Copyright Comerford.
  4. Hodges P. Transversus abdominus and lumbar multifidus muscle. Course notes. 2002 Copyright Hodges.
  5. Tsatsouline, Pavel. Stretch Course. 2007 Copyright Tsatsouline.
  6. Vermeil A. Sports & Fitness. Course notes. 2005 Copyright Vermeil.
  7. All the coaches and sports-medicine scientists who have shared their knowledge with me.
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Making Fitness a Rehab Habit

by Alan Ruskin

Los Angeles DC helps patients assume control of their own rehabilitation.

More than 20 years ago, Jeff Tucker, DC, DACRB, left the practice he had shared with two other chiropractors for one reason: “I really wanted to do rehab,” he says. His colleagues didn’t share his singular enthusiasm, so he moved on and eventually established a multidisciplinary practice in Los Angeles with two medical doctors—one a specialist in pain management and the other a general practitioner with a background in acupuncture. “I found both doctors through the rehab community,” Tucker says with satisfaction.

While pain relief is the initial focus of Tucker’s practice, he also guides his patients toward optimum health by helping them assume control of their own rehabilitation. This includes teaching his patients how to use various exercises and therapeutic tools to achieve this goal.

Kicking Off with a Comprehensive Analysis

Tucker uses a variety of approaches, beginning with his own powers of observation. “My eyes are my best tool,” he says. “My examination begins as soon as I see the patient. I note their posture, watch their movement patterns.” From the patient’s health history and assessment forms, Tucker builds the foundation of his structural analysis. “The visual and postural analysis helps to evaluate the quality of their movements, more so than traditional tests that just evaluate strength.”

Next, Tucker performs an array of body-composition analyses, such as body mass index (BMI), intracellular and extracellular water, and basal metabolic rate. He uses the Biodynamics bio-impedance analyzer to help devise the kind of strength or weight-loss program that is right for the patient, and considers this phase crucial because “losing body fat and increasing muscle mass is a big part of the rehab process.”

Putting Out the Pain

Before implementing any BMI-changing program, however, Tucker must first ensure that the patient is out of pain. Calling upon his years of experience, he determines which modality will help the patient meet this goal. This may include one or more modalities, such as the recently developed technology known as Sound Assisted Soft-Tissue Mobilization (SASTM).

SASTM uses specialized instruments made from ceramic polymer, which resonate to create sound waves that are magnified as they pass through the instrument, detecting irregularities as the tool is pressed against tissue. (A lotion is used so the instrument can glide smoothly over the body.) Once the instrument has located adhesions and fascial restrictions, the doctor can treat the affected area with the pressure he applies to the instrument, which induces micro trauma to the affected area, producing a controlled inflammatory response. This in turn causes the reabsorption of fibrosis and scar tissue to facilitate healing.

SASTM is based on the ancient Chinese healing tradition of Gua Sha, which involves palpation and cutaneous stimulation to remove blood stagnation and promote normal circulation and metabolic processes. SASTM was introduced in the early 2000s by David Graston, a pioneer in the instrument-assisted soft tissue mobilization industry. The procedure is designed to reduce pain and restore function to many soft tissue injuries. “It breaks down myofascial restriction and scar tissue,” Tucker says, “allowing me to follow up with stretching and strengthening exercises. Graston developed it to aid in his recovery from carpal tunnel and a serious water-skiing injury to his knee.” Tucker believes this treatment is highly effective, and it is one of his first choices for injury and pain.

Another therapy that Tucker uses on roughly half of his patients is a Class IV High Power Warm Laser. The laser, Tucker says, stimulates cell growth and metabolism; accelerates wound healing; and results in a dramatic reduction of inflammation, fibrous scar tissue formation, and pain. “The high-power laser is more effective than its predecessor—the low level, or cold, laser—because it delivers considerably more healing photonic energy at a much greater depth of penetration, thus accelerating the healing process,” Tucker says. “Another interesting note is, because of the warmth, the patient can actually feel the laser’s healing properties at work, which contributes to greater effectiveness. The idea is to get the person out of pain as quickly as possible, and the high-power laser’s ability to alleviate pain makes it a valuable tool in my rehab armament.”

Tucker also uses standard modalities such as the Chattanooga ultrasound and Dynatron interferential electrotherapy, both of which are widely used adjuncts to mobilization and manipulation treatments. Additionally, Tucker’s use of specialty tables plays a significant role in his patients’ treatment. He believes that his Leander flexion-distraction table is invaluable in providing gentle traction and repetitive motion, and that his Repex tables for extension are particularly effective for disk patients.

Building Bodies Through Fitness and Rehab

Rounding out Tucker’s therapeutic collection are foam rolls, the Swiss Ball (aka the Gym Ball or the Big Ball), free weights, and most especially, the relatively new Gymstick (www.GymstickLA.com).

A simple, dense foam roll, 3 feet long and 6 inches wide, that clients lie on with their own body weight, is an important component of achieving and maintaining healthy, full range of motion around the joints. “By putting pressure on tender areas along the muscle tissue, the golgi tendon organs help trigger the relaxation of the muscle spindles, which helps to dissipate adhesions, increase blood flow and enhance overall movement,” Tucker says. “When used in self-massage the roll can have a positive effect on cellular viscosity, changing the fluid properties of tissues to help prevent the drying out and stiffness that are typical symptoms of aging. “It’s a wonderful modality,” continues Tucker, who teaches his patients how to use the rolls for maximum benefit.

Free weight and Kettlebell programs are also high on the list, along with the Swiss Ball. Tucker prefers free weights over stationary machines because, “Where in real life do you sit down and push weights other than in the gym?” He recommends their regular use for building strength and stamina. He also makes use of the Swiss (Big) Ball, which is excellent for developing balance and core strength.

But the real star of Tucker’s rehab program is the up-and-coming Gymstick, which he believes “is going to be one of the best home exercise devices for rehabilitation or small group exercise classes.” Developed in Finland, the Gymstick is regarded as a total body fitness tool that produces speedy results in cardiovascular, muscular, and endurance training.

The Gymstick uses an exercise stick and resistance bands. The bands are attached to each end of the stick, with loops on the other end of the bands that go under the feet. There are hundreds of exercises working out every aspect of strength, flexibility and balance, including replicating free weight exercises such as squats, curls, and presses. The device comes in five strength levels and colors, to suit any user, regardless of age or fitness level. Resistance can also be raised or lowered within each level. The Gymstick provides resistance training for both Type I (slow-twitch) and Type II (fast-twitch) muscle fibers, and it is very efficient in reducing body fat (at a rate of up to 700 calories per hour!).

An Ideal Approach

Tucker’s ultimate rehab and fitness regimen encompasses the use of SASTM and other modalities such as warm laser and ultrasound for pain relief, low-load body exercises such as bridges and quadruped maneuvers, and then whole-body stabilization exercises, including squats and lunges. Once this is accomplished, Tucker moves on to free weights and the Gymstick which, along with diet and nutritional counseling, puts the patient on the road to optimal, self-sustaining strength, flexibility, and cardiovascular health and endurance.

As Tucker puts it, “Many of my patients want to know, ‘What am I going to be like 20 years from now?’ ” It’s a good question, and Tucker’s goal is to provide a good answer.

Alan Ruskin is staff writer for Chiropractic Products. For more information, please contact linkEmail(‘aruskin’);aruskin@ascendmedia.com.

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Principles of a Rehab Specialist: From Fat Loss to Performance Ready, Part 3

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)
Example: 45-year-old
(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;
  • insomnia;
  • headaches;
  • decreased immunity;
  • decrease in training capacity/intensity;
  • moodiness and irritability;
  • depression;
  • 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:

  1. Train them how to perform self-myofascial release using the foam roll.
  2. Train them how to perform specific stretching maneuvers.
  3. 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.
  4. 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.

References

  1. 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.
  2. 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.
  3. 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.
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Principles of a Rehab Specialist: From Fat Loss to Performance Ready, Part 2

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.

Reference

  1. Tremblay A, Simoneau JA, Bouchard C. Impact of exercise intensity on body fatness and skeletal muscle metabolism. Metabolism, July1994;43(7):814-8.
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Principles of a Rehab Specialist: From Fat Loss to Performance Ready, Part 1

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) 20.8%
Fat-Free Mass (FFM) 79.2%
Body Mass Index (BMI) 25.5
Intracellular Water (ICW) 56.4%
Extracellular Water (ECW) 43.6%

Body Weight

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) Waist Circumference
Men = 102 cm (40 inches)
Women = 88 cm (35 inches)
Waist Circumference
Men > 102 cm (40 inches)
Women > 88 cm (35 inches)
Underweight = <18.5 Increased Risk? Increased Risk?
Normal weight = 18.5-24.9 Low Risk Low Risk
Overweight = 25-29.9 Increased Risk High Risk
Obese = 30-34.9 High Risk 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).

Muscle Mass

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.

References

  1. 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.
  2. Garrow JS, Webster J. Quetelet’s index (W/H2) as a measure of fatness. Int J Obesity, 1985;9:147-53.
  3. 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.
  4. Prentice AM, Jebb SA. Beyond body mass index. Obesity Rev, August 2001;2(3):141-7.
  5. 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.
  6. World Health Organization. Physical Status: The Use and Interpretation of Anthropometry. WHO Technical Report Series. Geneva: World Health Organization, 1995.
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Kyphosis Treatment by Deep Muscle Stimulator and Exercise

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.

Corrective Exercise

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

  1. Give patient advise on proper posture while sitting and standing. Teach clients to perform a sternal lift and “tall spine”.
  2. Train proper respiration.
  3. Deep Muscle Stimulator over the entire back.
  4. Mobilization/manipulation of hypomomobile/fixed joints in the thoracic spine and ribs.
  5. Foam roll at home (daily).
  6. Stretch/lengthen the latissimus dorsi, upper trapezius, subscapularis, pectoralis (daily).
  7. Perform isolated exercises to the lower trapezius and serratus anterior.
  8. Perform integrated exercises: lunge to overhead press with free weights in the hands.
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Muscle Activation Concepts

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.

References

  1. Comerford M. Lumbo-Pelvic Stability. Course notes.
  2. National Academy of Sports Medicine. Corrective Exercise Specialist. Course notes.
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