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:
- upper torso parallel with the tibia or toward vertical (back is relatively upright);
- femur below horizontal;
- knees aligned over feet;
- both arms overhead with the dowel aligned over feet;
- toes pointed forward; and
- 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:
- 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.
- Shortened hamstrings: The hips demonstrate less than 70 degrees of hip flexion during forward bending.
- Lengthened gluteus maximus: The hips demonstrate more than 90 degrees of hip flexion during forward bending.
- 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.
- Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthopaedica Scandinavia 1989;230(60):20-24.
- Caterisano A, Moss RF, Pellinger TK, Woodruff K, Lewis VC, Booth W, Khadra T. The effect of back squat depth on the EMG activity of 4 superficial hip and thigh muscles. J Strength Cond Res August 2002;16(30:428-32
- 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.
- Clark M. “Introduction to Kinetic Chain Dysfunction.” Course notes, 2005. Copyright NASM.
- Comerford M. “Lumbo-Pelvic Stability.” Course notes, 2003. Copyright M. Comerford.
- 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.
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:
- 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.
- 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.
- Pushing and pulling, such as standing rows and pressing maneuvers.
- 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:
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)?
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.
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.
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’);email@example.com.
Heart Rate and Exercise Intensity
by Jeffrey H. Tucker, DC, DACRB
In part 3 of this article, let’s discuss heart rate and exercise intensity. It’s imperative to have baseline information on your patients to determine how to most efficiently assist them in achieving their fitness goals.
It’s very important you know their resting heart rate and maximum heart rate (MHR). During a workout, their heart rate is a very reliable indicator of their personal performance level or training load – not as absolute numerical values, but in relation to their own heart rate values.
Calculating Maximum Heart Rate
Miller Formula: 217 – (0.85 x age)
(0.85 x 45 = 38.25)
217 – 38 = 189 MHR
Recent research identified the following formula as more accurately reflecting the relationship between MHR and age:1 MHR = 206.9 – (0.67 x age).
It’s relatively easy to measure your heart rate at rest by feeling your radial pulse or by using a heart rate monitor while still in bed after a good night’s sleep. Once trained, our patients easily can determine their resting heart rate. However, a reliable measurement of maximum heart rate often requires a visit to a testing facility or a sports-minded chiropractor.
If you are experienced in fitness training and are enjoying good health, you also can do your own test with a maximum performance session in your favorite sport. After 15-20 minutes of warming up, do two or three maximum intensity work cycles of around 3-4 minutes and recuperate between them for 30 seconds. If it’s difficult to reach high intensity in your favorite sport (e.g., cycling, cross-country skiing, rowing), you can perform the maximum intensity sessions on a steep hill. The highest measured reading you can achieve is a good estimate of your maximum heart rate.
Target Heart Rate Zone
Your target heart rate zone is the number of times per minute your heart needs to beat to achieve a desired workout effect. It’s represented as a percentage of the maximum number of times your heart can beat per minute (MHR). Most research recommends working out at a target heart rate zone between 60 percent and 75 percent of your MHR.
You need to be able to progress a patient to higher levels of fitness and ensure they are sufficiently healthy to exercise at the desired intensity. Tests performed in different sports mostly indicate your maximum heart rate in that given sport, not necessarily an accurate and absolute value. For example, many people’s heart rate is 10-20 beats per minute (BPM) lower when cycling than when running and even lower when swimming; while cross-country skiing often is slightly higher than when running. When you know your resting and maximum heart rates, it’s easier to control your training intensity.
Xavier Jouven, MD, did a study with men and found those whose heart rates increased the least during exercise (less than 89 BPM) were six times more likely to die of sudden death from myocardial infarction than men whose heart rates skyrocketed. More importantly, men whose heart rates didn’t drop by at least 25 BPM within one minute after exercise also had a greater risk of cardiac death. The risk of sudden death from myocardial infarction was increased in subjects with a resting heart rate more than 75 BPM; an increase in heart rate during exercise of less than 89 BPM; and a decrease in heart rate less than 25 BPM, one minute after exercise.
The conclusion is that the heart-rate profile during exercise and recovery is a predictor of sudden death.2
How the Training Effect Works
How can we use this information to design a training session? Using the National Academy of Sports Medicine (NASM) template, we can create an “integrated performance profile.” Establish the patient’s current fitness level (unfit, fit, athlete, etc.) from your general and medical history, exercise history, body fat analysis and circumference measurements. Combine this information with heart rate and progress your patients to develop better results. Understand that different types of workout intensities are needed and have their own important role to play in developing your fitness level and achieving better results. We cannot let our patients do the same 30-minute walk day after day and expect progress. We have a responsibility to progress and challenge them.
Exercising below 60 percent of your maximum heart rate is relatively easy on your system. When it comes to fitness training, intensity this low is significant mainly in restorative training and improving your basic fitness when you are just beginning to exercise or after a long break. Everyday exercise – walking, climbing stairs, cycling, etc. – usually is performed within this intensity zone. These sessions, when lasting more than one hour, can develop endurance, may enhance recovery, but will not likely improve maximum performance.
Exercising at 60-70 percent of your maximum heart rate is considered the fat-burning zone. Peak fat oxidation has been shown to occur during exercise at 63 percent VO2 max. Peak fat oxidation progressively lessens above this point and was minimal at 82 percent VO2 max, which is near the lactate threshold of 87 percent.
The 60 percent to 70 percent zone improves your basic aerobic fitness level effectively. Exercising at this intensity feels easy, but workouts with a long duration can have a very high training effect. The majority of cardiovascular conditioning training should be performed within this zone. Improving this basic fitness builds a foundation for other exercise and prepares your system for more energetic activity. Long-duration workouts at this zone consume a lot of energy, especially from your body’s stored fat.3
Exercising at 70 percent to 80 percent of your maximum heart rate begins to be quite energetic and feels like hard work. This zone will improve your ability to move quickly and economically. In this zone, lactic acid begins to form in your system, but your body still is able to completely flush it out. You should train at this intensity at most a couple of times per week, as it puts your body under a lot of stress.
Exercising at 80 percent to 90 percent of your MHR will prepare your system for competitive and high-speed events. Workouts in this zone can be performed either at constant speed or as interval training (combinations of shorter training phases with intermittent breaks; see my previous article on interval training). High-intensity training develops your fitness level quickly and effectively, but overtraining might result if it’s done too often or at too high an intensity.
Common warning signs of overtraining include:
- feeling washed-out, tired, lack of energy;
- mild, prolonged leg soreness, general aches and pains;
- pain in multiple muscles and joints;
- drop in performance;
- decreased immunity;
- decrease in training capacity/intensity;
- moodiness and irritability;
- loss of enthusiasm for the sport;
- decreased appetite; or
- increased incidence of injuries.
If a patient experiences these symptoms, the best prescription might be to recommend they take a break from their training program.
When your heart rate during a workout reaches 90 percent to 100 percent of the maximum, the training will feel extremely hard. Lactic acid will build up in your system much faster than can be removed, and you will be forced to stop after a few minutes. Athletes include these maximum-intensity workouts in their training program in a very controlled manner; fitness enthusiasts do not require them at all.
It’s important to note that a workout with a lower perceived exertion is not worse or less significant than a workout with a high-intensity value. Both are needed in balanced training. In fact, lower-intensity workouts are most important for endurance. Low-intensity training builds a foundation on which you can safely build workouts with a higher intensity.
Understand your body’s signals and how to react to them. Learn to recognize what the different heart rate zones feel like during your workouts and what kind of feelings different training effects cause in your body (sweating, ability to talk, muscle soreness). I encourage my patients to learn to notice when their heart rate differs from normal and how unusual situations (i.e., lack of sleep, stress, an oncoming flu) also affect their heart rates.
Using the NASM model as taught in the Corrective Exercise Specialist (CES) and Performance Enhancement Specialist (PES) courses, I implement an “Integrated Program Design” for my patients:
- Train them how to perform self-myofascial release using the foam roll.
- Train them how to perform specific stretching maneuvers.
- Discuss how to control heart rate, performance level and exertion during exercise. Take your heart rate and know your desired heart rate limits. Decide on a training effect target for your workout that day.
- Introduce training in the most sensible and result oriented way. This includes training programs that include core work, balance training, plyometrics, speed (straight-ahead speed), agility (lateral speed), quickness (reaction time) and resistance training.
Plan training wisely and with long-term vision. I don’t want my patients to go to a personal trainer for this type of information and intervention. I want to be able to design a training program with a personal trainer that matches my patient’s needs and goals. Most of my patients want to lose weight, “get in shape,” prevent osteoporosis or need to perform corrective exercises for musculoskeletal reasons. The problems I see most often in those who are working out is they have been doing the same workout without variety way too long. It’s worth saying again – help patients plan long-term.
As I work more and more closely with personal trainers, I see my role as helping each of my patients with injury prevention; maintaining a regular training schedule; an upward trend in strength, endurance, balance, etc.; a correct ratio between training and rest; variety; and keeping both of us motivated.
In part 4 of this series, I will discuss functional movement tests and corrective exercise training.
- Gellish RL, Goslin BR, Olson RE, et al. Longitudinal modeling of the relationship between age and maximal heart rate. Med Sci Sports Exerc, May 2007;39(5):822-9.
- Jouven X, Empana JP, Schwartz PJ, et al. Heart-rate profile during exercise as a predictor of sudden death. N Engl J Med, 2005 May 12;352(19):1951-8.
- Achten J, Jeukendrup A. Relation between plasma lactate concentration and fat oxidation rates over a wide range of exercise intensities. Int J Sports Med, January 2004;25(1):32-7.
Metabolism and the Benefits of Interval Training
by Jeffrey H. Tucker, DC, DACRB
In the previous article, I introduced you to Sheldon, who has been diagnosed with a pre-insertional tear of the Achilles tendon. Sheldon is now out of acute pain and has to start his exercise training in preparation for playing basketball in the upcoming Maccabi Games.
Eliminate Conventional Aerobics
What led Sheldon to an ankle injury was his personal choice in preparation for the games. He started spending about an hour on the treadmill three days per week and then played basketball another three times per week. He did not properly stretch or warm up prior to his activities. The probable mechanism of injury to his ankle was repetitive stress and faulty movement patterns. Sheldon’s diagnosis was a pre-insertional tear in the Achilles tendon. Initially, walking and running were painful. However, he could ride a stationary bike.
One of the first changes I make to a cardio program is to have my clients eliminate conventional aerobics. For example, if a client is spending 60 minutes on a treadmill or elliptical machine, I recommend they spend that hour of time performing: 10 minutes on the foam roll; 10 minutes isolated stretching; 20-25 minutes doing a combination of body-weight exercises, resistance exercises and/or lifting free weights; and 15-20 minutes of cardio training, especially using interval training techniques.
The foam roll is used as an inhibitory technique to release tension and/or decrease activity of overactive neuro-myofascial tissues in the body. After using the foam roll, clients are instructed to participate in static stretching of muscles to increase the extensibility, length and range of motion of neuromyofascial tissues in the body.
The next phase of the workout is muscle-activation techniques, often performing body-weight exercises. These exercises are used to increase intramuscular coordination and strength. Squats, lunges, push-ups and step-ups are examples of dynamic movements. When I train my clients to lift free weights, I want them to lift heavy weights. When I teach free-weight training, I recommend creating circuits of five exercises, performing six repetitions of each exercise and then performing the circuit three times. The sixth rep of each set should be difficult to complete if you are using the correct amount of weight.
In three separate half-hour, in-office sessions, (once per week for three weeks) I can teach my clients approximately 15 different resistance, body-weight and/or free-weight exercises. At the end of the three sessions, they have learned and practiced enough to perform a 15-minute, 30-minute or 45-minute whole-body, customized workout routine. The amount of time they work out and spend on the home program depends on the number of sets they perform. They can adjust this to their own schedule.
If clients are not ready to lift free weights, I use a fitness tool that combines a stick and exercise bands into one effective workout. You can do hundreds of different exercises and combination movements to improve strength and flexibility. Every Tuesday and Friday morning, I teach a small-group exercise class. My experience has shown that resistance-band or resistance-bar exercises can be performed for one-minute intervals and then changed to the next exercise for the next minute. This routine can be continued for 20-45 minutes. This provides a great cardio, strength and flexibility workout.
Teach Interval Training
Sheldon needed to get cardio fit and “court ready” for the basketball tournament. The best choice of training for his cardio is interval training. Interval training is broadly defined as alternating brief periods of very high-speed or high-intensity work, followed by periods of rest or very low activity. Simply put, interval training is based around the concept of “Go fast, then go slow, then repeat.” You can perform interval training routines on pretty much any machine you want, such as a treadmill, bike or elliptical machine, and it can apply to almost any sport (swimming, cycling, running).
In interval training, high heart rates during work periods and low heart rates during recovery follow each other. This not only results in increased cardiovascular strengthening, but also increases the energy expended per minute, increasing thermogenesis and thus resulting in increased fat loss. Just remember, the concept of interval training is to go fast and then go slow.
If you are dealing with an unfit client, I don’t recommend they run to get fit. They need to start a walking routine first. Once they are fit, they can run. Typically when a person decides to start an exercise program, they usually think of walking as the major form of exercise. Walking is an ideal place to start. How do you apply interval training? If you’re in good shape, you might incorporate short bursts of jogging into your regular brisk walks.
In my home gym, I have an elliptical machine for my interval training. For example, I warm up at a speed of 5.5 for five minutes and then perform short, fast (speed of 8-10) bursts for 30-60 seconds. I slow down for a minute or two and then repeat the fast burst again. This is performed for 15-20 minutes. If you’re less fit, you might alternate leisurely walking with periods of faster walking. For example, if you’re walking outdoors, you could walk faster between certain landmarks.
Have you ever noticed when people continue to do the same walk, day in and day out, and do not add periods of short bursts to increase metabolic activity to improve their fitness level, they simply stay at the same weight, BMI and body composition? If clients are just beginning an exercise routine, I also suggest they include bicycling in their routine. Since bicycling allows for maximum metabolic disturbance with minimal muscular disruption, metabolic rate and exercise activity efficiency easily can be increased. To apply interval training to cycling, you could pedal all out for 60 seconds and then ride at a slower pace while you catch your breath for the next two to four minutes. Try to keep the bursts of speed at around 90 percent to 100 percent of maximum effort.
An example of an interval routine for runners is to sprint for 20 seconds, rest 10 seconds, repeat four to eight times; or sprint 15 seconds, rest 5 seconds, repeat four to six times.
The Benefits of Interval Training
Major increase in fat loss. In a study done by Tremblay, et al., two groups were assigned different training regimens.1 Group A performed regular moderate intensity cardio (like jogging or bicycling) for 20 weeks and Group B performed interval training routines for 15 weeks. The results of each group were recorded. Group B lost nine times more fat than Group A in five weeks less time.1
Increased lactic acid threshold. Lactic acid threshold indicates how fast your body can remove the lactic acid in your muscles. When your body can remove lactic acid more efficiently, you can work the muscles at a higher intensity for a longer period of time before they become fatigued.
Shorter workouts. If you crank up your exercise intensity using interval training, you can work out in less time and accomplish more compared to performing steady-state cardio. It appears interval training burns more fat than regular moderate-intensity cardio. The rationale is that recovery of metabolic rate back to pre-exercise levels can require several minutes for light exercise and several hours for hard intervals. This phenomenon is called excess post-exercise oxygen consumption (EPOC). Intense exercise of a significant duration may cause EPOC or afterburn. This means extra calories are burned after an intense exercise bout. This indirect expenditure of energy has been shown to last from 30 minutes to many hours post-exercise.
Don’t forget that the training effect increases faster with increased intensity than with increased duration. A long-duration, low-intensity workout will not necessarily result in a high training effect, while a short, high-intensity workout may produce a high value. You need to develop an aerobic base in your fitness clients, but you must progress to intervals if you want real results in both fitness and fat loss. The bottom line is: The higher the intensity, the more calories will be expended. The more energy expended per minute, the more efficient your exercise time will be for fat loss. By the way, Sheldon’s team went on to win the men’s basketball championship.
- Tremblay A, Simoneau JA, Bouchard C. Impact of exercise intensity on body fatness and skeletal muscle metabolism. Metabolism, July1994;43(7):814-8.
by Jeffrey H. Tucker, DC, DACRB
This article is a real story about a client of mine, Sheldon, whom I am proud to call a very good friend. Last year, I was excited to find out that he was invited to play in the 2007 Maccabi Games (www.jccmaccabigames.org).
I want to personally share his story with you while educating you on the principles of rehab at the same time. Sheldon was given an opportunity to live a dream of playing in a basketball competition that few will ever experience. He came to me feeling confident with our past experiences I could help him recover from a serious injury and get him in shape for the tournament in about 12 weeks’ time. Like every client, Sheldon’s recovery and therapy required customization.
In mid-September 2007, Sheldon, a 49-year-old male presented to my office with left lower-posterior leg and ankle pain made worse with walking. He indicated to me that the pain was in the Achilles tendon region and attachments at the calcaneus. He had been recently invited to play for the U.S. basketball team at the 11th Pan American Maccabi Games in Buenos Aires, Argentina, in December 2007. He decided to make the trip to Argentina a family vacation. Sheldon was not unfit, yet he was not in condition for a world-class competition. The ankle injury had occurred as a result of his overexertion in preparing for the tournament.
He came to my office with an immediate goal of pain relief so he could practice basketball again. His bigger goal was a structured exercise program to get him ready for Argentina. The patient was diagnosed with pre-insertional Achilles tendonitis with a partial tear. His past history was remarkable for low back pain and previous diagnosis as a pre-diabetic. The goals of a complete chiropractic/rehabilitation training program for this client were to: decrease pain and body fat, increase strength, endurance, flexibility, lean muscle mass and performance; and prevent injury.
Sheldon’s treatment was guided by measurements such as bioelectrical impedance analysis (BIA), weight loss, heart rate, exercise intensity, ratings of perceived exertion, interval training timing and meal plans. The tools I used to decrease his pain as quickly as possible were a class IV, high-powered warm laser, sound-assisted soft-tissue mobilization (SASTM) as taught by David Graston, joint mobilization/manipulation and myofascial therapy. I had his MD prescribe ketoprofen cream, an anti-inflammatory used to massage into the Achilles area.
As part of his overall program to achieve the above goals, I recommended and initiated food plans, supplementation and a corrective exercise program. Diet is the best tool for fat loss. I have found the Mediterranean diet is easy for clients to follow and offers the best results.
The need for supplements depends upon the individual sitting in front of you. However, there are specific nutrients we can recommend for each individual to take on a daily basis. For example, Sheldon was instructed to take 3 grams of EPA/DHA per day for pain relief and to support joint and bone health, glucose and insulin homeostasis, and the integrity of neurological cells. He was instructed to take daily essential vitamins and minerals, and to increase his protein intake using a bioactive, pure whey protein powder concentrate.
Exercise creates changes in the musculoskeletal system, increasing strength and performance, along with stimulating physiological processes. However, we may not all agree on the best type of exercise to make such changes. In this article and the next, I will discuss these topics and much more, clarifying the connections between fat loss, fat-free mass, exercise and performance.
Measurement and Weight-Loss Basics
Within three weeks, Sheldon was walking without pain. At the end of the third week, he could jog with slight to moderate pain after 10 to 15 minutes of intermittent stops and starts, as in playing basketball. Once his pain diminished enough that he could jog, it was time to get serious and implement a corrective exercise program. We all recognize the value in measuring blood pressure, height and weight. As part of my workup before starting an exercise progression or before starting a weight-loss program, I measure body fat percentage and lean body mass. When I ask a client, “How much do you weigh today?” I often hear remarks such as, “10 pounds too much.” Then I ask, “But how much do you weigh now?” and get the usual response of, “I don’t know, I never weigh myself.”
Maintaining a healthy body weight includes maintaining healthy functioning immune, hormonal and reproductive systems without any traces of an eating disorder. It is also a weight that you can realistically reach and maintain with healthy lifestyle efforts. To effectively manage body weight and body composition, it is important to know your daily caloric requirements. A BIA test can tell us body composition and basal metabolic rate. Accurate assessments using BIA allows me to determine each client’s unique personal caloric requirements and to better plan and evaluate weight management/exercise programs. As mentioned above, I utilize therapeutic lifestyle changes (TLC) including food plans, supplements, exercise and relaxation that can be evaluated using objective measures before and after beginning my nutritional and/or exercise program.
Body Composition Measurements
In my practice, I use a body composition machine, which is a portable, battery-powered bioimpedance analyzer. Patient assessments are conducted using a connection between the analyzer and the wrist and ankle of the patient. Connections to the patient are through standard ECG sensor pad electrodes. Resistance and reactance, the two components of impedance, are measured directly from the body.
On Sheldon’s initial office visit, he was 78 inches tall and weighed 215 pounds. A look at some of the results from Sheldon’s BIA test revealed the following:
|Fat Mass (FM)
|Fat-Free Mass (FFM)
|Body Mass Index (BMI)
|Intracellular Water (ICW)
|Extracellular Water (ECW)
Body weight is the sum of your body fat or fat mass (FM) and your lean body mass or fat-free mass (FFM). FFM consists of dry lean mass and total body water (TBW). TBW is divided into water inside the cells (intracellular water – ICW) and water outside the cells (extracellular water – ECW). TBW is the sum of intracellular water and extracellular water (ICW + ECW = TBW). Keeping these components appropriately balanced is the key to staying fit and healthy. Compositional imbalance in the body is closely related to obesity, malnutrition, edema and osteoporosis. It also will contribute to suboptimal athletic performance.
Body Mass Index
Body mass index (BMI) is a common measure expressing the relationship (or ratio) of your body weight to your height. BMI is more highly correlated with body fat than any other indicator of height and weight, but it is not recommended for use as the sole measurement of your body composition. It does not apply to infants, children, adolescents, pregnant/breastfeeding women or adults over 65 years of age.1
BMI Measurements and Ranges: You can calculate your BMI using the formula: BMI = weight (kg)/[height (m)].2
BMI <18.5: This calculation may indicate an underweight status and may be associated with health problems for some people. This client may need to have a consult regarding diet or other health-related issues.
BMI of 18.5 – 24.9: This zone is the preferred range as it is associated with the lowest risk of illness. The client is living life in a way that improves health.
BMI of 25 – 27: This zone may be fine if you are physically active. You likely have lots of muscle mass and may be overweight but not overly fat. However, a BMI over 25 may be associated with health problems for inactive people. This client will need to consult with a doctor.
BMI of 27 – 29.9: This is a health risk zone and is associated with increased risk of heart disease, high blood pressure and diabetes. At this point diet, nutrition and exercise must be implemented.
BMI > 30: This is obesity. Clients must be provided with a program of balanced eating, supplements, regular exercise and reduction of stress.
Sheldon’s BMI was 25.5, putting him between 25 and 29.9. Although he is only 0.5 over, this still falls within the overweight range. Being overweight increases your risk for heart disease, diabetes and other serious health problems. I was not concerned about Sheldon being overweight, but I was concerned that he would be under stress from the workouts ahead and was on a tight time schedule to get ready for Argentina. Within the first week of treatment, I had discussed the Mediterranean food plan with Sheldon to promote healing and increase strength.
Table 1: Risks of cardiovascular disease relative to body mass index and waist circumference3
|Body Mass Index (BMI)
Men = 102 cm (40 inches)
Women = 88 cm (35 inches)
Men > 102 cm (40 inches)
Women > 88 cm (35 inches)
|Underweight = <18.5
|Normal weight = 18.5-24.9
|Overweight = 25-29.9
|Obese = 30-34.9
||Very High Risk
|Obese = 35-39.9
||Very High Risk
||Very High Risk
|Extremely obese = 40+
||Extremely High Risk
||Extremely High Risk
The BMI ranges are based on the relationship between body weight and disease and death.4 Overweight and obese individuals are at increased risk for many diseases and health conditions, including hypertension, coronary heart disease, stroke, type 2 diabetes, gallbladder disease, osteoarthritis, sleep apnea and respiratory problems, some cancers (endometrial, breast and colon), and dyslipidemia (high LDL cholesterol, low HDL cholesterol or high levels of triglycerides).
There are three types of muscle: cardiac, visceral and skeletal muscle. The quantity of skeletal muscle is most affected by exercise, particularly by strength-training programs. By comparing the percentage of body fat mass and skeletal muscle mass in each body component, the level of fatness or obesity can be measured in a more proactive and exact manner. An essential part of my program is to teach my clients how to train and lift free weights. By teaching Sheldon corrective exercises and a free-weight training program, I expect his muscle mass to increase and the body fat to decrease.
We will follow Sheldon’s progress in part 2 of this series and look at metabolism and the benefits of interval training.
- Mei Z, Grummer-Strawn LM, Pietrobelli A, et al. Validity of body mass index compared with other body-composition screening indexes for the assessment of body fatness in children and adolescents. Am J Clin Nutr, 2002; 75(6):978-85.
- Garrow JS, Webster J. Quetelet’s index (W/H2) as a measure of fatness. Int J Obesity, 1985;9:147-53.
- Gallager DG, Heymsfield SB, Heo M, et al. Healthy percentage body fat ranges: an approach for developing guidelines based on body mass index. Am J Clin Nutr, 2000;72(3):694-701.
- Prentice AM, Jebb SA. Beyond body mass index. Obesity Rev, August 2001;2(3):141-7.
- Gallagher D, Visser M, Sepúlveda D, et al. How useful is BMI for comparison of body fatness across age, sex and ethnic groups? Am J Epidemiol, 1996;143(3):228-39.
- World Health Organization. Physical Status: The Use and Interpretation of Anthropometry. WHO Technical Report Series. Geneva: World Health Organization, 1995.
by Jeffrey H. Tucker, DC, DACRB
There is a lot of excitement and “buzz” about kettlebells in the weight room and the rehab setting these days, so I want to make sure everyone is familiar with this valuable piece of fitness equipment. A “kettlebell” or girya is a traditional Russian cast-iron weight that looks like a cannonball or bowling ball with a handle. The kettlebell goes way back: The term first appeared in a Russian dictionary in 1704. So popular were kettlebells in Tsarist Russia that any strongman or weight-lifter was referred to as a girevik or “kettlebell man.”
Kettlebells come in several sizes/weights, from 5 lbs all the way up to 105 lbs. You can do standard weight-training exercises with kettlebells, including bench presses, overhead presses, curls, squats and rows. However, the unique value of kettlebells is derived from ballistic (fast exercise) work such as snatches, swings, cleans and jerks.
For those of you who don’t know me, I really do prescribe exercise in my practice. Exercise is a natural drug. We need to deliver the right drug, at the right dose, at the right frequency to get the right result. Learning to make good exercise selections is purposeful and designed to decrease pain, prevent injury, decrease body fat, and increase lean muscle mass, strength, endurance, flexibility and overall athletic performance. Currently, I am using kettlebells in my small-group exercise classes to achieve the above goals.
I became intrigued by the claims of the advantages of kettlebells, so I decided I wanted to learn how to use them. I met a well-known kettlebell expert and took workshops from him. I also met with Pavel Tsatsouline, the person responsible for popularizing kettlebells in the U.S. He taught me some of his stretching routines. Once I learned about kettlebells, I immediately realized the benefits to my rehab practice.
The All-in-One Workout Tool
Kettlebells develop all-round fitness and teach kinetic linking. For example, the kettlebell “swings” makes the deadlift functional. It gets you connected to the ground, draws energy from the ground and transfers energy through the shoulder. Kettlebells enhance awareness of posture, position, breath and grip.
Here is a short list of workout equipment the kettlebell replaces: barbells, dumbbells, belts for weighted pull-ups and dips, thick bars, lever bars, medicine balls, grip devices and cardio equipment. The good news is you don’t need to spend thousands of dollars on expensive equipment. For most of your clients, all you need are two or three kettlebells of varying weights. They do not take up much space, so you can train in a small area. In the office, you can get a great workout in a limited space while improving strength, agility and stamina.
I especially like the cardio benefits clients can get from kettlebells. It’s easy to use interval training principles (go slow, go fast, repeat). I have been teaching a twice-weekly exercise class for the past four years. When I first started the class, we used body-weight exercises, balance balls and bands. Each year since starting the class, I’ve introduced a more challenging tool or device. Last year I added telescopic stick/band training to the class, which provided great variety and core work with bands. In January 2008, I started using kettlebells. The participants in my class are noticing more dramatic changes in body composition from kettlebell training than from anything else we’ve done in the past. Kettlebells develop shoulders, back muscles, arms, forearms, a cut-up midsection and strong legs.
Ballistic kettlebell drills involve a snapping action of the hips, and I have found this movement targets the gluteals better than bridges and are as good as squats. Once my clients can perform 50 consecutive bridges in a variety of poses, they are ready for the kettlebell swings. Whatever rehab techniques you use in your office, I always teach and recommend that you start and concentrate on functional asymmetries (right/left differences). Accumulation of asymmetries over time can lead to significant injury.
Most of us have learned something from the Janda method of movement pattern analysis. Kettlebell exercises are movement-based, not just lifting-based. You’re getting movement training with weight instead of weight training with single-plane movement. We’re not just trying to hypertrophy muscles like a bodybuilder; we’re trying to groove movement patterns throughout the body that are both strong and stable.
For sports, you need explosive hips, stable joints and quick hands. Kettlebell training develops those attributes. Most of the moves are done standing (bilateral or single-leg stance), and many moves are done lying supine. Multi-joint movements comprise most of the drills. Kettlebells complement core stabilization, body-weight exercises and telescopic stick/band exercises. Many are characteristic of work, sports, and activities of daily living. With kettlebells, we don’t need machines, so we have more room in our workout areas!
Building Muscle, Losing Fat
With kettlebells, your clients will build muscular endurance when performing high repetitions, and with proper nutrition they will lose fat. Ballistic exercises are not the only exercises to help accomplish this; the Turkish get-up, press and windmill will develop hard midsections and increase shoulder flexibility and stability. Some of my favorite kettlebell exercises include the clean and press, front squat, renegade row, swings and the double clean (holding a kettlebell in each hand).
I love free weights and try to get most of my clients on a free-weight program, but you really can’t do the above exercises with dumbbells. I think kettlebells are actually more challenging than dumbbells. Kettlebell handles are much thicker and will give you a vice grip in no time. Also, the off-centered weight of a kettlebell will force you to use more stabilizer muscles and work the targeted muscles through a longer range of motion.
Progressive, Whole-Body Training
Kettlebell rehab exercise progressions are the same as with other exercise programs. Progress from slow to fast – start a skill at a speed that allows success. Slow down to gain control, and then once it can be mastered, progress to explosive speed. Progress from simple to complex. Finally, build from stable to unstable: a client does not belong in single-leg stance, on a ball or on any unstable surface if they cannot stabilize on the ground with both feet first. Only progress to a less stable environment when the initial exercise is completely mastered and no longer provides a training effect.
I want my clients to get out of pain as quickly as possible so I can begin to train them for fitness. Being fit is a means toward an end, not an end in itself. I use kettlebells to develop complementary motor skills and abilities, and couple effort with execution. Power, flexibility, agility, speed and endurance are the elements of athleticism. Each is trainable, but they must be trained collectively because they are parts of a larger whole. None is a separate entity or more important than another. Sometimes we need to train isolated muscles, but most of the time we train movement patterns, not individual muscles. Kettlebells help achieve this.
No-Nonsense Exercises to Build Core Strength and Tone Your Entire Body
by Jeffrey H. Tucker, DC, DACRB
Your core is your center of gravity, located around your trunk and pelvis, and having a strong core is vital to good posture, muscle control, injury prevention, maximum athletic performance and even basic activities of daily living. There are a variety of ways to work the core muscles, and these days, it’s not always necessary to use free weights or weight machines. Body weight, foam rolls, stability balls, bands, tubing and medicine balls are tools that can be used at home, on your own, to create a solid foundation for developing dynamic strength in your torso, shoulders, arms and legs.
For example, body-weight exercises such as squats, lunges, push-ups, and pull-ups can target the small and large muscles that influence the spine. Working out with balls and bands can help develop a lean torso and abs, build muscles in your pelvis, lower back, hips, abdomen, arms, and create flexibility. And using a foam roll can relieve tension in tight, overactive muscles.
It doesn’t take very much equipment to get started. In my own experience working out at home on a daily basis for the past 15-plus years, a disk used to move furniture becomes the perfect tool to perform sliding lunges. A chin-up bar replaces a lat machine. A chair or a bench becomes a platform to perform step-ups and step-downs. An 8 lb medicine ball can be thrown against an outside wall while performing a chest press. A padded surface or a rocker board/ balance board can be used to perform single-leg stance movements and improves joint stability. A band with handles works just as well as barbells or dumbbells. (Band training provides variable resistance to the popular exercises we use machines or free weights for, such as pressing, rowing, squatting and many others ). A stability ball can be used instead of a flat bench.
What exercises should beginners start with? The National Academy of Sports Medicine recommends starting a workout using the foam roll for what is known as “self myofascial release.” Pressure placed on tender points within the muscle are held for 30 seconds. This allows for optimal muscle lengthening and acts as part of the warm-up phase. Next are lengthening or stretching maneuvers. After stretching only tight, overactive muscles, you then perform basic exercises and progress to advanced strength movements. Maneuvers requiring co-contraction of the small stabilizer and larger mobilizer muscles, such as the”plank” exercise (see below) are great for the abs. Pick exercises that target the front, rear and side muscles of the trunk.
Plank: Start to assume a push-up position, but bend your elbows and rest your weight on your forearms instead of your hands. Your body should form a straight line from your shoulders to your ankles. Pull your abdominals in; imagine you’re trying to move your belly button back to your spine. Hold for 20 seconds, breathing steadily. As you build endurance, try to do one or two 60-second sets.
Side Bridge: Lie on your side with the forearm on the floor and your elbow under your shoulder. For beginners, start with your knees bent 90 degrees. For advanced exercisers, start with your body forming a straight line from head to ankles. Pull your abs in as far as you can, hold the abs stiff throughout and raise the hips off the floor. Hold this position for 10 to 60 seconds, breathing steadily. Relax down slowly. Repeat on your other side. If you can do 60 seconds, do one repetition per side. If not, try for any combination of reps that gets you up to 60 seconds.
Traditional ab crunch: Lie on your back with your knees bent and your hands behind your ears. Slowly crunch up, bringing your shoulder blades off the ground. Perform 1-3 sets, 12-15 repetitions per set.
Ball and Band Exercises
Everyone wants to learn more “butt” or gluteals exercises. The gluteus maximus and gluteus medius are important muscles of the body and often need extra work. The following are good exercises to target the gluteals:
Gluteal ball bridge: Lie on the ball with your head and upper back resting on the ball, feet on the floor with knees bent. Squeeze your gluteals and then push your hips up until there is a straight line through the knee and hip to the upper body. Shoulders remain on the ball. Beware of rising too high or flaring the ribs, which will push the back into hyperextension. Hold the “up” position for two breaths. Let your butt come down and then repeat. Perform 2-3 sets, 10-12 repetitions per set.
Supine ball bridge: Lie on your back with your heels on the top of a stability ball, hip-width apart to aid stability. Suck in the abdominals and squeeze up from your gluteals, lifting your hips until there is a straight line from heels to upper back. Shoulders and head stay firmly on the floor. Take care not to lift the hips too high or flare the ribs so your back hyperextends. Hold for 30 seconds and lower. Perform 2-3 sets, 10-12 repetitions per set.
Lateral band walking: With elastic tubing around both ankles, stand with toes straight ahead, knees over feet and hands on hips. Draw abdomen in and step to right while maintaining upright posture. Don’t rock your upper body when stepping. Step again with the right foot, bringing your feet back to shoulder-width distance. Repeat for six steps to the right and then six steps to the left. This exercise strengthens the glutes, core, and abductors and adductors (the muscles of the outer and inner thigh, respectively). Perform sets of six steps to each side until you feel a slight burn in the gluteal muscle.
Ball back extension: Training the important posture muscles of the thoracic (middle) and lumbar (lower) portions of the spine also can be done on the ball. Position yourself with your chest on the ball and hook your feet under a leg anchor, or put them up against the bottom of a wall. Hold your arms straight out in front of you. Your body should form a straight line from your hands to your hips. Raise your upper body until it’s slightly above parallel to the floor. At this point, you should have a slight arch in your back and your shoulder blades should be pulled together. Pause for a second and then repeat. You can perform this exercise with the arms in a 10 o’clock and 2 o’clock position or a 3 o’clock and 9 o’clock pose. Perform one set of 12-15 reps.
Stability ball push-ups: If you want to build big arms, especially the triceps, stability ball push-ups will take you to next level. Do a push-up with your feet on a stability ball. Keep your body straight – don’t let your hips sag or stick your butt up in the air. Switching positions and having your feet on the floor and hands on the ball challenges the core further. The instability of the ball increases the level of trunk muscle activation. Do as many as you can with strict form, until you feel fatigue; at least 10-15 repetitions.
Band lunge press: If you want more intensity, working with the bands performing pull and push moves is ideal. The band lunge-press helps develop strength, endurance, balance and coordination; there’s not much this exercise doesn’t hit. With a band securely in place behind you, grip the handles and hold them at shoulder level, palms facing toward each other and elbows bent. Feet should be shoulder-width apart. As you step forward into a lunge position, press the handles forward and finish the press with outstretched arms. Return to the starting position. Form is key: Make sure your front knee is aligned over the heel in the lunge position and concentrate on keeping your upper body erect, chin up, eyes staring forward throughout, as if you were trying to balance a book on your head. Do 10-15 lunges with each leg.
Swimmer’s lat pull is a back exercise you’ll feel throughout your entire body. Use an anchored resistance band. With feet shoulder-width apart and knees slightly bent, lean over at the hip – don’t roll your back – until your upper body is almost parallel with the floor. Extend your arms in front of you and grab the band handles. Dynamically draw your arms down and extend them in back of you until they’re at hip level. Think of the motion of a swimmer doing a butterfly stroke – the arm breaking the surface of the water and then continuing down and back. Slowly reverse the motion. Perform 1-2 sets, 10-15 repetitions per set.
Up-chop kneel develops excellent core stability and trunk rotation strength. Kneel with a band or tubing handle attached below hip height. Grasp the handle in both hands to the side of the hip nearest the band. Lift the arms up and at the same time, rotate the shoulders away from the anchor, keeping hips facing forward and arms straight. Complete 1-2 sets of 10 reps on each side.
Down-chop kneel is the opposite of the up-chop. Begin with the handle attached above head height, grasping the handle in both hands above the head to the side of the band. Keeping the hips facing front and the arms straight, pull the hands down and turn the shoulders away from the band. Perform 1-2 sets, 10 repetitions (each side) per set.
Medicine ball slams are a great ab exercise. This exercise involves complete integration of the total body. It will also teach you power development from the ground up and get your heart racing. Take a medicine ball and get in an athletic-ready position (knees slightly bent, ball held with both hands in front of you, as if you’d just caught it) . Bring the ball overhead really fast and slam it down to the floor or ground as hard as you can. Make sure you do a few slow reps first to get a feel for the bounce of the ball, since you have to catch it. Perform 2-3 sets, 10-12 repetitions per set.
Other Tips to Maximize Results
If you work out with another person like your kids or a spouse, you can practice speed and agility drills. Speed is the rate at which something is done or occurs. Agility is the ability to move our body quickly in many directions and speeds with great control. All forms of tag and chase games improve reaction time.
Diversifying your workout will provide new stimulus to muscles and variety of movement. It’s important to change your workout program every 8-10 weeks. One of the biggest mistakes I see my patients do is repeat the same workout over and over again. Show me variety! Often time’s client’s workouts were the first workout they ever learned and it’s the same workout they were doing several elections ago.
Whenever you work out, check yourself for muscle weakness and imbalances from the right side to the left side. Asymmetries cause problems. Exercises that balance your muscles help to avoid injuries, especially those involving the back, groin, hamstrings and knee. A combination workout consisting of foam rolling, band and tubing exercises, medicine ball training, and stability ball exercises can improve your spine and help increase power and performance.
Most people are familiar with Pilates and yoga; these are systems that provide stretching, strength training (especially for the core area), balance training and endurance.
Home exercise programs should include the same fitness challenges and include cardiovascular training (walking, bike, elliptical), reactive training, and speed/agility training.
Getting fit and, training without actually going to the gym is possible when you follow a proper progression and give yourself enough variety of exercises. Becoming your own personal trainer, identifying and fixing muscle weaknesses will benefit your core strength and overall fitness. Your doctor can give you more tips on which exercises and equipment will best help achieve your individual fitness goals.
The Power of the Exercise Band
A recent study published in the Journal of Strength and Conditioning Research suggests a short-term resistance exercise program utilizing exercise bands is as effective as a weight-machine program in increasing strength and reducing fat. The study, which compared the effects of each type of exercise program in 45 previously inactive women (average age: 51-54) for 10 weeks, yielded similar results in terms of functional capacity (assessed by knee push-up and 60-second squat tests) and loss of fat mass. The study authors concluded, “[Exercise bands] can thus offer significant physiological benefits that are comparable to those obtained from [weight machines] in the early phase of strength training of sedentary middle-aged women.”
||Rest (Between Sets)
||30 seconds per tender point
||N/A (one-time warm-up)
||1 or 2 (build to 60-second holds)
||1 per side, 60 seconds each side
|Traditional Ab Crunch
||Build to 3 sets of 12-15 repetitions per set
|Glute Bridge on Ball
||2-3 sets of 10-12 repetitions per set
|Supine Ball Bridge
||2-3 sets of 10-12 repetitions per set
|Lateral Band Walk
||6 per side or until you feel fatigue
|Back Extensions on Ball
|Stability Ball Push-Up
||10-15 repetitions or until you feel fatigue
|Band Lunge Press
||10-15 repetitions per leg
|Swimmer Lat Pull
||1-2 sets of 10-15 repetitions per set
||1-2 sets of 10 repetitions per set
||1-2 sets of 10 repetitions per set
||2-3 sets of 10-12 repetitions per set
|Note: Total workout time should be approximately 30-45 minutes. Be intense! Be consistent! Change your workout routine every 8-10 weeks. You can complete the entire program three to four times per week, or pick a few each day to create a daily 20-minute workout.
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.