I am a chiropractor educated in ‘evidence-based’ acute care, chronic pain management, sports injuries and injury prevention. Cutting edge, patient friendly solutions and tools for restoration of musculoskeletal injuries, health and fitness, sports medicine, and long-term athletic participation, and life-long exercise are embraced. I utilize standard medical and chiropractic evaluations, functional movement assessments, skilled hands-on, modalities, body weight and sports performance training tools to improve musculoskeletal injuries and imbalances, and movement efficiency to decrease the risk of injury.
I use Deep Muscle Stimulation (DMS), warm laser, Graston like tools, fascial therapy, and other modalities. I am known for ‘figuring out’ the difficult cases, teaching patients self-care and supervised corrective exercise programs.
Most insurance companies cover my sessions.
For more information please call 310-473-2911.
Seattle Rehab dates :
Oct 1, 2011
Jan 7, 2012
NW Sports Rehab
33400 13th Place S
Federal Way, WA 98003
These are some of the topics we will cover over the year.
Human Movement System concepts; Core concepts & core training programs; foam roll training, weight loss.
Forward Head Posture; Movement Screens & corrective exercises; Muscle length testing; Kettlebell weight training.
Low Back conditions & rehab exercises; Flexibility training; Isolation exercises; Balance pads, balance boards, BOSU, slides.
Neck conditions, headaches & rehab protocols; TMJ treatment.
Thoracic spine conditions & rehab protocols; Thoracic Outlet Syndrome; Band/tubing training (mini-bands, bands with handles); Low-load isolation exercises.
Shoulder conditions & rehab protocols; bodyweight exercises; stability ball exercises.
Hip conditions & rehab protocols; Free-weight training.
Knee conditions & rehab protocols; Group exercise training concepts.
Feet/ankles conditions & rehab protocols; medicine ball training; Plyometrics.
Carpal Tunnel Syndrome; Cardio training concepts; Speed/agility; Post-surgical therapy.
Forms; Nutrition; Performance Enhancement.
Chronic pain treatment; Fibromyalgia Syndrome.
Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain.
Ann Rheum Dis*. 2010;69:1643-1648.
Surgery is not superior to a short, intensive cognitive and exercise intervention among patients with common low back pain. This research suggests that surgical treatment for chronic low back pain may be overused. Nearly 80% of patients continue to experience some pain or disability at 1 year following their initial clinic visit for low back pain. In a more recent study of 973 primary care patients with less than 2 weeks of low back pain, the rates of returning to work were approximately 50% at 14 days and 83% at 3 months. The fact that many patients have lingering symptoms, in combination with the introduction and promotion of new surgical techniques and equipment, has led to an explosive increase in the use of surgery for low back pain.
Surgery did not improve pain or disability compared with usual care on intent-to-treat analysis. Prescribed exercises with chronic low back pain found that outcomes were similar in the surgical and nonsurgical groups.
Clinical Pearls – More than one fourth of Americans have experienced significant back pain in the past 3 months, and the total cost of low back pain exceeds $100 billion per year in the United States alone; – Surgical treatment of low back pain has become more prevalent; – In the current study, an intensive, brief program of cognitive and exercise treatment produced similar outcomes as surgical treatment of chronic low back pain; – The current study is in accord with previous systematic reviews of treatment for low back pain without significant anatomic changes (such as spinal stenosis) or symptoms (such as radiculopathy); and – Further research could highlight how to use elements of the intensive back rehabilitation program in everyday practice.
By Dr. Jeffrey Tucker
My personal in-office experience of patients that present with pain after a motor vehicle injury is consistent with a 2010 study by Hincapié CA, et al. I find most patients report pain in multiple body areas and that isolated neck pain is extremely rare. Hincapié CA, et al report 86 percent of 6481 Saskatchewan residents that responded reported posterior neck pain, 72 percent indicated head pain, and 60 percent noted lumbar back pain. Ninety-five percent of claimants reported some pain within the posterior trunk region, comprising the posterior neck, shoulder, midback, lumbar, and buttock areas.
Regarding cervical rehab for these patients, in the past I’ve used everything from bodyweight isometrics and elastic Thera-Bands to strengthen the neck; dumbbells and kettlebells to strengthen the upper body; low load exercises for strength and motor control concepts performing 10 repetitions of deep neck flexor activation against an inflatable blood pressure cuff and a whole lot more.
All of these are effective at reducing acute and chronic neck pain. Oh, I can’t forget teaching patients all the foam rolling, stretching, warm-ups and cool downs I can get them to do. I can probably do an entire seminar on rehab compliance at this point.
My treatment choice has always depended on the individual patient, whether they are young or old, active or inactive, conditioned or deconditioned. Truthfully I don’t see a significant difference between the different treatment modalities. Most patients obtain clinically important improvements at 6 weeks after the beginning of treatment and exercise programs. I think that is in line with what most practitioners were taught to expect. However, I still see that 10% (plus or minus) or so of clients take a lot longer than 6 weeks to resolve and have on-going residual complaints and problems. On the other hand, I love treating chronic pain patients that come into my office that were not originally treated by me – those who had previous chiropractic care, acupuncture, medical care or physical therapy without active rehab (they just received passive modalities). With some new tweeks on rehab, I expect good results with these individuals. My hands-on treatment over the past few years seems to include more cervical mobilization (stair-stepping technique), lower cervical manipulation (rather than upper cervical manipulation), thoracic manipulation, and I continue to do a lot of specialized deep soft tissue therapy for pain reduction. The deep tissue work is especially valuable to the upper cervical region. Over the last few years, I’ve added warm laser, but it is so unpredictable who will benefit and change and who doesn’t, I’m losing interest in the whole “laser” thing for the cervical region.
One of the most helpful things I’ve learned in the last five to six years is Dr. Kim Christensen’s Neuromobilization technique. If you have a patient with radiculitis, this technique can produce some clinically important reduction of pain immediately posttreatment. The biggest changes in my cervical treatment come in my rehab. Helpful strategies in the past several years include using the NASM protocol for the ‘overhead squat’ as a diagnostic tool and treatment guide, and using the Functional Movement Screen (FMS) as a predictor of risk for injury.
My latest rehab management strategies for MVA & cervical spine patients:
Manual therapy: lot of personal thought and patient time figuring out manual maneuvers and stretches to influence the fascia – that thin fibrous layer consisting of longitudinal and transverse connective tissue fibers. Restrictions seem to show up everywhere. Along the sacrotuberous ligament, the thoracolumbar fascia, the latissimus dorsi muscle, the spinous processes of all of the thoracic vertebrae, the angles of ribs, the serratus muscle, the splenius capitis muscles and the deep fascia of the neck.
Balancing (sensorimotor training) exercises as early as possible. I start patients standing with a narrow stance, progressing to tandem stance and single leg stance. The progression includes the use of foam under each foot to augment postural instability. Manipulate visual inputs (focusing on a point 2 meters away on the wall at eye level and under, with eyes open (EO) plus eyes closed (EC) conditions). I use 30 second bouts.
Stretching exercises is still part of many cervical rehab programs but dynamic stretching and mobility of the thoracic spine to influence the cervical spine is enhancing rehab routines. Mobility needs to be taught before stability. We have to reduce neck/shoulder stiffness and enhance neck range of motion. The static stretches for the levator scapulae, suboccipitals, SCM, pectoralis minor, and scalenes continue to be at the top of the list. I am enjoying using the stretch strap from Theraband.
Strengthening exercises after the deep neck flexors (DNF): Sometimes I begin with the head positioned against gravity to enhance isometric strength of the neck extensor muscles. I still do typical strengthening exercises for the paraspinal muscles and shoulder girdle muscles (upper and middle trapezius, rhombo-serratus). These exercises help increase the sustained isometric effort tolerance of the neck muscles. Progression includes unstable surface
and escalating resistance and movement pattern improvement. I begin my corrective exercise strategy with bodyweight, progress to Therabands resistance, then progress to free weights and kettlebells.
Oculomotor and head/eye exercises
: In the upright, sitting and supine positions I teach patients eye tracking while moving the head. This involves coordination exercises and re-establishing proper movement patterns.
The progression includes increasing neck rotation amplitude, instability on a stability ball and augmenting neck muscle activity with the head in a weight-dependent position. For the past few years I’ve been using the overhead squat for cervical evaluation. Dr. Christensen and I wrote a chapter on the cervical spine in Mike Clark’s new book. In the past we used the overhead squat as a movement pattern to evaluate the ankles, knees, and lumbopelvic-hip complex. Now we use it to evaluate the cervical spine as well. Just think of it as closely rel ated to the supine cervical flexion movement pattern. Have the patient perform the overhead squat. Observe them from the front and side. The normal pattern would be for them to lead with the posterosuperiour aspect of head. If the SCM’s and subocciptals are dominating, they will lead with their chin. This is a faulty pattern. Remember these muscle actions:
Antomical action of longus capitus and colli (cranio-cervical flexion) nods the chin.
SCM extends the cranio-cervical region and flexes the neck.
Scalenes are neck flexors.
During the overhead squat I seem to find a lot of overactive SCM, anterior scalene, and suboccipital muscles.
Here are a couple of corrective exercises:
Scalenes and hyoids can be short, limiting cervical extension. Hyoid stretch: teeth touching – extend the neck – open mouth and your head extends further. The stretch is close the mouth = fascial stretch of hyoids. To find out if it‘s articular, perform the chin tuck and extend the cervical spine over the upper thoracic region.
4 Point Kneeling: The head and neck are passively positioned in neutral alignment, then the patient actively moves (turning side to side, looking up and down) and attempts to return to neutral position. Perform this procedure twice. Notice if they can come back to the neutral position. Score: Good = the patient accurately and confidently returns to the neutral position both times without making adjustments. Average = the patient returns to neutral position with reasonable accuracy but lacks confidence – may need to make several adjusting movements or is “not quite sure.” Poor
= the patient cannot return to the neutral position and is often very unsure of the correct position as evidenced by the vacant facial expression that frequently is associated with performing this test.
I’m sure there are dozens of specific treatments, exercises, and natural remedies out there for our patients. I’d be interested to know about them, but if you’re following the rehab model in all its facets – manipulation/mobilization, modalities, diet, activity, exercise, leisure, sleep, stress prevention – I think you’ll find we do so much good!
I have new material to share with you.
Dr. Jeffrey Tucker can be contacted at:
11600 Wilshire Blvd. #412, Los Angeles,
CA 90025, phone 310.473.2911
and on the web at www.DrJeffrey-
1. J Occup Environ Med. 2010 Mar 30. Whiplash
Injury is More Than Neck Pain: A Population-
Based Study of Pain Localization After
Traffic Injury. Hincapié CA, Cassidy JD, Côté P,
Carroll LJ, Guzmán J.
2. Comerford lecture notes 2009.
Dr. Tucker completed Chiropractic training at Los Angeles College of Chiropractic.
He has a post graduate Diplomate degree in Rehabilitation and is certified in
chiropractic spinal trauma. He is a past-president of the Santa Monica Chiropractic
Society. Dr. Tucker served on the Chiropractic Rehabilitation board. He is a
member of the California Chiropractic Association and the American Chiropractic
The first kettlebell maneuver I teach my clients is the swing. It is the most common kettlebell exercise. The swing should be viewed as the foundation exercise and I like to see clients master the swing before other kettlebell exercises are introduced.
Once clients can perform the 2-handed swing, this is a typical progression I teach my clients in the office:
One-Arm Swing. Grasp the handle with one hand in overhand grip with slight elbow bend. Position feet slightly wider than hip width, and assume athletic stance. Upper body should be upright, with chest lifted and shoulder blades retracted. Free arm should be out to side of body. Rotate body slightly, allowing kettlebell to hang between legs. Initiate swing by rocking hips (versus using shoulders to lift bell). Raise bell upward with momentum, and give forceful hip thrust at top of movement. Bell should go no higher than eye level, with bell pointed away from body at end of arm. Allow gravity to bring bell downward in controlled manner. Keep spine at neutral, rather than rounded, at bottom of movement. Perform 10 repetitions in each hand.
One-Arm Alternating Swing. Repeat steps above (one-arm swing), but switch to other hand at top of movement. Perform 10 repetitions in each hand.
Around-the-Body Pass (at waist level). Grasp handle with both hands in overhand grip with slight elbow bend. Position feet slightly wider than hip width apart, and assume athletic stance. Upper body should be upright, with chest lifted and shoulder blades retracted. Release one hand from bell, allowing opposite hand to bring bell behind body. Free hand should grasp bell at back of body and complete the rotation. Grasp kettlebell firmly to avoid dropping it. After 10 repetitions in one direction, repeat 10 reps in the opposite direction.
Figure Eight (between the legs). Grasp handle with right hand in overhand grip with slight elbow bend. Position feet slightly wider than hip width apart, and assume athletic stance. Upper body should be upright, with chest lifted and shoulder blades retracted. Left arm should be out to side and ready to accept kettlebell. Begin movement by handing bell from right hand to left hand through legs from front of body to back. Left hand then brings bell around from back of body to front of body. Continue this figure-eight pattern by passing bell through legs again from left hand to right hand. After desired number of repetitions, repeat in opposite direction.
These exercises provide a good cardio and fat-loss workout, creating a great foundation for other exercises. After a full-body warm-up, perform each exercise for approximately 30 seconds or 10 reps. Do one exercise after another and rest at the end. Repeat the circuit 2 or 3 times depending on your condition and the amount of time you have to train.
For a one-on-one in-depth kettlebell session, please call my office at 310-473-2911.
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.
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.