Low Back Pain: Get Started with Abdominal Exercises

Low back injuries usually do not occur from one single incident or event like lifting a heavy box.  Instead, most back injuries occur from small incremental stress or load applied over time.  Sitting slouched for prolonged periods at a desk or repeatedly performing bending and twisting can overload sensitive spinal structures.  These structures include the muscles, facet joints, ligaments, discs, and nerves.   Muscle weakness, poor endurance, poor position awareness, and previous history of injury can make one more susceptible to low back injuries.  Most of these injuries are not serious and do not require extensive testing or treatment.

The core muscles function to spare the lumbar spine and surrounding structures from excessive load.  These muscles include the abdominals, low back musculature, diaphragm, and pelvic floor muscles.  No single muscle is more important than the others.  Human movement and low back pain are more complex than one muscle or structure.  Instead, all muscles should ideally function together in coordination.  Pain interferes with coordination and control.  The specific task being performed determines the magnitude and timing of core muscle activity.  Some tasks require a very low load and level of muscle activity such as bending to tie the shoes.  Other tasks require greater muscle activation patterns at high speeds such as swinging a baseball bat.

Exercises to train the core musculature should begin with low loads focusing on control and endurance.  Exercises performed lying on the back targeting the abdominal muscles is a great place to start.  The following exercises can be performed by those with low back pain or those with a history of back pain looking to prevent recurrences.  Once these exercises are no longer challenging, progression is needed.  Future articles will address proper progressions.

Abdominal Bracing

Begin lying on your back with the hips and knees bent.  Find a neutral spine position by gently rocking your pelvis back and forth.  Your neutral position is somewhere between a fully arched and fully flattened position.  In your neutral position, you should be able to hold a small grape under your low back without crushing it.  Maintain a neutral spine and gently contract your abdominal muscles in the front and sides continuing 360 degrees around to the low back.  This muscle contraction should be gentle and no movement should occur.

Once a neutral spine can be maintained with gentle bracing, breathing is added.  Diaphragmatic breathing is performed while maintaining a neutral spine and gentle bracing.  This involves expanding through the belly and rib cage in a 360-degree fashion.  Minimal or no movement occurs in the upper chest and shoulders.  Five deep slow breathes are performed while maintaining a neutral spine and bracing.  No breath holding or movement of the spine should occur.  It is helpful to place one hand on the abdomen and the other hand on the chest to ensure a proper breathing pattern is maintained.   This exercise forms the foundation for all subsequent abdominal exercise progression to follow.

Bent Knee Fall Out

The bent knee fall out is performed after abdominal bracing and diaphragmatic breathing have been mastered.  Begin with a neutral spine, bracing, and diaphragmatic breathing.   Lower one knee to the side towards the floor in a slow and controlled fashion.  No movement in the spine or hips should occur.  It is helpful to place the hands on the hip bones to ensure no movement is taking place.  With each repetition alternate sides.  To increase the challenges add a resistance band around the thighs.  Perform 10 slow repetitions on each side.

90/90 March

This exercise begins with a neutral spine, bracing, and diaphragmatic breathing.   Elevate the legs so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly alternate lowering the heels to the floor.  Gently touch the heel to the floor without relaxing.   Perform 10 slow repetitions on each side.

Heel Hover

Begin with a neutral spine, bracing, and diaphragmatic breathing.   Elevate the legs so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly alternate extending of the knee so one leg straightens without touching down.  As you lower the legs, it is important that the low back does not arch away from the floor.  Perform 10 slow repetitions on each side.

Double Leg Lift

Begin with a neutral spine, bracing, and diaphragmatic breathing.   Both knees and feet are then simultaneously elevated so the hips and knees are at right angles.  Maintain a neutral spine, bracing, and proper breathing as you slowly lower the legs together.  Do not touch down or relax the feet to the floor.  It is important that the low back does not arch away from the floor.  Perform 10 to 20 slow repetitions on each side.  To increase the challenges add a small ball to squeeze between the thighs.

Closing Thoughts on Abdominal Exercise for Low Back Pain

Pain interferes with how our brain transmits signals to our muscles.  This is especially important when your low back pain has persisted for more than several weeks.  These 5 abdominal exercises re-program the lost connections between the brain and core muscles.  Slow coordinated and controlled movements are crucial for success.  Absolutely no holding of the breath should occur.  Breathe holding increases tension throughout the body and interferes with retraining of the muscles and nervous system.   Practice these exercises, master them, and improve your endurance by increasing repetitions.   Once these goals are achieved, you are ready to build strength and resilience with more challenging exercises.

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Gluteus Maximus Exercise: Training in Multiple Planes

The gluteus maximus is the most powerful hip extensor.  This is important for functional activities performed in one plane such as walking, running, and climbing stairs.  However, this muscle also has important functions outside of straight ahead planes of movement.  The gluteus maximus also helps control balance and generate power in other planes.  Rotational and lateral movements in everyday life and sport require important contributions from the gluteus maximus.

Training the gluteus maximus should incorporate single-plane hip extension exercises and exercises in multiple planes.  Single-plane exercises such as the squat and hip hinge do not fully develop the glutes.  Training programs should also include exercises with rotation of the trunk or lower body on one leg.  These types of exercises prepare athletes for changes or direction, throwing, and jumping from one leg.   Performance improvements and reduced risk for injury often occur with long-term training in multiple planes.  The five exercises included in this article are only examples.  Many other exercises can be adapted to train the entire body with rotational movements.

Crossover Step Up

The crossover step up helps expose and improve any side to side difference in gluteus maximus strength.  Stand to the side with your left leg next to an elevated step or box.  Cross your right foot in front and step up onto the box.  Keep your hips square throughout the exercise.  Next, cross your right foot behind the left while stepping down to briefly touch the floor on the opposite side.  When descending think about sitting back into the hips.   Reverse the movement in the opposite direction.  Perform the exercise slowly with control.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hands or close to the chest.

1-Leg RDL

The single-leg Romanian dead lift (RDL) is a single-leg exercises which requires stabilization of the trunk on the lower limb in multiple planes.  These exercise begins by standing on one leg with the opposite hip and knee extended.  The weight bearing knee can be slightly bent throughout the exercise.   Initiate the movement by slowly flexing at the hip, keeping the back straight.  The non-weight bearing leg extends straight back behind the body.  Both the descending and ascending parts of the exercise should be performed in a slow and controlled manner.   Also, maintain control and the position of the weight bearing leg during the exercise.   Perform 8-10 repetitions on one leg before switching sides.   The challenge of the exercise can be increased by holding a dumbbell or kettle bell in the hand on the side of the swinging leg.

Transverse Lunge

The transverse lunge starts standing with the feet near each other and hands on the hips.  Throughout the exercise the trunk is maintained in an upright position, so the knee and hip of the lunging leg can be flexed to 90°. This prevents the knee from moving forward past the toes.  Also, the knee remains over the toes so it does not cave inwards into valgus.  During the transverse lunge, the body is rotated 135° towards the lunging side.  This involves twisting behind the body and lunging in one motion.  Add load by holding a dumbbell or kettlebell in the hand opposite the lunging leg or against the chest.  This exercise shows high activation of both the gluteus maximus and gluteus medius.

Skater Squat

The skater squat introduces rotation of the trunk on the lower limb.  The exercise begins by standing on one leg and performing a squat to a comfortable depth.  The depth is determined by the ability to maintain balance and good control of the trunk and entire lower extremity.  The non-weight bearing leg extends at the hip and flexes at the knee. The torso slightly rotates and the arms swing reciprocally as if skating.  The toe of the non-weight bearing leg can touch the floor between repetitions if needed.  Hold the downward position for 2 seconds then return to the starting position.  Add load by placing a resistance band around the thighs just above the knees.

Rotational 1-Leg Squat

 The rotational 1-leg squat is a progression of the skater squat.  Both exercises have a rotational component to the squat.  This exercise further challenges the balance and stability of the hip.  Begin by balancing on one leg holding a medicine ball in both hands.  The non-weight bearing knee and hip flex to approximately 30°. Slowly lower toward the floor being sure to maintain control of the trunk and supporting leg.  The depth of the squat is determined by the ability to maintain balance and control the movement.  Rotate the hands and medicine ball upwards and towards the weight bearing leg as you perform the squat.  Return to the starting position and keep the knees over the toes to prevent knee valgus throughout the exercise.

Glutues Maximus Exercise: Closing Thoughts

Gluteus maximus weakness is common in those with chronic back pain, hip bursitis, hip arthritis, knee arthritis, and runner’s knee (patellofemoral pain).  Training the glutes primary function of hip extension is important but often not enough for most demands of sport and everyday life.  These five exercises are challenging and not for everyone.  If you are unable to maintain balance and stability on one leg try other exercises first (basic gluteus maximus exercises).   If you are still unsure how to start, contact your physical therapist for help.

 

Power Training in Seniors

Typically training for power is thought of as something that is more for the younger, athletic population. However, today older adults are trying to stay more active with activities such as tennis, golf, hiking, or dancing.  All these activities require some component of power.  Are older adults performing any power-based exercise to help with these activities?

What is Power?

First of all, what is power? Power is simply adding speed to a movement.   Power is a combination of strength and speed.   When exercising, we typically encourage slow and controlled movement, but when you are able to control during the exercise, what’s next? We can add resistance to the movement, or sometimes we can add speed. Why would we add speed? Say you are playing tennis and have to move across the court for a drop shot, how do you move to get the ball? Is it slow and controlled or quick? Does it make sense to only strengthen with slow and controlled motions? Or should we think about adding some speed to the movement you are training?

Muscles change with age and they also change with the demands we put on them. As we get older and stop doing fast movements is it fair to expect the body to continue to move quickly to react to a drop shot, field and ground ball, or even jump to catch a ball when playing with grandchildren?

Adding Power Training to an Exercise Program

Adding power to an exercise routine is simple, and can be fun.  You can simply do a movement or exercise that you can do properly and add some speed to it. Another idea can be bouncing a medicine ball or any ball that can bounce onto the ground or a wall. Mini jump hops are also another way to add speed and dynamic movement.

In Closing

Seniors are continuing to stay active in sports and similar to any athlete, they need to train to play the sport they want to do. A lot of the sports and activities seniors do on a daily basis are not slow and controlled. Power is something to think about with a regular workout routine as we age.  If you are not sure how; give your physical therapist a call.

 

Bulgarian Split Squat Variations

The rear-foot-elevated or Bulgarian, split squat is an excellent exercise to train the lower body for sport or everyday life.  It is unclear where how this exercise received it’s name but this is of little importance.  The split or asymmetrical stance of the lower body introduces unique deands on the muscles and nervous system.  Acceleration, deceleration, change of direction, sprinting and jumping all require stability of the lower body in similar positions.   Elevating the rear foot increases the difficulty by allowing a deeper squat.  The Bulgarian split squat trains the hip to support the upper body while also controlling the knee position in an athletic stance.

A traditional squat is performed with the feet placed symmetrically side by side.  This creates challenges in primarily one plane.  The Bulgarian split squat is performed with a narrow split stance creating challenges in multiple planes.  Raising the rear leg on an elevated surface shifts the load to the front leg.  The front leg assumes approximately 85% of the total load.

There are many variations to the Bulgarian split squat.  Progressions and regressions can be tailored for the beginner or advanced lifter.  The purpose of this article is to describe several of these modifications.  The Bulgarian split squat can be modified so those new to strength training can incorporate the exercise.  The advanced progressions are best suited for athletes or those with several years of training experience.  The exercise can be modified to challenge balance and stability using lighter loads.  It can also be performed with heavy loads.  Under these conditions, maximal strength development is emphasized similar to training with common multi-joint exercises such as the back squat.

Muscles Involved with the Bulgarian Split Squat

The main lower body muscles involved in the Bulgarian split squat is the quadriceps, hamstrings, and gluteus maximus.  The quadriceps is the first muscle to fatigue, especially when heavier loads are used.  This then requires the gluteus maximus to compensate.  The gluteus medius and minimus are involved to maintain proper positioning of the pelvis and balance. The hip rotators are recruited in order to control the inward or outward movement of the thigh and knee.  The ankle muscles are highly active in order to maintain balance in the narrow stance. The abdominals and low back muscles help maintain a neutral spine position and balance.

Set-Up and Positioning

Taking time to position yourself before the movement will allow for proper performance of the exercise.  Assume a split squat stance with the trail leg just in front of a support box/bench on the floor. While shifting the weight toward the lead foot, place the top of the trail foot on the support box/bench.  The distance from the lead foot to the trail foot support is approximately the length of one leg.  Adjust the support box/ bench distance so the lead knee is directly above the toes. The trail leg support can range from approximately 6 inches to knee height.  This may require some experimentation.  Start with a lower height and adjust as needed.  For stability and balance, the top of the trail foot should remain in contact with the support box/bench throughout the exercise.  The width between the front and trail leg is approximately hip width.

TRX-Assisted Bulgarian Split Squat

Once proper set-up has been achieved grasp the suspension trainer in both hands.  Bend the elbows and hold the straps close to the chest.  This will assist with maintaining proper balance and a vertical position of the trunk.  Maintain this vertical trunk throughout the exercise.  A forward lean is difficult to control with the split stance and rear foot elevated.  Keep the weight of the lead foot distributed in the middle of the foot or near the heel.  Perform the movement by “sitting back” so the trunk remains vertical and the lead knee does not track excessively past the toes. It is acceptable to have the knee pass slightly ahead of the toes.  Lower the trail knee only to a position 1-2 inches above the floor.  Complete the desired number of repetitions on one leg before switching legs.

Bodyweight Bulgarian Split Squat

For many, the weight of the body is enough to provide a training effect.  Progressing away from using the suspension trainer increases balance and stability challenges.  Place the hands on the hips or arms across the chest.  If you are unable to perform the exercise without the arms in these positions you many lack adequate balance.  If this is the case, regress back to the TRX-Assisted exercise or try holding two light dumbbells with the arms at the sides.

Kettlebell (Goblet) Bulgarian Split Squat

There are a few advantages to performing the Bulgarian split squat with a kettlebell held at the chest.  First, this promotes a vertical position of the trunk.  Other variations, such as holding dumbbells at the side of the body or a barbell on the back, require the trunk to slightly dip forward.  Second, the kettlebell helps activate the core musculature and cue proper positioning of the rib cage on the pelvis.  It is important to stack the lower rib cage on top of the pelvis.  The abdominal muscles are primarily responsible for this.

2-Arm Dumbbell Bulgarian Split Squat

Holding two dumbbells to the side of the body lowers the center of mass.  For some, this improves balance and stability compared to the bodyweight exercise.  Start with light loads and progress as strength improves. If you prefer, try holding two kettlebells instead of the dumbbells.

1-Arm Dumbbell Bulgarian Split Squat

Holding a dumbbell in one hand increases balance and stability challenges.  Hold the dumbbell in the hand on the side of the trail leg.  This will increase activity to the hip musculature, especially the gluteus medius of the lead leg.  This exercise is more challenging than it looks.

TRX Bulgarian Split Squat

This variation is performed with the trail foot placed in the suspension trainer loop. Position the suspension loop so the trail lower leg is parallel to the floor.  Maintain the trunk in a vertical position.  Maintain the hands on the hips.  The knee of the lead leg should not track excessively past the toes.  Compared to the bodyweight split squat, this exercise shows greater activation of the hamstrings, adductors, gluteus maximus, and gluteus medius.  The suspended position increases stability and balance challenges.  This is a more demanding exercise for the hip muscles.  It is a progression from the bodyweight Bulgarian split squat.  To further increase the challenge, try holding a dumbbell in the hand on the side of trail leg.

Barbell Bulgarian Split Squat

Performing the exercise with a barbell allows for the progression of the load for strength development.  The barbell also causes the trunk to angle slightly forward to support the load.  Before positioning the bar, pull the shoulder blades back.  Place the bar on the base of the neck resting over the trapezius muscles. Tuck the elbows to your side and maintain the retracted shoulder blade position.  With barbell training, heavier loads and fewer repetitions are optimal.  Start with a weight which allows you to perform 6 to 8 quality repetitions.  As always, focus first on proper technique before progressing load on the bar.

Closing Thoughts

The Bulgarian split squat is an excellent exercise for rehabilitation, injury prevention, and strength development.  This exercise requires stability in multiple planes and challenges the hip muscles to control the position of the lower limb.  Performance in many sports involves lower-body, weight-bearing skills in positions similar to the split squat. Sprinting, change of direction, throwing, and kicking require the transfer of forces from one leg in a similar fashion.  If you are unsure about how to best incorporate the Bulgarian split squat, give your physical therapist or strength coach a call.

Gluteus Maximus: 5 Exercises to Get Started

The gluteus maximus is the largest muscle of the hip and buttock.  It functions to maintain an erect standing posture and to extend the hip joint.  The gluteus maximus is regarded as one of the strongest muscles in the body.  Strength of the gluteus maximus is required to walk with an upright posture, stand up from a chair, climb stairs, run, jump, and throw a ball.  Weakness is associated with low back pain, knee pain, hip arthritis, and poor balance.  Gluteus maximus exercises are often prescribed for hip arthritis, hip impingement, iliotobial band syndrome, low back pain, patellofemoral pain, and many other overuse injuries.

Exercises start in non-weight bearing positions such as lying on the back or kneeling.   It is recommended that each of these basic exercises is initiated with 3 sets of 8 to 15 repetitions.  When 15 repetitions can be performed, the intensity of the exercise can be progressed by adding weight or increasing the resistance band strength.  Muscle strength and hypertrophy can be achieved with any range of repetitions.  However, to optimize strength, higher intensities with lower repetitions are needed.   Each exercise should be performed 2 to 3 times per week to optimize improvements in muscular endurance, strength, and hypertrophy.  The main objective of this strengthening program is to progressively overload the gluteus maximus so muscular control, endurance and strength are developed in a systematic manner.

2-Leg Bridge

The bridge is a great hip extension exercise to start with.  Begin by lying on your back with the hips flexed and the feet lined up with the shoulders.  Perform the bridge by lifting both hips from the floor.  A common mistake is to excessively arch the low back.  Hold the bridge position for 2 seconds then return to the starting position.  Lower the body back down in a slow and controlled manner.

Be sure to achieve the bridge position by extending through the hips.  If you lack mobility in your hip joints or hip flexor muscles this may lead to compensation through the low back.  This can be corrected with manual therapy and mobility exercises.  You can also try bringing your fleet slightly closer together and the knees slightly wider apart.  This will allow you to achieve greater hip extension range of motion.

Cook Hip Lift

Begin by lying on the back with your hips flexed and feet lined up with the shoulders.   Flex the hip by holding one knee to the chest.  It is helpful to place a small towel roll or ball in the crease of your hip.  Lift your toes off the floor and perform a bridge from one leg.  A common mistake is to excessively arch the low back.  Be sure to achieve the bridge position by extending through the hips.   Hold this position for 2 seconds then return to the starting position.  Lower the body back down before repeating another repetition on the same side.  Complete the desired number of repetitions on one side before beginning with the other leg.

The positioning of the hips during this exercise facilitates a neutral pelvis and low back position.  This is helpful for people with a history of low back pain.  However, this also increases the challenge to the gluteus muscles compared to a standard bridge.   Raising the toes makes you press your heel into the ground as you lift your hips. This facilitates the glutes and hamstrings.

Quadruped Hip Extension with Knee Flexion

Begin on the hands and knees.  The shoulders are positioned directly over the hands.  The hips are positioned directly over the knees.  The spine is maintained in a neutral position throughout the exercise.  Initiate the movement by flexing one knee to 90 degrees.  Next, lift the heel up towards the ceiling keeping the knee flexed.  It is important to avoid arching through the low back.  Hold this position for 2 seconds then return to the starting position.  Lower the leg back down before repeating another repetition on the same side.  Complete the desired number of repetitions on one side before beginning with the other leg.

Prone Plank with Hip Extension

Start facedown supported on the elbows in a plank position with the trunk, hips, and knees in neutral alignment.  Initiate the movement by lifting one leg with the knee bent.   Extend the hip slightly past neutral by bringing the heel toward the ceiling.  Hold this position for 2 seconds.  Maintain the plank position throughout all repetitions on one side.  Complete the desired number of repetitions on one side before beginning with the other leg.  A common error with this exercise is to arch or overextend the spine when lifting the leg.  Also, as the abdominal muscles tire, the hips may rise.  Be sure to maintain a neutral trunk, hip, and knee alignment throughout the exercise.

Side Plank with Hip Abduction

Start side-lying supported on one elbow with the shoulders, hips, knees, and ankles in line. Rise to a side plank position with the hips off the floor to achieve neutral alignment of trunk, hips, and knees.  Maintain the side plank position and raise the top leg into abduction approximately 30 degrees.  Hold this position for 2 seconds then slowly lower the top leg. Maintain the plank position throughout all repetitions on one side.  Complete the desired number of repetitions on one side before beginning with the other leg.

A common error with this exercise is to allow the pelvis to tip forward or backward.  Also, as the top hip tires the abducting leg will move forward into flexion.  As the bottom side tires, the side plank position will be lost.  This exercise has been shown to activate the gluteus maximus and medius on both sides at very high levels.  It is also very challenging and may not be an option for everyone.

Closing Thoughts

These 5 gluteus maximus exercises do not need to all be performed during the same session.  Start with 2 to 3 of the exercises.  Exercise selection is based on your preferences and the level of difficulty.  The bridge is the least challenging and side plank with hip abduction is the most challenging.  Within 6 to 8 weeks, the exercises may feel less challenging.   This means it is time for a progression.  Progression may include adding resistance or substituting with a new exercise.  Next week we will highlight 5 more exercises which can be performed in standing.

 

Muscle Loss in Older Adults: Prevention and Treatment

Loss of muscle with advancing age is referred to as sarcopenia.  This process begins in the fifth decade of life and proceeds at a rate of almost 1% each year.  Declines in muscle strength usually progress faster than muscle size.  Muscle loss with advancing age is associated with many chronic conditions.  These include diabetes, cancer, reduced mobility, disability, and mortality.   It is estimated that 200 million people worldwide will experience sarcopenia that could affect their health over the next 4 decades.

Muscle loss with aging

Muscle loss is quickly becoming a major public health problem with significant clinical, economic, and social consequences.  Prevention and treatment strategies are challenging due to the growing number of older adults above 65.  Exercise and nutritional strategies are considered the primary treatments for age-related muscle loss.  The rest of this article summarizes findings from research on muscle loss in older adults and offers some practical solutions related to exercise.

Diet, Supplements, and Muscle Loss

Muscle is made of proteins.  Amino acids are the building blocks of proteins.  In younger adults (18-30 years old), eating sufficient protein can stimulate some muscle growth by itself.  This can occur with or without exercise in younger adults.  However, muscle growth does not come so easily in older adults.  Therefore, larger amounts of protein in the diet are needed for older adults to preserve or increase muscle.  Younger adults show increased muscle protein rates with the ingestion of 20 grams of protein during a meal.  Older adults require about twice this amount, or 40 grams, to stimulate muscle growth.

Recent research has investigated the role of protein and amino acid supplements for older adults.  The evidence suggests supplementing with protein or amino acids without engaging in an exercise, does little to preserve muscle mass in older adults.  However, increases in muscle size and strength through exercise can be enhanced by certain foods or supplements.    Diets rich in dairy and fish containing polyunsaturated fats make the muscle more sensitive to exercise.  There is also evidence showing protein supplements and creatine monohydrate is beneficial.  Most importantly, research shows that a specific type of exercise, resistance exercise, has powerful positive effects on muscle in older adults.  Resistance exercise is the key to preserving or increasing muscle size and strength as we age.

Resistance Training

Exercise is a highly effective strategy to offset muscle loss.   Exercising with weights has numerous beneficial effects for older adults.  These include increases in muscle mass, strength, power, mood, energy levels, walking speed, balance, and functional performance.  Other forms of exercise, such as aerobic exercise, do not confer these same benefits.  Aerobic exercise, including regular walking, is not enough to prevent muscle loss in older adults.

Contrary to popular belief, adults older than 75 years old can grow significant muscle through resistance exercise.  Heavy weights are not required.  Lighter weights with higher repetitions can result in significant improvements in muscle size and strength regardless of age.  In all cases, the success of any exercise program depends on adherence and staying committed for the long run.  Therefore, it is important to make exercise as enjoyable as possible.  Choose resistance exercises you prefer.  Exercise with friends.  Choose environments (gyms, classes, or in the home) you are most comfortable with.   If you are unsure about how to start, work with a personal trainer or physical therapist.

Developing an Exercise Program to Fight Muscle Loss

Many individuals are unsure about how to structure an exercise program.  Those without resistance training experience or those recovering from an injury have questions about what is safe and appropriate.  How often?  Which exercises?  How many sets?  High or low repetitions? How long should I rest between sets?  These are all excellent questions.  Below I have outlined a list of recommendations for older adults engaging in resistance exercise.  These recommendations are based on research evidence conducted on healthy older adults.

Length of the program

1 year to optimize results but small improvements are often evident after 6-8 weeks.  Ideally, a lifetime committment is best.

Frequency per week

2-3 sessions preferably with one day of recovery between sessions (i.e., Monday, Wednesday, Friday).

Duration of each session

Approximately 1 hour including rest periods between sets and exercises.

Exercises per session

6-8 exercises involving the major muscle groups of the upper and lower body.

Sets per exercise

2-3 sets have been shown to result in greater improvements than single set routines.

Intensity

50-80% of a one-repetition maximum which is the most amount of weight you can perform properly for one repetition.  An easier guide is to use the recommendations for repetitions per set below.

Repetitions per set

7-9 repetitions per set have been shown to be optimal for strength and muscle development.  This means you should only be able to perform 1-3 more repetitions beyond this range before fatigue becomes limiting.  If you can perform more than this amount without requiring a rest break you can increase the weight.

Duration of each repetition

6 seconds or slow controlled movements are recommended.  Muscle power development requires faster tempos of movement.

Rest between sets

1-2 minutes is optimal.  If this seems like a long time, perform some aerobic activity, such as brisk walking between sets.

Choosing Which Resistance Exercises to Perform

Contrary to the opinions of some, there are no good or bad exercises.  The selection of exercises should be based on several considerations.  This is where a personal trainer or physical therapist can help you get started.  As mentioned, the most important consideration is to choose exercises you enjoy performing.  Beyond this idea, I’ll provide some general recommendations and a few examples.

First, incorporate exercises performed in standing positions as opposed to seated or lying down.  For example, the body weight squat is preferred over a seated leg press.  Second, choose free weights over machines whenever possible.  All machines are not bad but using free weights requires greater muscle activation, control, and coordination.  Third, exercises using multiple joints are preferred over single-joint movements.  For example, the cable row is preferred over a biceps curl.   Finally, incorporate at least one exercise for the fundamental movement patterns such as the squat, hip hinge, upper body push (presses), and upper body pull (row).

Closing Thoughts

Aging is accompanied by a decline in physical activity and function.  Loss of muscle contributes to these changes and is also a consequence of them.  This creates a viscous cycle characterized by muscle loss, weakness, declining function, and developmennt of chronic conditions. Other negative consequences ensue such as osteoporosis and increased body fat.  Exercise can slow down these processes and even reverse them.  In fact, resistance exercise is one of the most effective means to combat the effects of aging and many chronic diseases.  Some have referred to resistance exercise as the, “Fountain of Youth.”  Dietary strategies and supplements can enhance the effects of exercise.   However, there is no magic pill.  Success requires goals, a plan, positive habits, and a commitment.  If you are not sure how to get started, call your physical therapist today.

 

 


 

Gluteus Medius Exercise: Advanced Progressions

Athletes are required to perform explosive powerful movements during sport.  The hip muscles, including the gluteus medius, help generate and transfer forces during sport-specific activities such as running, cutting, and throwing.  These types of athletic demands require high intensity training in the gym.  Gluteus medius exercise which emphasize multiple planes of movement in single-leg or asymmetrical stances are advantageous for these demands.

The advanced exercise progressions included here should first be performed in a slow and controlled manner with an emphasis on technique.  As technique becomes adequate, the speed of movement and load can be increased.  Under any conditions, control of the movement and body positions are extremely important.  Remember, the primary function of the gluteus medius is to stabilize and control the position of the pelvis.  This is mandatory for the rest of the body to generate, transfer, and dissipate forces optimally.

Skater Squat

The skater squats begins by standing on one leg and performing a squat to a comfortable depth.  The depth is determined by the ability to maintain balance and good control of the trunk and entire lower extremity.  The non-weight bearing leg extends at the hip and flexes at the knee. The torso slightly twists and the arms swing reciprocally as if skating.  The toe of the non-weight bearing leg can touch the floor between repetitions if needed.  Hold the downward position for 2 seconds then return to the starting position.   Challenge to the gluteus medius can be increased by placing a resistance band around the thighs just above the knees.

Transverse Lunge

The transverse lunge starts standing with the feet near each other and hands on the hips.  Throughout the exercise the trunk is maintained in an upright position, so the knee and hip of the lunging leg can be flexed to 90°. This prevents the knee from moving forward past the toes.  Also, the knee remains over the toes so it does not cave inwards into valgus.  During the transverse lunge, the body is rotated 135° towards the lunging side.  This involves twisting behind the body and lunging in one motion.   Challenge to the gluteus medius can be increased by holding a dumbbell or kettlebell in the hand opposite the lunging leg.

Rear Foot Elevated Split Squat

The rear foot elevated, or Bulgarian, split squat is an excellent exercise to target the gluteus maximus, gluteus medius, quadriceps, and hamstring muscles.  For this exercise, the rear foot is placed up on a 6 to 12 inch step or box.  The supporting leg should be positioned approximately one leg length in front of the box or step.  This may need to be adjusted based on comfort and balance.  However, it is important that the hip and knee of the front leg is able to flex to 90 degrees during the movement.

It is also important to maintain good upper body posture with a natural curve in the low back and the chest up.  This position should be maintained during the descent and ascent of the movement. Excessive trunk flexion or side bending are common errors.  The front knee should not move forward past the toes.  The knee should remain over the toes so it does not cave inwards into valgus.  Perform 8 to 10 slow and controlled repetitions before switching sides to the other leg.  Challenge to the gluteus medius can be increased by holding a dumbbell or kettlebell in the hand opposite the front leg.

Lateral Step Down

The step down exercise begins with the hands on the hips standing with one leg on the side of a step or 8-inch high box.  Maintain balance on 1 leg and slowly squat to lower the heel of the other leg toward floor.  Gently tap the heel and return to the start position.  Throughout the exercise the trunk is maintained in an upright position.  Avoid leaning the trunk to the side or waving the arms.  The knee should not move forward past the toes.  Also, the knee should remain over the toes so it does not cave inwards into valgus.  Perform 8 to 10 slow and controlled repetitions before switching sides to the other leg.

1-Leg Squat

 If the lateral step down can be performed with proper form, the next challenge is to progress to performing a single-leg squat.  Begin by balancing on one leg with the hands on the hips.  The non-weight bearing knee and hip are flexed in front to approximately 30°. Slowly lower toward the floor being sure to maintain control of the trunk and supporting leg.  The depth of the squat is determined by the ability to maintain balance and control the movement.  Return to the starting position and keep the knees over the toes to prevent knee valgus throughout the exercise.   This exercise can be performed with or without the assist of a chair.  Many times the chair is needed initially until control and strength improve.  Challenge to the gluteus medius can be increased by holding a dumbbell or kettl bell in the hand opposite the supporting leg.

Closing Thoughts

These five exercises require practice to perfect.  Often, a trainer or physical therapist is needed to coach an individual through these types of exercises.  These are higher level exercises which are not for everyone.  However, mastering these types of dynamic movements often translate to improved coordination, strength, and power on heavier compound lifts such as the squat or deadlift.  Team sport athletes often see improvements in explosiveness and agility on the field.  Unfortunately, many become frustrated with the amount of practice and effort it takes to perform these types of exercises.  If needed, regress back to perform less challenging exercises in non-weight bearing (here) or weight bearing positions (here).  This is all part of the process.  Be patient and stick with it and you will see results down the road.

Persistent Low Back Pain: The Physical Therapist’s Role

Low back pain is the most common cause of disability and lost work time in industrialized countries.   Persistent low back pain is characterized by periods of high and low pain intensity which can persist for years.  Periodic “flare- ups” are common and often result in the seeking of medical treatment.  Medications and surgery are often ineffective and may be harmful in some situations.  Physical therapy is a non-invasive treatment approach which is often considered in those with persistent low back pain.  However, improvements are often short-term for those with longstanding pain.  Similar to surgery and medications, the long-term success of physical therapy treatments for chronic back pain is questionable.

Traditional approaches utilizing physical therapy involve a short, but intense course of treatment such as 12 visits over a 4 to 8 week period.  However, this type of treatment approach is likely insufficient to positively influence a person’s beliefs and behaviors about their pain.  Changing these beliefs and behaviors are crucial if an individual with persistent pain is to self-manage through physical activity and lifestyle changes.

Persistent Low Back Pain is Complex

When pain persists beyond expected time frames, changes occur within our nervous system.  These changes include abnormal pain processing pathways and poor execution of movement patterns.  Because the nervous system is so complex, individual “pain experiences” vary greatly among those with persistent low back pain.  Diagnostic tests and scans, including MRI, are of little help because the primary problem is in the nervous system, not the low back.

The low back muscles of those with persistent pain undergo substantial changes over time.  This is believed to be caused by changes in the central nervous system.  These changes include atrophy (loss of muscle) and deposits of fatty tissue in the place of the lost muscle.  In particular the lumbar multifidus muscle has been shown to be selectively atrophied in many, but not all, individuals with persistent back pain.  Not only does the structure of muscle change with long-standing pain, but so does the nervous system’s ability to activate certain muscles.  Some muscles may become underactive while others become overactive.  These patterns differ among individuals with back pain making symptoms highly variable.   A common strategy is when many muscles of the low back contract simultaneously resulting in an unhelpful stiffening or bracing of the trunk.

Persistent Low Back Pain & Exercise

Altered pain processing pathways in the nervous system and changes in the back muscles leads to difficulty learning low back exercises.  A long term stimulus is likely needed to overcome atrophy of spinal muscles and to regain proper muscle function.  Performing low back exercise several times per week for 1 to 2 months is not adequate dosage.  Therefore, those with persistent pain may require repeated practice for several months in order to master the most basic of exercises.

In order to restore normal movement patterns exercise prescription must be matched to the individual’s beliefs and functional problems.  Ongoing types of cognitive interventions, such as education about the science of pain are beneficial to facilitate participation in exercise and physical activity.  An emphasis on education and a gradual progression of physical activity then becomes the long-term treatment.

The Role of the Physical Therapist in Helping Those with Persistent Low Back Pain

A recent episode of low back pain often responds well to manual therapy treatments such as mobilization, manipulation, or massage.  Sometimes, ice or hot packs can be helpful in these situations. However, passive interventions are of little help for those with persistent pain.  Instead, treatments that effectively involve the patient in long-term performance of physical activity are likely to be most valuable. These approaches seek to empower the patient by emphasizing their own preferred types of physical activities which can be progressed and modified as needed over time by the physical therapist.

There is no one-size fits all approach to prescribing exercise for those with persistent low back pain.  Core stabilization exercise receives a great deal of attention but this form of treatment is only helpful in some.  The same goes for stretching, resistance exercise, and aerobic exercise.  All these forms of exercise can be helpful in some but not all.  Therefore, the physical therapist and the patient should collaborate to develop an exercise plan which the patient finds enjoyable or preferable.  This is the only way the program will be adhered to for the long-term.

Final Thoughts on Physical Therapy for Persistent Low Back Pain

The traditional approach of attending physical therapy sessions 2 to 3 times a week for 4 to 8 weeks is not optimal.  Instead, the physical therapist and patient should seek to develop a long-term working relationship over time.  Initially, physical therapy sessions may occur multiple times a week but only for a few weeks.  Sessions should then be spaced out over time.  The physical therapist can assist the patient in progressing or modifying their exercise program at each session.

The physical therapists primary role is as a coach or guide who empowers the individual to self-manage for the long-term.   The ultimate goal is for the individual to manage and be prepared for fluctuations in their back pain.  Those with persistent back pain are ideally suited to directly access the services of a physical therapist without a physician referral.  In these instances, sessions are best when spaced out every few months or as needed.

Evidence for Exercise and Neck Pain

Neck pain can be debilitating and limit your quality of life. It may impact your ability to drive, participate in activities you enjoy, and enjoy activities with your family. Luckily physical therapy can have profound impacts on reducing disability and limitations associated with neck pain. Evidence for strengthening of your neck muscles including the longus capitis and longus colli as well as manual therapy provided by a licensed physical therapy can help improve your neck mobility and even improve numbness/tingling in your arms associated with neck pain.

A Case Study using Exercise for Neck Pain

In a clinical case of a 28-year-old individual with neck pain and left arm symptoms, a physical therapy program consisting of manual therapy directed at the mid back, neck, and left arm reduced pain and improved the overall quality of life in just 10 visits of therapy services. The patient also benefited from stretching exercises for the cervical musculature and strengthening of the longus capitis and longus colli. Treatments to improve the mobility of your nervous system can help decrease the numbness/tingling you may experience with neck pain, this is known as a cervical radiculopathy.

Posture can influence neck pain
Exercise for neck pain

Conclusion

See a physical therapist today if you are experiencing neck pain with arm symptoms associated with a cervical radiculopathy to determine if you can benefit from physical therapy treatment, even without a referral from a physician. The physical therapist is trained to determine if treatment is indicated, ask your local therapist today.

-Dr. Steven Ferro, PT, DPT

Reference

Cleland, J. A., Whitman, J. M., Fritz, J. M., & Palmer, J. A. (2005). Manual physical therapy, cervical traction, and strengthening exercises in patients with cervical radiculopathy: a case series. Journal of Orthopaedic & Sports Physical Therapy, 35(12), 802-811.

Exercise is Medicine for Depression

Depression can be a short-term state or a long-term clinical disorder.  Depression as a transient mood state is characterized by feeling sad, discouraged, or unhappy. These feelings generally resolve over the course of a few days or less.  Depression as a clinical condition is a psychiatric disorder where certain diagnostic criteria must be met.  The diagnosis of major depressive disorder requires psychiatric evaluation by a qualified professional. The diagnosis typically includes at least several of the following: weight loss, sleep disturbance, agitation, fatigue or loss of energy, feelings of worthlessness or guilt, diminished concentration, and possibly recurrent thoughts of death.  Major depressive disorder is distinguished from transient feelings of depression by both the severity and duration of symptoms.

It is estimated that one in five adults will suffer from major depressive disorder at some point in their life.  The incidence is higher in women.  One in four adolescents suffers from depression and this increases the risk of depression later in life.   Depression has also been linked to obesity, diabetes, and heart disease.  All of these disorders, including depression, are on the rise in the United States.   These disorders are also commonplace in outpatient physical therapy clinics where individuals are recovering from injuries.  Perhaps, the knowledge and positive habits learned in physical therapy can assist those with symptoms of depression and chronic disease.  Follow-through with a long-term exercise program can produce meaningful changes in mood, physical health, and quality of life.   All of these benefits can be achieved without the adverse effects associated with other forms of treatment.

Conventional Treatments for Depression

Antidepressant medication is the staple treatment for symptoms of depression.  Approximately half of individuals with depression will respond favorably to prescription medications without side effects.  The other half will either not respond to treatment or suffer side effects from the medications such as constipation, sleep loss, blurred vision, weight gain, fatigue, nausea, and sexual dysfunction.

Treatment may involve individual or group counseling lasting several months. Psychotherapy has been shown to be an effective long-term treatment for depression.  This form of treatment is often used in conjunction with antidepressant medication for individuals with more severe depression.   Cognitive behavioral therapy is one form of psychotherapy which aims to identify and change negative thoughts in those with depression.

Exercise as a Treatment for Depression

As a stand-alone treatment, exercise has been shown to result in moderate to large improvements in depressive symptoms.  Research has also shown no difference in outcomes when comparing exercise to cognitive behavioral therapy.  When combining the results from four studies, no differences were found between the effects of exercise and antidepressant medication.  This is not to suggest that medication and psychotherapy are ineffective.  Instead, exercise may enhance the effects of these conventional treatments for depression.  And perhaps, exercise may even be able to replace them over time.

Type and Dose of Exercise to Manage Depression

Most studies showing positive effects with exercise have included some form of aerobic exercise.  Walking, jogging, and cycling are the most commonly utilized forms of aerobic exercise.  The optimal frequency of exercise has not been determined but most studies have included exercising 3-5 times per week.  Programs with higher energy expenditures have been shown to produce greater results but positive effects can be achieved with lower intensity programs. A good starting point is to perform short walks 3 days per week.   As aerobic capacity and confidence improve, exercise should be progressed based on the American College of Sports Medicine recommendations of moderate intensity exercise performed for at least 30 minutes 5 days per week.  As aerobic capacity improves, exercise intensity and duration should be progressed in order to continue to make gains.

Tips to Increase Chances of Success

The first challenge with any exercise program is simply taking the first step.  Starting small and gradually building up the intensity, duration, and frequency is a wise approach.  Expect minor setbacks along the way and do not be discouraged when they occur.  The antidepressant effects of exercise takes time.  Be patient.   Once you begin to notice small progress in your exercise capacity and overall well-being, momentum will start to build.  The key to long-term adherence is to stay disciplined and develop habits for a lifetime.  Below are a few tips to help you on your journey.

  • Pick a form of exercise you enjoy and stick with it
  • Invest in a good pair of sneakers to exercise in
  • Pick a time of day to exercise which works best for you and make this part of your daily routine
  • Set your own goals and track your progress
  • Anticipate barriers (fatigue, work duties, bad weather, etc) and develop solutions ahead of time
  • Team up with a partner or partners and you will be more likely to stick with it
  • Do not be discouraged if you miss one session. If you fall off, get right back on the next day.
  • Take a minute and appreciate how you feel at the end of each exercise session

Let us know if you need help getting started and best of luck!

References

  1. Blumenthal JA, Smith PJ, Hoffman BM. Is exercise a viable treatment for depression? ACSMs Heal Fit J. 2012;16(4):14-21. doi:10.1249/01.FIT.0000416000.09526.eb.Is.
  2. Cooney G, Dwan K, Greig C, et al. Exercise for depression (Review). Cochrane Database Syst Rev. 2013;9:1-125. doi:10.1002/14651858.CD004366.pub6.www.cochranelibrary.com.