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.

 

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: Getting Started

In a previous article, we discussed the importance of the gluteus medius muscle in controlling lower extremity alignment during the squat.  This muscle also plays a critical role in positioning and stabilizing the pelvis in many other functional activities.  This includes any activity with requires a period of single-leg support such as walking, climbing stairs, and running.  Individuals with knee pain, chronic back pain, hip arthritis, and ankle injuries have all been shown to have weakness in this  important muscle.  Glutues medius exercise can help.

Getting Started with Gluteus Medius Exercise

Basic resistance exercise for the gluteus medius can be initiated in non-weight bearing positions such as lying on the side.  Progressions can include partial weight-bearing positions such as on all fours or plank positions.  As muscular endurance and strength improve, exercises can be progressed to weight-bearing positions in standing.  Standing exercises are initiated in a double-limb stance, or with both legs fixed to the floor and then progressed to single-limb stance.  Each exercise should be performed 2 to 3 times per week to optimize improvements in muscular endurance, strength, and hypertrophy.

It is recommended that each of these basic resistance exercises be 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.   The main objective of this strengthening program is to progressively overload the gluteus medius so that muscular control, endurance, and strength are developed in a systematic manner.

Clam Shell

Begin by lying on one side with the hips flexed to approximately 45 degrees.  The knees are flexed and the feet kept together.  A resistance band can be placed around the thighs just above the knees.   Start the exercise by rotating the top hip to bring the knees apart.  Hold this position for 2 seconds and then return to the start position slowly.  Be sure to remain lying completely on the side with one hip stacked on top of the other.  Allowing the pelvis to roll backwards during the movement is the most common mistake with this exercise.   The clam shell is a great exercise to start with because it elicits high levels of gluteus medius activity with minimal activity of the tensor fascia latae (TFL).  This is beneficial because the TFL is commonly overactive in individuals with hip and knee pain.

Side-Lying Hip Abduction

Begin by lying on one side with the bottom hip and knee flexed.  The top knee remains straight.  The top hip is maintained in neutral or slight hip extension with the toes pointed forward.  The toes are pointed forward to orient the hip in slight internal rotation.  This increases gluteus medius activation and decreases TFL activation.  Initiate the movement by lifting the top leg about 30 degrees.  Hold this position for a count of two and then slowly lower the leg to the start position.  Ankle weights can be added for resistance once 15 proper repetitions can be performed.

This exercise activates the gluteus medius to a greater level than the clam shell.  However, it is also more challenging to perform correctly.  Similar to the clamshell, it is important to remain completely on the side with one hip stacked on top of the other.  Allowing the pelvis to roll backwards during the movement is the most common mistake with this exercise.   Also, as the muscle tires, the leg will drift forward into hip flexion.  It is important to maintain the leg lined up or slightly behind the trunk and upper body.

1-Leg Bridge

Begin by lying on the back with both hips and knees bent.  Perform a bridge with both legs by raising the hips to a neutral trunk, hip, and knee position.  A common mistake is to excessively arch the low back.  Be sure to achieve the bridge position by extending through the hips.  From the bridge position, straighten the knee of one leg while keeping the upper thighs parallel.  Be careful not to allow the pelvis to drop on one side.  Hold this position for 2 seconds then return the leg to the bridge 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.  Resistance can be added by placing a band around the thighs just above the knees.

Prone Plank with Bent Knee 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 gluteus medius tires the abducting leg will move into flexion.  As the bottom side tires, the side plank position will be lost.  This exercise has been shown to activate the gluteus 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 exercises do not need to all be performed at once.  Instead, choose 2 to 3 exercises to get started with.  Exercise selection is based on your preferences and the level of challenge each presents.  The clam shell 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 indicating a need for 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.

 

Gluteus Medius: Controlling Knee Position during the Squat

The gluteus medius is a broad thick muscle on the outer part of the pelvis.  The muscle spans from the buttock to the upper aspect of the thigh bone (femur) on the bony part of the outer hip (greater trochanter).  The primary function of the gluteus medius is to stabilize the pelvis and femur during dynamic activities such as walking or performing a deep squat.  It is responsible for preventing the opposite side of the pelvis from dropping during walking.  The gluteus medius packs many short muscle fibers together.  This allows it to generate high forces.  However, a trade-off to its structure is its inability to produce large forces when in lengthened positions.

Poor squat due to gluteus medius weakness

The gluteus medius is lengthened when the hips flex and internally rotate.  This causes the knee to cave inward during the squat.  This may be more obvious during a 1-leg squat or landing from a jump on one leg.  This movement strategy is sometimes called, dynamic valgus, and is believed to be disadvantageous.   The gluteus medius is unable to accomplish its primary role of stabilizing the pelvis when in extreme joint positions.  This is the case when the hip is in flexion and internal rotation.  Hip internal rotation during the squat also impairs the ability of the gluteus maximus to extend the hip.  However, the hamstrings and adductors can often overcome this deficit to compensate.  Squatting with the hip internally rotated increases the demands of the gluteus medius and may be a compensation for the weakness of this muscle.

Gluteus Medius & Injuries of the Lower Extremity

It is commonly believed that squatting with hip internal rotation or dynamic valgus is indicative of hip weakness.  This is particularly thought to occur in those with knee pain and those at risk for anterior cruciate ligament (ACL) injury.  Other injuries which are characteristic of this pattern include runner’s knee, iliotibial band (ITB) syndrome, labral injuries of hip and femeroacetabular impingement of the hip.  In many cases, this pattern is likely a compensation for the weakness of the hip musculature.  Hip internal rotation may increase the force capacity of the weakened gluteus medius.   This allows for performance of the squat but subjects the knee and hip joints to excessive stress.

Lifestyle Factors Contributing to Gluteus Medius Weakness

Side sleeping with the leg crossed can place additional stress on the gluteus medius tenddons

Gluteus medius weakness can be the result of previous injury or lifestyle factors.  Standing with the body weight predominantly on one leg with the pelvis swayed sideways can lead to an underdeveloped muscle on one side.  Sleeping on one’s side with the top leg flexed and crossed over the other leg results in an elongated muscle.  Both of these scenarios can potentially weaken the muscle over time.  Repeated running on crowned roads or surfaces can also potentially lead to weakness of the gluteus medius on one side.

Closing Thoughts

Hip internal rotation and dynamic knee valgus negatively impact the gluteus maximus and increase the force generating demands of the gluteus medius.  This movement strategy may be a compensation to increase gluteus medius force production and a cause of gluteus maximus weakness.   In any case, this movement strategy should be addressed with resistance exercise targeting improvements in strength and hypertrophy of both muscles.  Next week, I will post an article about initiating and progressing exercises for the gluteus medius.

Five Exercises to Train the Abdominal Muscles

Abdominal muscle weakness and poor control of the trunk (or “core”) can negatively influence athletic performance and activities of daily living.  Poor trunk muscle strength has been associated with injuries in baseball players and several other sports.  Also, exercises to improve trunk muscle strength have been shown to improve soccer and distance running performance.  Trunk muscle weakness has also been linked to falls in seniors and low back pain in adults and children.

Exercises to strengthen the abdominal muscles and improve coordination of the trunk should be integrated into a comprehensive total body strength training program.  Training should never focus on any single muscle or body part.  In general, abdominal exercises should start in supported positions, such as supine lying, and progress to more functional positions, such as standing.  Exercises are predominately training for muscular endurance with short sustained holds (8 to 10 seconds) and a progressive number of repetitions.  As exercises become less challenging, the number of repetitions should be increased or the exercise itself should be progressed to a more challenging position.  The five exercises which follow are ordered from the most basic to the most challenging.

Dead Bugs

Begin in a supine lying position with the arms held straight up and the feet off the floor.  The hips and knees should be bent to 90 degrees.  Gently flatten the low back into the floor and maintain this abdominal contraction throughout the exercise.  Simultaneously raise the right arm overhead and extend the left leg without touching down.  Hold this position for several seconds and maintain low back contact with the floor.  Reverse the movement back to the starting position. Then, perform the opposite diagonal pattern with the left arm and right leg.  You should alternate sides with each repetition.  Maintain low back contact with the floor throughout the exercise.

Stability Ball Roll-Outs

Begin in a tall-kneeling position with both hands on the ball.  Roll the hands along the ball until the elbows or upper arm contacts the ball.  The elbows should remain extended as the hands and hips move together.  Engaging the gluteus and abdominal muscles help maintain proper position during the exercise.  As you lower the body towards the floor, maintain a neutral spine position and avoid arching the low back.  Hold this position for several seconds before reversing the movement back to the starting position.

Side Plank with Rotation

Begin in a side-lying position resting on one elbow.  Raise the trunk and knee off the floor until you are fully supported by your elbow and feet.  While maintaining the side plank position, reach up and then under and behind the body with the top hand.  This will induce trunk rotation and challenge the oblique abdominal muscles.  Hold this position for several seconds before reversing the movement back to the starting position.

Half-Kneeling Cable Chop

Assume a half-kneeling position next to a cable column or anchored resistance band.  The kneeling position removes contributions from the lower body and increases the demands on the trunk, pelvis and hip musculature.  From a balanced and upright kneeling position, pull the cable or band diagonally across the body towards the opposite hip.  Maintain a neutral spine and trunk position throughout the exercise.  Avoid rotating the body as your arms pull across the body.  Resisting this movement is what activates the abdominal muscles.  Hold this position for several seconds before reversing the movement back to the starting position.

Lateral Lunge with Press and Reach

This advanced exercise starts from a standing position next to a cable column or anchored resistance band.   Holding the handle or band close to the body; initiate the exercise with a lateral lunge.  Once the lunge position is attained, slowly press the arms straight out in front of the body.  The band or weight will induce a rotational challenge to the trunk muscles.  Resisting this movement is what activates the abdominal muscles.  Next, slowly raise the arms straight overhead while maintaining the lunge position.  Maintain a neutral spine and trunk position throughout the exercise.  Hold this position for several seconds before reversing the movement sequentially back to the starting position.

Closing Thoughts on Abdominal Exercises

Abdominal exercises are one component of a comprehensive exercise program targeting total body muscular strength and physical performance.  Abdominal exercises performed in isolation are rarely successful for improving performance or decreasing pain.  When developing your program, consider these five trunk muscle exercises.   Performing each exercise in a controlled fashion, with a focus on proper technique and muscular endurance will elicit the best results for the long-term.

References

  1. Chaudhari AMW, Mckenzie CS, Pan X, Onate JA. Lumbopelvic control and days missed because of injury in professional baseball pitchers.  Am J Sports Med. 2014;42(11):2734-2740. doi:10.1177/0363546514545861.
  2. Granacher U, Gollhofer A, Hortoba T, Kressig RW, Muehlbauer T. The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: A systematic review. Sports Med. 2013;43:627-641. doi:10.1007/s40279-013-0041-1.
  3. Reed CA, Ford KR, Myer GD, Hewett TE. The Effects of isolated and integrated “core stability” training on athletic performance measures: A systematic review. Sports Med. 2012;42(8):697-706.

Strength is the Foundation: Getting Stronger Benefits Us All

Muscular strength is defined as the ability to exert a force on an external object or against some type of resistance. Strength may be expressed when hitting a baseball during sport or when standing up from a low chair during everyday life. Strength is required to press a loaded barbell overhead or strength may be needed to carry groceries from the car into the home. Optimizing strength across the lifespan can have profound effects on athletic performance, quality of life, health, and longevity.

Strength & Sports Performance

During sport, athletes exert large forces against gravity (i.e., sprinting or gymnastics), against an opponent (e.g., football) or when manipulating an object (e.g., throwing a baseball). Muscular performance can be a limiting factor in performing any of these athletic endeavors. Power refers to the rate at which force is produced. Stronger athletes produce more force and often do so in much less time. Power is associated with several important sport variables such as sprinting speed, jumping, change of direction, and throwing velocity. Improving muscular strength through resistance training is a sure fire way to improve power and subsequent sports performance.

An athlete’s ability to run, jump and change direction is crucial for success in most sports. Enhancing muscular strength improves these characteristics which often transfer to sport specific skills during competition. Stronger athletes jump higher and further than weaker athletes. Strength may be expressed when an athlete elevates for a rebound in basketball, jumps to spike a ball in volleyball, or dives to catch a ground ball in baseball. Athletes, who produce large forces on the ground, are able to jump higher and further than weaker athletes. This results in a true competitive advantage in many sports.

Stronger athletes are also able to accelerate running speeds over short distances. Elite athletes are able to produce greater forces, with short ground contact times, and with greater stride lengths compared to non-elite athletes. Evidence strongly suggests a correlation between maximal strength and running speed1. Athletes who produce greater amounts of force over a shorter period of time are able to change direction at greater velocities. This is important in basketball or football when attempting elude defenders. Becoming stronger is a no-brainer for any athlete looking to jump higher, run faster, or rapidly change direction during their sport. Lateral lunge variations are an excellent way to improve strength in the frontal plane where many athletic injuries occur.

Strength transfers to performance in both strength-power sports and endurance sports. Stronger cyclists are faster than weaker cyclists. Handball players with greater strength outperform weaker handball players. Stronger sprinters have faster 100-meter times than weaker sprinters. Stronger baseball players possess greater bat speeds and throwing velocities than weaker players. Strength alone does not ensure athletic success, but the evidence is compelling that stronger athletes possess a competitive advantage over weaker athletes in most sports.

Strength & Quality of Life

There has been a steady decline in fitness and muscular strength in children and youth across the world. Research shows greater muscular fitness in school-aged youth (4-19 years)is associated with improved body composition (e.g., decreased body fat), and improved risk factor profiles for heart disease and diabetes2. There is also strong evidence for a positive association between muscle strength and bone health and self-esteem in children2. Therefore, youth physical activity programs which promote muscular strength can have many benefits related to overall health and quality of life.

Sarcopenia refers to the age-related loss of muscle size and strength in older adults. Loss of muscle mass begins at approximately age 25 and progresses to a loss of 30% or more by the age of 80. Loss of muscle mass occurs primarily in type II muscle fibers which are highly responsible for muscle strength and power. Therefore, the rate and magnitude of strength loss usually exceed that of muscle mass by 2-5 times.

Age-related loss of muscle strength and bone mass (osteopenia) are associated with impaired functional mobility, compromised balance, and increased risk of arthritis, joint replacement surgeries, falls, and fractures. All of these factors can substantially diminish the quality of life. Nearly 20% of women and 10 % of men over the age of 65 cannot lift a 10-pound weight or kneel down on the floor. The age-related loss of strength is also associated with an inability to live independently and premature death3.

Maintaining muscle strength is a key strategy that leads to healthy aging. Sedentary behavior and physical inactivity are key drivers of sarcopenia and can accelerate the loss of muscle mass and strength. Maintenance of physical activity and engagement in a regular strength training program can diminish or even prevent these age-related changes. Pulling exercises or row variations are great for strengthening the upper body and core musculature.

The Importance of Strength for Optimal Health & Longevity

It is well-known that aerobic fitness is associated with decreased risk for chronic disease and premature death. The health benefits of exercise programs which target muscular strength is less known to the general public. A 2017 study published in the American Journal of Epidemiology showed resistance training reduced the risk of all-cause and cancer-related death to a greater degree than aerobic exercise4. There is now a growing body of evidence suggesting poor muscular strength is associated with death from all causes in both healthy and diseased populations

Another review in the European Journal of Internal Medicine reported a reduced risk for all-cause mortality with increased levels of muscular strength5. This association persists even after controlling for age, body fat, smoking, alcohol intake, medications, other health conditions, physical activity, and levels of cardiorespiratory fitness. Handgrip strength has been associated with survival and long-term outcomes in patients with cancer. Muscular strength has also been shown to be associated with long-term outcomes in patients with heart disease.

The health and mortality benefits of muscular strength appear to be related to multiple physiological mechanisms. This includes improved blood pressure, blood lipids, and body composition. Reduced systemic inflammation and reduction in insulin resistance have also been linked to improved muscular strength and mortality. Based on the available evidence showing a strong association with muscular strength and mortality, adults should perform muscle-strengthening exercises at least 2 days per week in order to reduce mortality risk. For most, basic lower body exercises such as squats and hip hinges are great places to start with a strengthening program.

Conclusion

We continuously perform activities during sport or our daily routine which require the expression of muscular strength. To a certain extent, muscular strength can be inherited. However, strength will never be optimized and will ultimately decline with age unless strength promoting exercises are undertaken. Optimizing or preserving muscular strength is strongly associated with improved sports performance, improved quality of life, improved physical function, reduced risk for chronic disease, and reduced risk for all-cause death. This should be sufficient evidence for all individuals, regardless of age or health status, to engage in some form of resistance training today.

References

  1.  Suchomel TJ, Nimphius S, Stone MH. The importance of muscular strength in athletic performance. Sports Med. 2016;46(10):1419-1449. doi:10.1007/s40279-016-0486-0.
  2. Smith JJ, Eather N, Morgan PJ, Plotnikoff RC, Faigenbaum AD, Lubans DR. The health benefits of muscular fitness for children and adolescents: A systematic review and meta-analysis. Sports Med. 2014;44:1209-1223. doi:10.1007/s40279-014-0196-4.
  3. McLeod M, Breen L, Hamilton DL, Philp A. Live strong and prosper: The importance of skeletal muscle strength for healthy aging. Biogerontology. 2016;17(3):497-510. doi:10.1007/s10522-015-9631-7.
  4. Stamatakis E, Lee I, Bennie J, et al. Does strength promoting exercise confer unique health benefits? A pooled analysis of eleven population cohorts with all-cause, cancer, and cardiovascular mortality endpoints. Eur J Intern Med. 2017; Ahead of P:1-37. doi:10.1093/aje/kwx345/4582884.
  5. Volaklis KA, Halle M, Meisinger C. Muscular strength as a strong predictor of mortality: A narrative review. Eur J Intern Med. 2017;26(5):303-310. doi:10.1016/j.ejim.2015.04.013.