For exercises, while it is true that repetition helps commit to memory, I am not for that “magic number” theory of “20 repetitions and you got it.” I love the fact that we are all unique, so is it any wonder that the number of repetitions it may take one to memorize may not be the same as anyone else? Then how do we know how many repetitions are enough to have the effect an exercise is meant to have or visualize the outcome it is supposed to produce? Basically, it all depends on the intent of exercise or in other words the goal of exercise.
Exercises are classified on basis of the effect- strengthening, increasing endurance, or range of motion- which used to be primary goals. Nowadays, the goals have diversified to include stability and achieving a good movement pattern in addition to the prior goals. We now have the tools to precisely gauge and progress these objectively as our knowledge of biomechanics, kinesiology, and neurosciences deepens.
Spinal stabilization exercises are probably most widely prescribed, and rightfully so, as all other movement depends on this fundamental ability on which other movements patterns are based. Consider it to be the foundation on which the rest of the body structure is built and given freedom to move. Once the stabilizing muscles fire properly, repetition is key to set this pattern on which any other dynamic movement is based. Even though there may be a foot or knee discomfort or injury, the root cause may lie in the improper spinal stabilization. A physical therapist is hence required to consider the body as a whole and detect where the dysfunction originates. In that context, I love Sherlock Holmes’ quote on elimination: “Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth.” Functional Movement Assessment does precisely that. It looks at whole movement patterns for dysfunction, and then breaks down movements to specific joints and considers surrounding soft tissue to determine where dysfunction originates. That is more often than not a work in progress, and one should be very flexible in making ongoing changes without losing sight of the end goal. So that, for example, if it is the foot or knee with symptoms, while it should be addressed and local symptoms treated, the spinal stability must also be looked into. If not, the symptoms may eventually reoccur or show up at another site, since the fundamental issue may not be resolved.
To achieve an end goal, the exercise prescribed must be specifically tailored to the individual. While finding dysfunction is like detective work, determining which exercise must be utilized is an art. A physical therapy gym/clinic must be equipped with different choices based on each individual’s preference. For example, a housewife who is a homemaker, may do well without much equipment and is more likely to follow through with the home exercise program with simple exercises just activating the muscles (maybe using the wall or easily available things within the home: tennis balls, strap/belts, cans/bottles, etc). On the other hand, an athlete used to various equipment in a gym may be proficient with foam rollers, balance discs, weights, bands, and multiple other tools employed by a physical therapist and may be likely to follow through with a set home exercise program if it employs such equipment.
Broaching on the topic of home exercises, it forms a very prominent part of the rehabilitation process, since you see a physical therapist only 1-2 per week. The journey back to wellness is based on an efficient, engaging, and workable home exercise program. A good understanding of the exercise patterns and repetition is key. Sometimes one is diligent with exercise, yet the rehabilitation program may not achieve the goals because of incorrect movement patterns. Ask questions if needed, study your body well, and go with the guidance from the physical therapist. Only you can make that difference in your wellness, and with sincerity and constant eye on the goal, one cannot fail.
This week I did not have to think at all about what I would write. Of course it would be on the back, after having written about stability in the last post, and backache being one of the foremost ailments generally experienced. Backache can be caused by a multitude of factors, which may range from habitual bad posture and movement patterns to trauma and injury with surgical component. Interestingly, as I am writing this post, I have come across an article in the Wall Street Journal regarding meditation as an option for pain relief in lieu of narcotic pain killers after a back surgery. In my opinion, pain killers overdose acts much in the same way as antibiotics overdose. That is, it eventually decreases in effectiveness.
I will keep this post simple- backache, as a result of poor postural habits and non-traumatic back pain, and an insight into its prevention.
At birth, the spine is c-shaped or “kyphotic.” After birth as the child lifts the head and starts walking, the “lordosis” (convex forward curve) in cervical and lumbar curves develop. The primary “kyphosis” (concave forward curve) is preserved in thoracic and sacral vertebrae. The sacral vertebrae are 5 in number, however they are fused into 1 bone, “the sacrum.” Pretty interesting? Moving on then, in an adult human being, the spine is made up of 33-35 vertebrae (7 cervical, 12 thoracic, 5-6 lumbar, 5 sacral, and 3-4 coccygeal). With all daily activities which have an impact, like walking, running, jumping, the spine must transmit forces multiple times that of the body weight. To absorb the magnitude of these forces there are the intervertebral discs or IVDs, which are made of cartilage and a soft gel-like center. The muscles and ligaments as well as the “taken for granted/forgotten” fascia allow a smooth movement during any activity. Fascia is the soft tissue that is semi- fluid and very forgiving, providing much needed flexibility, protection, and freedom of space to move to all structures like muscle, nerves, blood vessels, and even organs, which it completely surrounds.
Now with habitual poor postures (static posture), the soft tissue may shorten and tighten at certain places and stretch at others, straining nearby structures including ligaments and joints/bones, causing visible postural deviations. The adapted soft tissue alters the movement patterns (dynamic posture) in slow and steady progression (over months to years) and eventually, at a “critical point” the system fails and may be experienced as discomfort or pain, predisposing to further micro- injuries. Once injured, any healthy, soft and flexible tissue can be replaced with non-flexible, cord- like collagenous tissue. This continues and is cyclical, leading to recurrence of back pain. This then is the most prevalent and most benign form of chronic backache with episodes of acute exacerbations. The point I am making here is not to create fear, albeit amplify that, if alert (and there is plenty of time and opportunity to do so), this is totally preventable at any point in the cycle. The simple answer to that: “awareness and stability before mobility.” Sound familiar?
I will consider some examples here: this being the “Silicon Valley,” a large population is made of professionals spending majority of time on computers or at the desks, sitting with slumped posture. How about the students and children writing and involved in use of technological devices? How about impact caused by improperly done yoga or other popular fitness routines nowadays? Technology is not good or bad in itself, it is just a tool in our hands. Good posture lies not in the desk and chairs we use, but within us.
To keep your back healthy and strong:
*Be aware of the sensory signals that your back, the neck, legs, and hands/arms send to the brain.
*Listen to the body and make that important decision to stand and stretch frequently (every1-2 hours), keeping the muscles and ligaments supple, flexible, and happy.
*Proactively engage in spinal stabilization exercises maintaining a healthy back.
Recently there was a young girl who reached the finals in America’s Got Talent. The amazing flexibility she demonstrated was “beyond this world.” Bending backwards and folding in half, hanging onto a ring by the neck, shooting an arrow with amazing accuracy with the feet, and so on. One statement she made impressed me. She said “People often wonder does it hurt? No, it does not hurt at all.” One does not need to go to such lengths to prove anything. However, it is possible to do all this if it is our calling and train to be the masters of our bodies in our own way.
As contributing members in society, we each play a valuable role. Being healthy and to continue doing what each one of us does the best, it is important to not only to respect the body, which is one of the instruments along with our minds and hearts being the others, but also to keep it efficient to serve the best we can. There is a lot more awareness nowadays to stay “fit.” Popular fitness lays emphasis on movement mainly, undermining the stability aspect. Let us then bring our awareness to the important function of stability underlying all mobility/movement, and enjoy being ourselves. Our back has an important role to play here. So let us bring the “backbone to the forefront of our awareness.”
The last post was about functional movement patterns. Here I will lay emphasis on stability. So what do we mean by stability? The dictionary defines stability as:
“1. The state or quality of being stable, especially:
a. Resistance to change, deterioration, or displacement.
b. Constancy of character or purpose; steadfastness.
c. Reliability; dependability.
2. The ability of an object, such as a ship or aircraft, to maintain equilibrium or resume its original, upright position after displacement, as by the sea or strong winds”
In physical therapy, as in other allied health fields, the focus is shifting to a wholistic approach. When one visits a PT and develops goals, it involves all of the above. In this case it would mean balance or the body’s ability to maintain an upright position at rest or after displacement, or in other words- shift of the center of gravity(cog) of the body. It also means, however difficult the task may seem, stay steadfast on the set goal for achieving that stability and that you may rely on, or depend on, your physical therapist to guide you through the process.
The center of gravity is a hypothetical point where the mass or weight (mass on which gravity is acting) of the body is concentrated. The cog of the human body lies just in front of the S2 vertebra, very close to the navel or belly button. In order for a body to be stable, the plumb line (simply a string with weight at the end-easily made at home) through the cog must fall within the base of support (BOS), not merely within, but rather at the center of the BOS. Let’s consider static stability in the standing position with the area under and in between the feet being the BOS. (Please refer to the pictures 1. and 2. below). Now, if we drop a plumb line from the cog or for practical purposes from the navel, it falls in the area between the 2 feet, in front of the ankle joints. In this position we are fairly stable. Consider a displacement of the cog forward, for example, when we walk or bend forward. This movement brings about a shift in the BOS, yet we do not fall at every step. This then forms the dynamic stability, with a constant change in BOS and muscular forces bringing about movement to maintain cog over the BOS. Very efficient is it not? Who knew?
Well, don’t just sit and read, go ahead and try it for yourself-find out where your cog is within the BOS.
Now let’s consider the dynamic muscular forces responsible for stability. Our trunk and spine is the central core from which extend our extremities. Trunk musculature is therefore extremely critical to maintaining stability, while the limbs are freely moving and reaching out during activities. We have all heard about the “core muscles” in this respect (I think “trunk stabilizers” or just “stabilizers” is a better term to refer to these muscles). Though there are several muscles in the trunk, we will consider only the prime stabilizers. The muscles that form a sort of corset around the trunk/waist are the Transverse Abdominus (abdominals) in the front, the Multifidi (back extensors) in the back and the Internal and External Obliques (also part of abdominals) and Quadratus Lumborum along the sides or flanks. (Please refer to picture 3. below). Also included are the pelvic floor muscles which sort of form the floor or base of the bucket, and the diaphragm, which is like the lid, with the corset being the sides of the bucket. This brings us to the importance of breathing and stability, and also explains why yoga and other forms of exercises use breathing techniques to train the stabilizers- it is because the stabilizers and diaphragm as well as pelvic floor muscles work in synchrony.
For stability, it is not only the strength in these muscles that matter, as is popularly believed. The timing at which these muscles contract during movement is very crucial to stability and efficient functional movement patterns. For example, for a back ache, your PT trains you to increase awareness of these stabilizing muscles by having you lie down when your body weight is supported and muscles are relatively relaxed. Therefore you can focus on “isolating” these muscles initially to activate them voluntarily. Stability must always come before mobility, and these trunk stabilizers must essentially fire first prior to those prime movers by as little as a fraction of a second. This allows you to experience an effective, efficient, and purposeful movement pattern. Once your muscles fire in the right pattern, this pattern is repeated in different positions through various exercises, and finally strengthened with the use of thera-bands, weights etc. Frequently, the latter two happen simultaneously.
Hope this gives some insight into the importance of keeping the trunk stable while the peripheral limbs are engaged in motion. Till next week…
You see a lot of “functional movement patterns” mentioned on the StableMovement Physical Therapy website: www.stablemovement.com. So what is this “functional movement pattern” all about?
Our bodies move at joints, and it is the muscles that facilitate movement from a mechanical perspective. The brain sends out a message and nervous tissue conducts these as electrical signals to essential joints and muscles, which bring about precise movement within seconds. All this is so automatic to the point, that unless we keenly observe and bring our awareness to it, it is near impossible to make any changes to fine tune it.
A movement is functional when it achieves a purpose. For example, sitting to standing from a bed or a chair. We are all able to connect with this as we perform this several times in our day. Go on and try it, only this time, bring your awareness to the movement instead of doing it “automatically”. Notice how the trunk muscles fire first, stabilizing the spine and then the limb muscles fire in a coordinated pattern to allow the joints to have a smooth movement rising up? A symphony of orchestrated muscles firing; the static stabilizers, the dynamic stabilizers, the prime movers, the tuning muscles. The trunk stabilizes foremost, as weight is shifted forward onto the feet which will now serve as the base of support. The shoulder blades may be stabilized in order to push up with the arms, or the arms may not be used at all if one has good stabilization at the spine and strong legs to support. Next the hip and knee joints flex, the ankles dorsiflex, then hip and knee joints extend and elongation of spine takes place for an upright posture. The body’s center of gravity (weight)shifts upwards and translates back towards the heel for even distribution on the feet so that the body’s line of center of gravity falls within the base of support (the area covered by the 2 feet and space in between). You are now in the standing posture. Well done.
You just brought your awareness to this simple, taken for granted pattern. It is fun to do this in slow-motion, and then fast speed. What needs more muscle control? What needs increased muscle restraint? See how the 2 movements are alike, yet different in the muscular demands? Want to have some more fun? Break down the pattern at the joints at particular parts of the motion. Hold that posture for a few seconds. You will really bring awareness to the most active muscles during that posture in the pattern. For example: the trunk stabilizers, quadriceps, hamstrings, calf muscles, or back extensors.
The functional movement is actually made up of many such “dynamic postures” performed in series for a smooth movement pattern, much like a film is made of many frames of pictures. If any one of these dynamic postures is “faulty” due to lack of adequate joint range of motion or muscle tightness, the pattern changes or compensation at different joints takes place to complete the motion. This pattern change may be subtle and go unnoticed or ignored. Over a period of time, these changes accumulate until it reaches a critical point when the individual is aware of discomfort or even pain in the movement. That may be the point when you decide to see a doctor or health care professional, while all along, your body knows what is going on and all you need do is bring awareness to this pattern. Once you get a good grasp, this awareness translates into everything you do, and you start noticing subtle nuances in movement. In fact, that is what gymnasts, dancers, or athletes are doing as they train.
A physical therapist, having studied the norms of movement range for various joints (anatomy) and muscle action (kinetics) and analyzing human motion (biomechanics and kinesiology), simply applies this to your movement patterns. To change a faulty movement pattern, the movement is slowed down first to bring awareness to the appropriate joint and muscles in question. The pattern may even be broken down into its components, and other functional movements that employ a similar pattern may be used to train the corrected pattern. Once mastered, attention is focused on repetition and speed so that this relearned movement pattern is performed subconsciously, without thought-which indicates true mastering of a skill, kind of like being in the drivers seat in a self-driving car.
TGIF and welcome to the long weekend. Here is the weekly post. Hope you enjoy reading.
Let’s delve into stretches and how important they are by drawing a parallel between exercise and music or art. For example, just as you hold your notes prior to singing, or recognize lines, edges, angles and various shades/tones prior to drawing, stretches are a must prior to exercise, a prerequisite to any exercise program for the best possible movement pattern. I will cover only general stretch principles in this post.
You probably have noticed how you begin your day with a stretch, as you get out of bed, stretching simply feels good: stretching arms up overhead, or stretching the torso, even leg and foot stretches feel good. How about yawning? It stretches the muscles around the mouth and chest cavity. These are what I call the “informal” or “spontaneous” stretches. After a period of restful sleep, these stretches gently guide your awareness towards the body and allow you to safely navigate in your surroundings. Then there are the “deliberate” stretches we perform to achieve a certain effect. The stretches we are looking into fall in this category. One key to stretches, whatever category they belong to is that when done correctly, they feel good.
With some of the popular forms of exercise to stay fit these days such as walking, running, hiking, bicycling, or participating in specific sports or dance forms, muscles tend to tighten in certain patterns, slowly decreasing available range of motion and creating new movement patterns unbeknownst to the exerciser. Yoga, gymnastics, and such forms of fitness methods on the other end of the spectrum, come with probability of increased flexibility, sometimes to the point of hypermobility, which needs a different solution: one of stabilization. The point I am making here is moderation is important in any activity.
Putting the aforementioned points together, it now makes a lot more sense that, done in moderation, stretches feel good. Underdone stretches on one hand are ineffective and may lead to pain and injury by persisting on improper movement patterns due to stressing some joints to limit of available movement and then compensating demand for remaining movement at other joints which may be needed to provide stability. On the other hand, overdone stretches may become a source of pain and injury for lack of proper movement patterns as well, recruiting the increased range available from joints that are meant to provide stability.
Now that we have some basic information, let’s consider techniques in stretching. Simple stretches involve acquiring certain body positions and holding the muscle in stretched position, progressively increasing the time from a few seconds to minutes. This ability differs from person to person and hence it becomes important to establish an ideal individualized stretching program. During stretches, physiologically, muscle tissue, due to elastic properties, lengthens according to its tensile strength. There are mechanisms in our body which tell us the appropriateness of stretch: done slowly it allows muscle tissue to adapt and lengthen in healthy fashion. When done quickly and with large amplitude, stretches may lead to pain/injury by causing micro-tears in the muscle fibers. Eventually the body heals the micro-tears by laying down collagen tissue (which is not as elastic as original muscle tissue) and increasing the tightness. Hence, technique of stretch is important in achieving flexibility goals.
As I mentioned in a previous post, our bodies are a gateway to knowing ourselves better, and stretches are a valuable tool in that respect. Increasing awareness may help in mastering the skill of gradual and progressive stretches based on your goals. After a certain period of stretching and performing activity to take the muscle through that newly acquired range of motion, it becomes a “way of life” so to speak, and further stretches may not be needed for that activity. For the achievers amongst us, the next goal awaits, and for those content, you have arrived at your desired lifestyle, at least for the moment.
Ami Gandhi is a licensed physical therapist in the state of California. She is the owner of StableMovement Physical Therapy, a small boutique practice in San Jose that offers patient centered, one-on-one, hands-on physical therapy.