Month: July 2016

Sitting is bad

Consider the human behavior that we call sitting. Notice what’s going on all around you. Our environments largely reflect that so much of our work and leisure involves prolonged sitting. Sitting has been implicated in numerous orthopedic problems like headaches and disc herniations. You do not have to earn a PhD in biomechanics to confirm all the protruding heads, C-shaped spines, and extremities that have adapted to the chair position.

A recent study by the American Heart Association found that whether or not you exercise, long sedentary periods raise your risk of developing heart disease, diabetes, cancer, and obesity. In other words, a lunch time jog does not make up for a typical day of sitting at work or class, and in the car, and while eating and reading and watching TV.  In 2010, British experts linked prolonged periods of sitting to a greater likelihood of disease, and Australian researchers reported that each hour spent watching TV is associated with an 18% increase in the risk of dying from cardiovascular disease.

Blaming the chair

In the United States, the science of ergonomics is generally considered to have originated during World War II. Since then, both the medical community and furniture companies have attempted to design safe chairs, desks, and anything else needed to perform repetitive sedentary work.

Numerous ball-shaped chairs, kneeling chairs, and ultra adjustable chairs have been proposed. These are definite improvements with some degree of scientific and plenty of anecdotal evidence for effectiveness. Yet many ergonomic solutions spare one part of the body at the expense of another, don’t fit properly at common table heights, or have an odd appearance that is unacceptable for a professional workplace. Other ergonomic chairs simply don’t accomplished what most people still want: enabling us to sit still and comfortably accomplish work.

It is my opinion that we are asking far too much from our chairs. The research seems to indicate that a healthy chair is an oxymoron. We may as well be talking about designing a low-impact hammer or the best Oreo for weight loss.

At this point, the conversation on Sitting Disease warrants some perspective.

Lesser of evils

I imagine ages past when people hoped for a time when less strenuous work would allow them or their children to lead happy and healthy lives. These days, we are far less optimistic about that idea. Only recently have we began to understand some of the risks of white-collar work.

Sitting is not the only thing that is taxing on the body. The far majority of humans throughout history have had to perform more or less repetitive physical labor, rarely by choice. In modern times, blue-collar workers of all ages are in worse health than white-collar workers, even after controlling for socioeconomic variables. Blue collar workers are more likely to suffer from arthritis and report 3.4 more musculoskeletal injuries per one hundred workers. At age 65, blue-collar men score a mortality rate 42 percent higher than white-collar men.

When the daily grind involves repetitive lifting, carrying, pushing, pulling, kneeling, and operating heavy machinery, a good sit is legitimately therapeutic.Who among us hasn’t been there after even a few hours of yard work?

“Ahhh. The chair.”

The average American has far more leisure time than ever. We have the time and freedom to choose whether or not we want to watch TV, exercise, or otherwise fight back against what ails us.

The problems

When researchers closely examine the evidence, much of the data shows that it is physical inactivity, and not necessarily just sitting, that is unhealthy in various ways. And we already know that too much of anything is bad for us, and extensive sitting happens to be our default mode of sedentary living.

Sedentary living is undeniably linked with sitting, and modern society demands sitting long and often. But the fact of the matter is that our bodies gradually break down and fail us. If not from sitting, we would likely suffer repercussions from months and years of farming, hanging drywall, sorting packages, standing on cement, or some other task.

Some not-quite solutions

1. All movement counts! Be mindful of the realities of sitting for the majority of the day. Do not take the threat of sitting down…sitting down. Work with focus and efficiency, but don’t get “locked in.” Fidget, stand, kneel, walk and move as if your life depended on it, because it does. Search the keyword NEAT (Non-exercise activity thermogenesis). Fascinating evidence is emerging that every small movement does count.
2. Exercise Smarter! If many of your waking hours involve sitting, for heaven’s sake, don’t sit during the time you allocate to exercise. For example, the seated leg extension machine, the bicep curl machine, and the recumbent bike are not your best choices at the gym unless you have a specific disability or other good reason for using them. I’m an advocate of exercises like squat and lunge variations, step-ups, shoulder presses, and pretty much anything where you must practice good posture, balance, and control the movement of multiple body segments against gravity.
3. Work Smarter! Schedule breaks from sitting, stretch, and take the requisite time and effort to create an environment that enables you to work efficiently over the long haul. Stand up and move or do something different for 10 minutes out of every hour. Remind employers that an ounce of prevention is indeed worth a pound of cure. For instance, when the Take-a-stand protocol was introduced to a large number of sedentary workers, the time spent sitting was reduced by and average of 64 minutes per day and health care costs were reduced by 34%.
4. Mandatory Posture Lecture! As a physical therapist it is my duty and obligation to lecture you about posture. If only you could see my hypocritical posture as I type this! Why is it so difficult not to slouch? Gravity, our ancient friend and foe, is relentless. Stretching, strength training, “adjustments” and ergonomic chairs all only provide the potential to sit and stand with good posture. In the end, the only way to actually achieve good posture is relentless attention to sitting and standing with good posture. 

Don’t stay in any one positions for too long, and don’t give up. Variety, the spice of life, is also good medicine!

Given this problem with no easy or complete solutions, one of the most powerful things we have is gratitude. We can envision a narrow road that lies between the broad paths of sedentary living and backbreaking manual labor. With the perspective and time we have been granted to learn and engage in activities that do not involve chairs, maybe we can even be thankful for our place to sit.

 

References available upon request.

Can you handle the truth about stretching? When we’ve invested so much of our precious time droning through boring stretches and touting their benefits? And we floss our teeth and wear sun screen and eat yogurt and stretch, not because we particularly like any of these things, but because they’re good for us.

Right??

Well the truth is that stretching is limited. It’s necessary and good at times. But for relatively healthy individuals, stretching is definitely overrated.

Stretching neither prevents nor promotes healing of muscle sprains strains.

In fact, I’ve seen quite a few people try to stretch muscle strains to the point that they interfere with proper healing. So after a muscle strain, back off for a while. For circulation that promotes healing, try some light calisthenic and cardiovascular type activity that involves the strained muscle group but does not reproduce the pain.

A lack of flexibility is NOT the primary reason why you strained your hamstring while trying to stretch that single into a double.You expected your body to sprint full steam on a cold day in March after months of sitting on the couch and jogging?

What prevents muscle strains? Proper training progressions and strength training are the most helpful things you can do to form strong, resilient muscles that don’t get torn apart from high force, high speed muscular contractions.

Prepare for weekend warriordome by building up gradually with lunges and squats and dead lift variations and weekly sprinting sessions during the winter. Identify and work on significant asymmetry and form imbalances, which are the enemy of muscles.

Stretching does not reduce muscle soreness. 

It just won’t. You can decrease muscle soreness by going easy at first and gradually acclimating to whatever it is you need to do. Or by going like a mad man and making up for it with ibuprofin.

Stretching before activity does not increase performance.

In fact, there’s ample evidence that static stretching causes a short-term slackening effect on muscle-tendon units, which translates to decreased peak strength and power. Not exactly what you want for acts of powerful athletic awesomeness.
Instead try regularly strength training and working on muscle and movement imbalance. Before activities and events, go through 5 to 10 minutes of dynamic warm up and simply going easy and breaking a sweat before pushing full steam.

Stretching does not improve strength gain or muscle size. 

Muscles grow larger from the progressive overload of being torn apart, healed, and torn apart again. The best way to do this is through heavy resistance training. Muscles get stronger through both an increase in their size and (even more so) through the brain learning to utilize them more efficiently.

Stretching lengthens muscles only temporarily, and little to no permanent structural adaptations take place. Much of our apparent increase in flexibility is due to increased stretch tolerance; the nervous system learning to put up with the discomfort of a stretch.

Stretching does not improve posture. 

Let me be careful here, because I truly believe that specific stretches that reverse the mechanical forces that we regularly place on our bodies are quite valuable. But more than anything, posture is a result of complete neural programming. You could say it’s a lifestyle thing.

Stretching and strength training and exercise in general will all effect posture, but not nearly as much as whatever it is you do for hours at a time over days and weeks and months. Duration is king when it comes to posture, that’s why the only real fix is to be ever mindful of how you carry yourself. It’s a matter of adopting the correct posture until neural reprogramming is established. It will take time.

That being stated, every single person who sits for a spell (and that means you!) should be doing thoracic extension, hip flexor stretches, and cervical retraction. But it’s all for naught if you collapse back into a heap in front of the computer.

Don’t hate on stretching too much though.

Physical therapists make a living by getting people to stretch and performe corrective strengthening exercise. I regularly implement hands-on mobilizations and manipulations that help loosen tight tissue and establish new movement patterns. By tight tissue, I’m referring to joint capsules and ligaments and scar tissue that’s may be interfering with proper joint mechanics or directly putting strain on neural structures.

There are certainly some stretches that specific athletes should be doing at specific times. For example, most (but not all) pitchers, volleyball players, and other overhead athletes should be doing some version of shoulder internal rotation and horizontal adduction (cross body) stretches to counteract the bazillion repetitions of external rotation and abduction strain they place upon their shoulder joint complex.

So stretch what you need to and when you need to. But don’t feel too guilty if you have to skip it before exercise. My dentist says you should floss your teeth every day though.

“My back is feeling mostly better. Now I just need to get back to yoga to stretch and strengthen my core.”

This, a direct quote from a former physical therapy client, is the type of statement that I hear fairly often. In two physical therapy sessions, this patient had made fair progress in terms of pain control and basic function. She would have gained a lot from a few more weeks of PT.

Yoga can be challenging. Yes, I’ve done yoga. Three times. I’m not anti-yoga. Let it be known that I’m definitely pro- good yoga. What I’m against is the many yoga instructors and their followers who preach yoga as the magical end-all, be-all solution to every ailment.

With yoga, the total body movement is quite limited. It doesn’t burn many calories as compared to other forms of activity like a modest walk or cleaning the house. The intensity is limited. Jogging up a hill or a few minutes of step-ups will better increase your muscular and cardiovascular endurance and rev your metabolism. Although better than nothing, the benefit of yoga for strengthening is limited as there are no external forces to control. Even in terms of improving flexibility, yoga is far more limited than you may think.

-Gasp- He won’t even concede that yoga is good for flexibility?

Yes, I said yoga is limited in its ability to appreciably effect flexibility. I know from experience, that for every person who learns how to bend their body into an inverted, single leg wobogong, there is someone who achieves minimal gain in flexibility. People who are already quite mobile gravitate toward yoga because they are good at it. They are usually not powerhouses in activities that require running, jumping, and change-of-direction. But for those with average or below average flexibility, the chances of improving is truly about 50/50.

How could this be? Well, here are a few reasons why yoga may fail to appreciably improve flexibility.

1. When there is true stiffness at a muscle or joint, the body will take the path of least resistance unless given a darn good reason not to. I often see this in the clinic: people who frequently do yoga still have spines that move too little at some segments and too much at others. I see people who stretch their legs daily yet their ankles and hips move horribly. They unknowingly stretch and move in the path of least resistance. Getting the tightest segments to contribute to the movement requires much intent.

2. The feeling of tightness may be from inadequate strength elsewhere. A common example of this is that errbody wants to stretch their tight hamstring, when in reality the hamstring are on over-drive in order to help stabilize hypermobility (too much movement) at the spine. If this is the case, more stretching of the spine will not help the situation, and aggressively stretching the hamstring may make matters worse.

3. The feeling of tightness may be from too much flexibility elsewhere. This happens often. An overly flexible foot will present as tightness or shin splints in the lower leg. A too flexible spine will present as chronic muscle spasms in the back and hips. Again, stretching will do little to correct this and definitely has the potential to worsen the issue.

There are more examples of when a yoga type stretch is not ideal for addressing perceived inflexibility. The important thing is not to simply stretch or strengthen, but to concern yourself with the details of exactly how you’re moving when you stretch and strengthen.

Please understand that my claim is that yoga, in a generic sense, is by no means a magical cure for every ailment, including poor flexibility. While I’m picking on yoga, the same could be said for many other forms of exercise. And here we arrive at what I believe is the heart of the matter.

Some version of this comes up fairly often in this time of escalating copays and less financial margin. I get it. The alternatives are enticing: the $50 per month boot camps, the $10 per session or $5 per month gym membership. It’s certainly more affordable than the cost of having an expert professional (yes me, but not only me) assess an individual structure and way of moving, and match that up with what that person needs and wants to do in life.

Can *good* yoga take the time to perform an individualized assessment and come up with a detailed exercise and form prescription? Absolutely! But it’s rare within most fitness settings. This level of service demands a certain skill set, time, and attention. There is no trainer or facility that will stay in business providing this level of care for $10 per month.

The guy to the far right is approaching ideal form.
The rest of them could use a detailed assessment.

But does $10 per month work well? Can a person effectively manage their own pain and recover function armed with a membership and maybe some knowledge from a friend or YouTube? Sometimes they can, quite honestly. But the success is often short-lived. Problems seem to resurface with a vengeance.

The adage holds true in the fitness realm: You get what you pay for.

You tried off-the-shelf inserts, injections, and a host of other treatments to manage your lingering foot pain. None of these resolved the issue and you sought further advice. After a thorough (or not-so-thorough) examination, your orthopedist, podiatrist, physical therapist, or chiropractor recommended custom orthotics.

You said, “Sure, anything to get back to normal,” to the tune of approximately $285.00 (or much, much higher so I hear).

You eagerly received the custom devices prescribed by a specialized medical professional and precisely molded to capture every contour of your very own feet. A few hours or days later you cursed while shaking your fist to the sky, asking why the blasted things hurt so much.

This NEVER happens in our practice, where every client prescribed custom inserts happily skips away on the wings of magical inserts carved of unicorn horns for maximum durability and control, lined with a plush top-cover of genuine baby alpaca feathers beneath New Zealand rainbows.

“Yeah that’s marginally cute. But my foot hurts.”

Before you trash your custom inserts or use them as a door jam or ice scraper, here are a few common reasons why they may be hurting your feet:

1. Inadequate break-in period.

Many people who are accustom to squishy insoles in cushiony shoes do not take it seriously when we advise them to wear the inserts for just two additional hours per day. Others don’t believe us when we instruct them to get use to the inserts in simple everyday activities before trying to exercise or work for prolonged periods in them. While some people need more or less time, this is a realistic and appropriate tapering period.

The fix is to wear the inserts an additional two hours per day, building to a full day of light activity prior to exercising or working hard in them.

2. Inadequate footwear.

If your shoes are too tight and you jam a custom insert under a sensitive foot, it will usually make the pain worse. If your shoes are old and worn down, the custom device will be sitting on an uneven surface and the contours captured in your foot mold will not apply well. Even new shoes that are chincy (you bought on sale at Kohls) or intentionally flimsy (think minimalist shoes) will work against what the orthotic is supposed to achieve, again causing it to sit on an uneven surface.

The fix is to get into a quality shoe with a firm sole that is also adequate in length and width. Don’t try to ride a Cadillac engine on a junk frame.

3. Poor “loading” of the insert.

The most perfect insert in the world may not function as intended if, for example, you have tight hips that force your legs and feet into a toe-out “duck foot” position. If you have weakness or tightness in the ankles, calves, or toes this will likely play into some type of compressive, shear, or tensile strain on tissues in the foot and a compensation in your gait pattern. If you sound like a herd of elephants coming through the house, it is not the “fault” of your shoes, inserts, or even your feet. You may have some old habits to break or strength and flexibility to improve.

The fix is to do all that you can to get your body to move better. Address impairments in balance, flexibility, and strength, and work to approach a more normal gait pattern.

4. Pain and inflammation too severe.

Almost anything that’s a change from the norm will cause a highly sensitive foot to feel even worse. The fix is to lessen severe and intense symptoms medically or with physical measures like exercises, ice, ultrasound, and massage. In some instances 2 to 4 weeks in a night splint or walking boot is warranted to give the foot a fresh start.

5. Orthotics need to be adjusted.

What should be is not always what is. If your feet still hurt after allowing an adequate transition period, placing the insert in an appropriate fitting quality shoe, working on your movement patterns, and taking time to rest and “calm down” highly irritated tissues, it’s certainly possible the the inserts are plain wrong for you.

In that case, your foot specialist should be eager to help you and capable of making adjustments and modifications. Sometimes that means adding or taking away supportive material on the device. Other times that may mean adding a heel lift to one side, an extra layer of padding here or there, or redoing the insert all together.

The fix is to ask your foot and ankle specialist, on the front end, if the cost of the inserts includes time to follow-up and make adjustments as needed.

**The physical therapists and pedorthists at Cardin & Miller PT do allow for this as part of the process.While we make no guarantees, we are quite experienced in dealing with people who have failed other treatments and are going on their second or third set of inserts.

Trouble shoot with these fixes before you use your inserts as a candy dish or book mark. Because anything can be a book mark ; ).

Today I finished treating a runner who had been struggling to recover from a foot injury. She is back on the road again, hoping to complete her first marathon in early 2017.

In order to run faster and stay healthy, she began an on-line strength training routine for runners. The injury she sustained while doing the program set her back at least six months. This is not the first or last occasion of treating an injury caused by an on-line or DVD program like P90X. This is not even the first time that IronStrength For Runners has brought business to my office.

This particular program was created by a “nationally known sports medicine physician” and sponsored by Runners World magazine. The workouts are not terrible if you consider the mode of delivery. But they’re not good, either.

I assume that Dr. Metzi, the creator, ignored or does not know what I’m about to tell you. I have mixed feeling about saying it outright. After all, injuries keep me gainfully employed. But here goes:

—  DO NOT PERFORM PLYOMETRICS FOR CONDITIONING (i.e. what most people call burning calories or generally getting in shape).  —

Inappropriate use and progression of plyos are some of the top reasons for active young- and middle aged people to require physical therapy.

[Plyometrics are explosive powerful training exercises (usually variations of jumping, hoping, and throwing) that effectively activate a quick response and elastic properties of muscles and joints. Here is the Wikipedia entry.]

Plyometrics are included in most home-based programs because they are challenging, require very little equipment, and they produce results.

I’m not against them. Plyometrics are actually great…so long as they don’t destroy you.

Almost every single DVD or on-line fitness guru will have you doing plyometrics inappropriately:

-You will be doing plyometrics without feedback on your form.

-You will be doing plyometrics without even knowing if your body possesses the flexibility and strength to achieve proper form.

-You will often be jumping into plyometrics without systematically increasing the resiliency of the muscles and connective tissue.

-You will often be jumping and thrusting around until you’re blue in the face (in a state of high fatigue).

Each one of these factors -alone- is enough to cause injury, even in young people. Sorry, but it’s the nature of the beast. On-line and DVD fitness programs simply cannot be custom tailored to assess and coach each person on the other side of the screen. And some of them are downright bad (poorly designed).

People of all fitness levels and walks of life make errors in their training. We go too hard or heavy, for too long, too often. We perform exercises incorrectly. We assume that what is healthy or “worked” for someone else is necessarily going to “work” for us. A fitness program or DVD simply cannot navigate the details of where you fit in.

I’ve made my share of training errors and experienced (and continue to experience) the consequences. Injuries…they happen. But the risks are often manageable, and well worth the benefit (and fun!) of leading an active lifestyle.

So put some thought into your plyometric training:

-While plyometrics impose various amounts of impact on the joints, the target body part is the nervous system. Plyos teach the brain to control and coordinate the entire body to be powerful and quick. If 20 minutes once or twice per week is good, more is NOT better.

-Seek instruction from someone who knows what they are doing. Ask questions like “Why am I doing this?” and “What does that certification mean?” If the answers sound like fitness jargon b.s., it is.

-Ideally, you should go through a basic movement screen to see that you pass the known prerequisites to beginning plyometric exercise.

-If you do stand to benefit from and tolerate plyometric activities, do not perform them in a state of fatigue. Keep the rest periods long and the work periods short and powerful. You should never feel completely gassed from these activities.

-For conditioning (getting in shape, calorie burning for weight loss, etc), find lower impact, grinding alternatives like variations of sled push, kettlebell swings and carry, farmer walk, rowing and stationary bike intervals, battling ropes, hill walks, jogs, and sprints, etc.

-If you are a serious runner or other endurance based athlete, see the above points AND do not confuse your resistance and plyometric training with just adding more endurance work. Your muscular endurance is already stellar, and you will benefit most from increasing your strength and power. So “lift” relatively heavy, leap and bound in short, powerful blasts, and be smart about exercise selection.

Again, find a guide for six or 8 weeks. This is usually plenty of time for you to …

lose 30 pounds and gain huge amounts of strength and vertical jump and rock hard 12 pack abs

…you to TRULY LEARN how to best fit an effective exercise program to the structure of your bodyand the demands of your activity.

My apologies to Insanity. I want to thank them for the referrals. And if I spared you an injury, please direct your friend, uncle, or cousin who sustained an Insanity injury to my office.