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Strength Training During Pregnancy

Pregnancy is a time of many physical changes for a woman, and recent research has shown that maintaining or even starting an exercise program can provide benefits to pregnant women and their babies. The majority of research has focused on cardiovascular exercise, but the importance of strength training during pregnancy is often overlooked.

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The Lumbar Spine: Understanding the Science Behind Both Movement and Dysfunction

The spine is a complex structure, comprised of nerves, connective tissue, bones, discs, muscles and other essential integrative components. Whether it getting out of a chair or car, lifting or carrying items, some 29 muscles around the pelvic girdle and lumbar spine, provide stability. In this article, we will review the anatomy of the spine, common injuries to the lumbar spine, functional assessments and training strategies to work with clients with previous injuries.

Matt Cavalo Photo

Fearing the Gym after Injury or Illness

One of the activities my wife and I used to really enjoy doing together was going to the gym. We had a personal trainer named Eric. Eric was funny, knowledgeable and understood how to maximize the workout for both me and my wife. Having a personal trainer that understood both our individual needs kept us motivated to workout. Eventually we moved and got a gym membership. However, we did not sign up with a personal trainer and the gym experience was no longer that unified activity we enjoyed together like we did when we worked out with Eric.

Senior woman with help of physiotherapist

Cancer Wellness Within Healthcare – A Date With Destiny

There are three distinct areas of exercise as it relates to healthcare – and reimbursement. Most trainers and fitness professionals are aware of cardiac rehab, which actually began in the US in the 1960s, but gained ground as a reimbursable health care service in the 1980s. At that time there was a lot of good exercise and sports medicine research available in peer reviewed publications, and there was a push on the part of health care to include cardiac rehab as part of rehab and health promotion services. The fact that most cardiac programs were reimbursed up to 36 sessions was a plus.

The second area of healthcare that is relatively new is the Silver Sneaker’s program – started in Arizona in 1994, it quickly grew to the nation’s leading reimbursable wellness program for seniors. It was accepted by Medicare Plus Choice, and a host of other health plans across the nation – so that within a few years of its inception, seniors from anywhere in the US could take advantage of free exercise and health classes at area health clubs, YMCAs, and JCCs. The program was recently sold to Healthways health systems from Nashville for over $400 million – a testament to the interest of such programs within the healthcare industry.

The third area is the use of exercise therapy in worker’s compensation programming. Over the past decade there are some significant programs implemented that contract with large employer groups and HMOs to use exercise both in a preventive and therapeutic format. These programs include strength and aerobic training geared to improve functional strength, reduce WC costs and reduce lost work days. Clearly these areas of clinical exercise have set a precedent regarding both the use of fitness programs in healthcare, and reimbursement for these programs through third parties.

Active seniorsEnter Cancer Wellness. There were few programs for cancer survivors for any type of health program in the early 1990’s. A few health clubs and hospitals had specialty exercises for persons with cancer, but programs really started to grow when Dr. Meryl Winningham from University of Utah began publishing the first sports medicine research in the field in the 1980’s (which became more widely read in the mid 1990’s), and champion cyclist Lance Armstrong made his remarkable comeback from cancer in the late 1990’s. Over the past decade the number of health clubs and hospital wellness centers that offer cancer exercise programs has grown exponentially. There are now hundreds of programs in existence nationally – in clubs, private training centers, Pilates studios, and hospitals. More are interested, but the main question remains – is this program reimbursable?

For those in health promotion who haven’t noticed – reimbursement has changed dramatically in the past 10 years. Programs that historically received reimbursement (such as cardiac rehab), have been cut dramatically (while, ironically, cardiac operations and prescription medication costs have escalated three-fold). However – that doesn’t mean that reimbursement doesn’t exist for health programs, you just have to know where to look. An example is smoking cessation classes. Instructed by counselors and physician assistants, most of the reimbursement for these classes (and nicotine replacement therapy) is funded by state tobacco settlement grants and initiatives, which is very helpful in terms of passing along savings to patients.

Is reimbursement possible for cancer wellness? Select groups from areas in the US are working with local health plans, or pharmaceutical companies to capture their markets in terms of offerings to patients. For those who are interested in looking towards reimbursement for their program – here is some advice for getting started:

  1. Find out how many persons in your region are cancer survivors. Your local cancer treatment center should have statistics. Most areas have well over 1,000 new cases per year. You may also market to persons who have had cancer diagnosed years before. They may still attend support groups, or be on mailing lists from the same cancer centers.
  2. Establish a relationship with a local oncologist or treatment center. You may be able to hold exercise programs on-site and bill through your community local oncology or rehab clinic. This is similar to billing for group therapy or physical therapy. However – it should be remembered that this is a wellness program, and there are specific wellness codes that physicians and billing departments can bill under.
  3. Know your billing codes. In order to receive any form of reimbursement – you should know the system you are working in. There are resources that may assist you in learning coding for wellness programs, and you should take advantage of them (see resource section).
  4. Know what outcomes you are interested in reporting. For many cancer patients, a reduction in lymphedema, less pain and fatigue, and increases in fitness parameters are an excellent way to show that the program is working well. Improving these outcomes will also boost attendance, which is another important aspect of the program (compliance).
  5. Look for local sponsors. A proposal to local pharmaceutical reps may increase your odds of receiving reimbursement – through a third party such as a pharma company. They often set aside money in their budgets for health programs, and cancer wellness may fit the bill very well.

Health Care Collage Words Medicine BackgroundWhat to do once you’re up and running? In the first year it’s important to have a working budget. This may only lend itself to 3-5 patients coming to your program to start. Once they experience the benefits of exercise and wellness, they will quickly tell their fellow patients. It’s also important to spread the word via small group lectures and fitness demonstrations. Since most cancer centers have monthly support groups, it’s a great place to conduct a 30 minute lecture and demonstration for local survivors. Next – a couple of sample articles for the local newspaper (perhaps a series) on the benefits of exercise for cancer survivorship. There are new research reports out each month. Lastly – call your local radio show and book a time to discuss exercise for cancer survivorship. They would love to have a topic like this for their time slots.

The initial year is a “make or break” one for survivor programs. In my experience with many of my national programs – those that got some funding, and did some promotion have programs that have grown. Those who relied solely on patient membership fees in many cases have not been able to grow their programs. Funding is important, and reimbursement may be a part of patient’s health plans, so it would benefit you to contact local health plan reps to see if they cover the cost of post rehab exercise, and/or health club membership for their members.

Cancer Wellness is one of a handful of growing wellness programs in this country that health specialists AND physicians are looking to for avenues of increased reimbursement, or sponsorship. There are many local and regional resources (cancer treatment centers, non profit organizations and foundations, pharmaceutical companies, and regional HMOs) that may be interested in funding such programs. It is up to you to start looking for financing as you start your education program. This will ensure future success at both the educational AND financial levels.


Written by Eric Durak, Medical Health and Fitness ©2011-2014. Eric Durak is the President of Medical Health and Fitness, and Director of the Cancer Wellness CEU Program in Santa Barbara, CA. He is also the author of The Reimbursement Book for Health and Fitness Instructors . Contact him at edurak@medhealthfit.com / 805-451-8072. www.medhealthfit.com

References
Durak, EP. The important link between exercise and cancer. ACE Matters. Pg. 13, Sept. 1999
Author – Exercise reduces cancer treatment side effects. Health News. 12(9):pg.8, 2006
Jones, LW, Denmark-Wahnefried, W. Diet, exercise, and complementary therapies after primary treatment for cancer. Lancet Oncology. 7(12):1017-26, 2006.
Korstjens, I, Mesters, I, et al. Quality of life of cancer survivors after physical and psychosocial rehabilitation. European Journal of Cancer Prevention. 15(6): 541-7, 2006.

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The Foot and Ankle Complex: Understanding the Science Behind Both Movement and Dysfunction

The foot is where movement begins, from the initiating of simple functional movements such as sit to stand or walking, to climbing stairs, to more complex dynamic sport movements such as playing soccer, football, rugby, and tennis. The ankle and foot complex require proper mobility in order for the body to initiate movement or change direction. In this article, we will review the anatomy of the ankle, common injuries to the ankle, functional assessments and training strategies to work with clients with previous injuries.

Todays Dietitian1

The Potential Danger of Acrylamide

This chemical in foods has been shown to cause cancer in mice but more research is needed to determine its risk in humans. Did you know that if clients broil, fry, toast, bake, or barbecue starchy foods, such as bread and potatoes, they can increase their intake of the chemical acrylamide? The more the food browns, the more acrylamide is present.

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The Hip Complex: Understanding the Science Behind Both Movement and Dysfunction

Introduction

The foot is where movement begins requiring mobility to initiate daily and sport specific movements. However, the knee however, requires stability with daily movements, but more importantly, dynamic sport movements such as soccer or football. The hip, like the ankle, requires mobility, to perform such simple movements as sit to stand, climbing stairs and other functional movements. In this article, we will review the anatomy of the hip, common injuries to the hip, functional assessments and training strategies to work with clients with previous injuries.

Figure 2. Hip joint with supporting ligaments

Hip joint with supporting ligaments

Let’s look at the basic anatomy of the hip. The hip joint is a multi-axial ball and socket joint between the femoral head and the acetabulum, similarly to the shoulder joint. The hip is surrounded in white, several ligaments that provide support and stability.

The labrum attaches to the acetabulum deep within the socket between the femur and acetabulum. The joint is covered by a capsule blended with three strong ligaments: iliofemoral or “Y” ligament, which resists extension, the ischiofemoral ligament, which resists extension and internal rotation, and the pubofemoral ligament, which resists abduction.

Muscularly, the glute medius and minimus are located along the anterolateral aspect of the hip to stabilize in the frontal pane, whereas the glute maximus, is located in the sagittal plane posteriorly to facilitate hip extension.

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Supporting muscles around the hip

Common injuries and causes

There are different types of injuries the hip can sustain. The most common are the hip osteoarthritis, iliotibial band syndrome and total hip replacement. In this next section, we will review each condition providing a deeper understanding of each.

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Osteoarthritic hip on left, normal hip on right

a. Hip osteoarthritis(OA)

Mechanism of injury/pathophysiology: A degenerative process of varied etiology which includes mechanical changes within the joint. O.A. affects some 40% of those aged over 65 in the community may have symptomatic OA of the knee or hip(Zhang, W. et al 2007).

Pathophysiology: Osteoarthritis (OA) is a relatively common musculoskeletal disorder, with a high prevalence that increases with age. O.A. is a degenerative process of varied etiology, which includes mechanical changes within the joint (Pisters, M., et al 2007).

Risk Factors: Excessive weight born on hip joint, muscle imbalance, repetitive stressors.

Sign and symptoms: Pain in the a.m. described as “achy” that decreases as the day progresses, pain with weight bearing or walking, difficulty squatting, and lateral thigh discomfort. Patients will describe of pain and stiffness in the a.m. described as “achy.” During the day, movement and activity, improves mobility and activity(Fernandes, L et al 2010). However, the volume of activity if too much, will increase pain. Patients typically have pain with weight bearing or prolonged walking, difficulty squatting, and lateral thigh discomfort.

Medical treatment: Non steroidal (NSAIDS)(examples are Ibuprofen/Advil).

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Iliotibial band syndrome

b. Iliotibial band syndrome(ITB)

Mechanism of injury: Iliotibial band syndrome (ITBS) is a common injury of the lateral(outside) aspect of the knee particularly in runners, cyclists and endurance sports. ITBS is the most common running injury(Ellis, R et al 2007).

Pathophysiology: ITB syndrome is a non-traumatic overuse injury caused by repetitive friction/rubbing of the distal(farthest) portion of the iliotibial band (ITB) over the lateral femoral epicondyle with repeated flexion and extension of the knee.

Contributing/Risk Factors:
• Muscle imbalances/weakness: per the research and my clinical experience, hip flexors and quadriceps are stronger and than the hamstrings.
• Shoe support-important to rotate running shoes every 6 months or 500 miles according to multiple podiatrists I have worked with over the years.
• Increased bouts of running, altered foot mechanics-ie. Orthotics or need for orthotics.
• Lack of stretching, particularly tight ITB, hip flexors and quadriceps. Contributes to increasing compression along the outer hip.

Sign and symptoms: Lateral knee pain over the lateral condyle of the femur described as “dull/achy” that gradually develops & worsens particularly with running. Pain then becomes “sharp” in nature.

c. Total hip replacement

Mechanism of injury: Osteoarthritis is a musculoskeletal condition that develops over time affecting primarily the hip and knee joints. O.A. affects some 40% of those aged over 65 in the community may have symptomatic OA of the knee or hip(Zhang, W. et al 2007).

Pathophysiology: Osteoarthritis (OA) is a relatively common musculoskeletal disorder, with a high prevalence that increases with age. O.A. is a degenerative process of varied etiology, which includes mechanical changes within the joint (Pisters, M., et al 2007). Significant pain, decreased mobility and compromised function, are the primary reasons, a person would typically undergo a total joint arthoplasty(joint replacement). Total joint arthroplasty is a highly efficacious and cost-effective procedure for moderate to severe arthritis in the hip(Santaguida, P. et al 2008).

Common assessments

A simple functional test to assess a client’s movement pattern, is the squat. The squat is a classic fundamental primal movement that someone typically performs almost on a daily basis. With this test, you can observe how the client’s ankle, knee, hip and back moves compared to normal movement patterns.

What am I looking for?
The approach to assessment is all about asking and answering questions about movement:
• How does the client start, finish the movement?
• What strategies do they use? Do they have the appropriate flexibility to perform the movement?
• Is stability a problem? Are there compensations elsewhere in the movement sequence?

How do I interpret the movement?
• It is important to observe the client in both the frontal and sagittal planes
• Observing globally first, then examine how the entire kinematic chain is working as it relates to timing and sequence to achieve the movement

Dynamic Movement Assessments

1. Functional squat
The squat is a classic fundamental primal movement that someone typically performs almost on a daily basis. Whether it is to perform to pick something up or move an item. Therefore, it is important to assess the movement pattern a client uses during this movement.

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Squat in frontal view; Squat in side view

What is required in a squat?
• Adequate ankle mobility, knee stability, hip mobility, lumbar spine(lumbo-pelvic junction) stability

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In place lunge

Observations:
• Note the overall quality and range of movement in the frontal plane and sagittal plane
• Note the symmetry or lack of symmetry with the movement
• Note the point of transition from descending to ascending
• Note if there is an shaking(juttering), which indicates weakness in the lumbo-pelvic junction affecting the entire kinematic chain

Another simple assessment is an in place lunge, which examines one’s control through the entire kinematic chain. The lunge is another fundamental primal movement. The lunge is a dynamic movement that is typically performed during daily activities (stooping down to pick something up) or as part of an athletic movement. This test examines ankle control, knee control and pelvic movement in the sagittal plane.

Training strategies and programming for hip injuries

With any injury, the most important thing to remember is the type of injury, healing time and prior level of function of the client. Let’s begin with ankle sprains.

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SLS stance with TRX

a. Hip Osteoarthritis(O.A.)

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ITB stretch

Recommendations for training: Aqua therapy has been shown in the research to significantly reduce pain, improved physical function, strength, and quality of life(Hinman, Rana S., et al 2007), stretching ITB, hip flexors, quadriceps and hamstrings, strengthening weaker hip abductors(glute medius/minimus). Strengthening specifically hip abductors in various studies when compared to general strengthening, resulted in significant reduction in knee pain, objective change in functional outcome tests, physical function and daily activities(Bennell, K.L., et al. 2010 & Hernández-Molina, G et al. 2008). Core strengthening should also be an integral part of the training program.

b. ITB Syndrome

Recommendations for training: Important to keep stretching the ITB after exercise. Client education on the changing of running shoes every 500 miles or 6 months is key. Resistance training should focus on strengthening weaker phasic muscles (glute medius, minimus and maximus), which are required to stabilize and push off during running. Dynamic core strengthening should always play an integral role of training. Use of aqua therapy can be extremely beneficial and relaxing. It is very important to educate the client on the importance of cross training(ie. yoga, pilates, hiking, and swimming to condition the lower extremity muscles.

c. Hip replacement(THR)

Bridging with physioball

Bridging with physioball

Recommendations for training: Prior to commencing training, it is important to clarify with client, that there are no other underlying health issues. Important to follow hip precautions: avoidance of crossing affected leg towards midline(adduction), and squatting past hip flexion 90 degrees. Training should focus on strengthening weak glute medius/minimus, glute maximus and hamstrings. Effective and safe exercises include; in place lunges, diagonal lunges, seated leg extension and seated leg curl machine. Core strengthening should also always begin with static exercises, and then progressed to dynamic accordingly. Safe and effective core strengthening exercises include; standing trunk rotation with tubing or cable, four point planks, and side planks. Safe dynamic core strengthening exercises include bridging with physioball, single leg bridge with physioball, traveling forward lunge with medicine ball trunk rotation, and four-point plank on physioball as examples.

Summary

The hip is a complex unit thitbdat is comprised of a multitude of ligaments, tendons, connective tissue, muscles that synergistically initiate and correct movement, and stabilize when an unstable environment. Understanding the anatomy, biomechanics and weak links of the hip, common injuries and evidenced based training strategies, should provide you with the insight to better understand and work with clients with these kind of injuries more confidently.


Written by Chris Gellert, PT, MMusc & Sportsphysio, MPT, CSCS, AMS.

Chris is the CEO of Pinnacle Training & Consulting Systems (PTCS). A continuing education company, that provides educational material in the forms of home study courses, live seminars, DVDs, webinars, articles and min books teaching in-depth, the foundation science, functional assessments and practical application behind Human Movement, that is evidenced based. Chris is both a dynamic physical therapist with 14 years experience, and a personal trainer with 17 years experience, with advanced training, has created over 10 courses, is an experienced international fitness presenter, writes for various websites and international publications, consults and teaches seminars on human movement.

REFERENCES
Bennell, K.L., et al. 2010, ‘Hip strengthening reduces symptoms but not knee load in people with medial knee osteoarthritis and varus malalignment: a randomized controlled trial,’ Osteoarthritis and Cartilage, vol. 18, issue 5, pp. 621–628.

Ellis, R., et al., 2007, ‘Iliotibial band friction syndrome—A systematic review,’ Manual Therapy, vol. 12, pp. 200–208.

Fernandes, L., et al 2010, ‘Efficacy of patient education and supervised exercise vs. patient education alone in patients with hip osteoarthritis: a single blind randomized clinical trial,’ Osteoarthritis and Cartilage, vol. 18, issue 10, pp. 1237–1243.

Goodman, Catherine., Boissonnault, William., 1998, G. Pathology: Implications for the Physical Therapist, W.B. Saunders Company, Philadelphia, pp. 267-274, 279-292, 318-328, 412- 417, 609-610, 614-615, 617-621, 660-667, 736-745, 748-755.

Hernández-Molina, G et al. 2008 ‘Effect of therapeutic exercise for hip osteoarthritis pain: Results of a meta-analysis,’Arthritis Care & Research, vol. 59, issue 9, pp. 1221-1228.

Hinman, Rana S., et al 2007, ‘ Aquatic Physical Therapy for Hip and Knee Osteoarthritis: Results of a Single-Blind Randomized Controlled Trial,’ Journal of Physical Therapy, vol. 87, no. 1, pp. 32-43.

Pisters, M., et al., 2007, ‘Exercise adherence improving long-term patient outcome in patients with osteoarthritis of the hip and/or knee, Arthritis Care & Research, vol. 62,

Santaguida, P. et al 2008, ‘Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review,’ Canadian Journal of Surgery, vol. 51, issue 6, pp. 428-436.

Zhang, W., et al., ‘OARSI recommendations for the management of hip and knee osteoarthritis, Part I: Critical appraisal of existing treatment guidelines and systematic review of current research evidence,’ Osteoarthritis and Cartilage, vol. 15, issue 9 pp. 981–1000.

pilates woman stability ball gym fitness yoga

Pilates Exercises for Healing: Shoulder Stretches and Bridging

There are three phases of Pilates for breast cancer survivors. The goal of Phase 1, the Protective Phase, is to ensure tissue healing without sacrificing range of motion and flexibility of the chest and arm. In these exercises, only move your arms to shoulder height or 90° and during this phase try to use your affected arm normally to perform daily living tasks such as brushing your teeth, putting on deodorant on, or wiping up your kitchen table.

Below are two examples of Pilates exercises for breast cancer survivors that fall under the Protective Phase. Protective Phase exercises should have three to five repetitions each. This phase will last approximately 2 weeks, or until you feel comfortable progressing to more difficult exercises. The exercises should feel easier and there should be less and less discomfort as you progress.

Exercise 1: Scapula Protraction and Retraction

The scapula is another name for your shoulder blade. The purpose of this exercise (shown in the image below) is to warm up the shoulders in preparation for movement, as well as strengthen the scapular muscles, which are necessary for proper shoulder movement.

Contraindications: None

Equipment: Pad, small pillow, towel, or block under head if needed. Optional medium-sized ball (squeezing the ball between your knees will help to activate the pelvic floor and transverse abdominis muscles and prevent your knees from collapsing in).

Start:

  • Lie on your back with both knees bent and feet on the ground, hip distance apart.
  • Pelvis is level with the floor or slightly tilted toward your nose if you have back problems.
  • Arms and fingertips are reaching toward the ceiling only to shoulder height.
  • Optional: Squeeze ball between your knees.

Exercise:

  • Inhale, and reach fingers tips toward the ceiling (shoulder blades will lift off the mat). This is protraction.
  • Exhale, and bring your shoulder blades together (not too hard) as you imagine you are gently cracking a walnut between your shoulder blades. This is retraction.

Modification for an Added Challenge: Stretch a resistance band between your hands. If you are undergoing a breast implant expander program, TRAM, or DIEP flap reconstruction, do not use a resistance band until medically cleared.

Exercise 2: Bridging

The goal of bridging is to warm up the spine as well as your hamstrings and gluteal muscles. This exercise will help make it easier to put on your underwear and pants and reposition yourself in bed.

Contraindications: Check with your physician to make sure that this exercise is safe for you to do when recovering with drains in place.

Equipment: Pad, small pillow, towel, or block under head if needed. Optional medium-sized ball (squeezing the ball between your knees will help to activate the pelvic floor and transverse abdominis muscles and prevent your knees from collapsing in).

Start:

  • Lie on your back with both knees bent and feet on the ground, hip distance apart.
  • Pelvis is level with the floor or slightly tilted toward your nose if you have back problems.
  • Arms are long at your sides.
  • Optional: Squeeze ball between your knees.

Exercise:

  • Inhale to start, and then exhale as you tilt your pelvis toward your nose to imprint your spine.
  • Then push off through your heels, and lift your spine off the mat one vertebrae at a time. You will start moving the lower back, middle back, and then upper back off the mat.
  • Inhale as you hold this position at the point where you can remain still, without any movement of your pelvis. Both the upper part of your shoulder blades should remain on the mat.
  • Exhale as you return to the start position by gradually bringing the upper back, middle back, and lower back gently down to the mat, vertebrae by vertebrae to your neutral or imprinted pelvis. Think of rolling the spine slowly down to the floor.

NOTE: Be sure to… Keep both shoulder blades on the mat. Do not let the pelvis rock forward/back or side to side.

Modification for an Added Challenge: Hold a Magic Circle between your inner thighs for resistance as you lift your hips. Hold a Magic Circle between your palms with hands facing each other and fingertips toward the ceiling. Squeeze it when the hips are lifted.


Written by Naomi Aaronson and Ann Marie Turo. Reprinted with permission from Naomi Aaronson, MA, OTR/L, CHT; Also published on demosHEALTH; Images via demosHealth article.

Naomi Aaronson, MA, OTR/L, CHT can be reached at www.recovercisesforwellness.com.