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Exercising woman

Lymphedema: Personal Trainer Perspective

Cancer surgery and treatment often results in survivors suffering debilitating physical impairments. These can often be ameliorated by a good exercise program that has the added benefit of helping survivors to engage in those activities in which they participated prior to their diagnosis. This article addresses some of the physical side effects cancer survivors may face, including lymphedema and a series of safe and effective techniques to restore functional fitness for those with or at risk for lymphedema.

feel better

Surgery, chemotherapy, radiation, and hormonal therapy have side effects, which exacerbate the problems faced by cancer patients. Surgery can create adhesions that can limit range of motion, and cause pain, numbness and tightness. Removal of lymph nodes creates scars and may decrease range of motion. Radiation can cause fatigue, tightness and stiffness. It also can increase the risk of developing lymphedema. Chemotherapy may affect balance, a patient’s immune system, and cause neuropathy, fatigue, sarcopenia, and anemia. Hormonal therapy can cause joint pain and early menopause and the side effects associated with menopause.

Before beginning a cancer exercise program, a patient must receive medical clearance. A medical history, base line range of motion and girth measurements, and a general fitness assessment are taken. It is important to note that many exercises and movements may be contraindicated based on a person’s fitness assessment, medical conditions, and particular surgery. There are different exercises necessary for each type of reconstruction. For those who were active prior to surgery it is imperative to slowly work back up to the previous level of activity. It is not wise to go back to a gym and immediately continue with a pre-cancer exercise routine.

Research has shown that exercise is safe for cancer survivors, even those with or who are at risk for lymphedema. Dr. Schmitz stresses the importance of starting slowly and using proper form with a well trained certified professional. Her study demonstrates the importance of exercise after cancer with slow progressive improvement in order to decrease risk of lymphedema. The research shows that breast cancer survivors no longer have to give up activities that they enjoy doing and avoid activities of daily living. Aerobic exercise is essential to good health and we advise a patient to walk as much as possible. Initially, one might start by walking around their house or up and down their block and then slowly increasing the distance walked. Many physicians recommend that their patients try to walk during chemotherapy. This may decrease fatigue. If using aerobic equipment, make sure not to grip on the railing.

Unfortunately, there is no way to know which patients with lymph node dissection will get lymphedema. This makes it imperative to follow the established guidelines and take a prudent approach to exercise. Patients who have lymphedema need to progress slowly and use a properly fitted garment. Our goal is to promote physical activity without exacerbating lymphedema. Severe range of motion issues and cording problems are referred to lymphedema specialists. Moreover, measurement of the limbs that are at risk for lymphedema are performed frequently to make sure they have not changed in size. Symptoms can be managed easier if they are addressed promptly. Progress is monitored in order to make appropriate modifications to a patient’s program. It is important to learn the right exercises for a patient’s particular situation and how to do them properly and with good form. The patient should learn which exercises to perform, the sequencing, and quantity of repetitions. Exercise smartly and under professional guidance!

Lymphedema can be debilitating and painful and can affect the emotional health of the patient. Our bodies work better if engaged in regular physical activity, but it must be done in a safe manner if lymph nodes have been removed or radiated. A cancer fitness program for someone with lymphedema should begin as an individualized program. The patient must be supervised to make sure there are no subtle volume changes to the limb. Ultimately, we want a patient to be able to exercise on his or her own.

The starting point is a low impact exercise program, performing range of motion stretches and techniques to improve venous drainage. First, we elevate the affected area above heart level. Over time, stretches are incorporated until a patient can achieve 80% of range of motion. At that point, we start adding strength training. A stretching program for those with upper body lymphedema begins with moving or stretching the neck and shoulder areas. If a patient is still healing from breast cancer surgery, begin with pendulum arm swings. The arm is then moved and stretched in all directions, going across the chest and behind the head and back. Stretches that move the arms in shoulder flexion, extension, abduction, and adduction are added. Finally internal and external rotations are addressed. Patients suffering from fatigue can perform many of the stretches while in bed. An easy-to-follow DVD is Recovery Fitness Simple Stretching, which can be found on www.recoveryfitness.net.

All of the exercises incorporate abdominal breathing, which can stimulate lymphatic drainage. This intra-abdominal pressure may help move sluggish lymph fluid, stimulate lymph flow, and act as a lymphatic system pump. This type of breathing enables oxygen to get to the tissues. Abdominal breathing and relaxation breathing, along with the proper exercises can also reduce stress, a common cancer side effect. If weak, it may be best just to stretch and breathe deeply.

Strength training may help pump the lymph fluid away from the affected limb. Exercise helps the lymphatic fluid to April / June 2013 ~ NATIONAL LYMPHEDEMA NETWORK 13 move. Muscles pump and push the lymph fluid and can help move the lymph from the affected area. Strength training may also strengthen the arm so that it can handle those activities that may have otherwise led to swelling with a greater level of ease. Always wear a sleeve and stop if there is swelling or pain. Start with light weights and slowly increase repetitions and eventually weight.

Cancer survivors should follow a systematic and progressive plan. Exercise starts with a warm-up and cool down. Begin with deep breathing. Keeping a strong core should be emphasized. It is important to remember that following treatment the body may have become weaker. Even if a patient had exercised using 10 pound weights before surgery, if one is at risk for lymphedema they must start with a light weight. We teach patients to always listen to their bodies and to stop if they feel tired or if their limb aches or feels heavy. Patients must be aware of any changes in their body.

Exercising womanProgression of exercise should be gradual. A deconditioned person should start without using any weight and concentrate on proper technique. If 8-10 repetitions can not be executed, repetitions should be decreased or the weight lowered or resistance band used changed to less resistance. The exercise routines have to be adapted for the day-to-day changes that that can affect the ability to work out. Our program will start using a very light weight, with few repetitions, typically 10. In subsequent sessions, patients can add repetitions. After performing 2 sets of 10 repetitions with no problem then a small amount of weight may be added in 1 pound increments. We also alternate between a strength training exercises with a stretch for each muscle group and to alternate an upper body and lower body exercises. Pilates exercises are great way to incorporate deep breathing with strengthening the core. The deep breathing helps to pump lymphatic fluid and will also help reduce stress.

Every patient is unique. Many patients have pre-existing medical issues. The exercise program should be modified to accommodate all body types and needs. Some might need pillows for comport or postural problems. Also if osteoporosis is an issue, a cancer therapist should have experience working with this population. Always monitor the affected limb. Look for feelings of fullness or aching. We do not want to overwhelm the lymphatic system. Drink plenty of water and stop immediately if any pain. Lymphedema patients should elevate their limbs after a session.

Learn which aerobic exercises are considered safe. Walking, biking, and swimming are considered very safe. Hot tubs, pools, and warm lakes may increase risk of infection. In choosing an activity, consider the risk of injury, prior medical condition, and fitness level. Injuries can create further complications for those with lymphedema. It is still unclear whether certain sports can be safe. For example, tennis can put a lot of stress or repetitive activity on one’s limbs. It is important to know if the activity was something performed prior to lymphedema. If the patient wants to resume the activity in order to exercise, have fun, and to have good quality of life, a sports fitness program can be instituted. This should be performed under medical guidance. In a sports fitness program, the muscles used in the sport are progressively strengthened so that the sport can be resumed. Patients must use caution as they return to a sport.

One of the most important things that can be done to decrease the risk of lymphedema is to keep weight at a good level. Those individuals with whom I have worked who have had lymphedema typically see a marked reduction of swelling in conjunction with weight loss. My students who are successful in losing weight have the most success in lymphedema control. Proper nutrition is important and decrease salt intake. Evidence suggests numerous benefits of exercise: improved fitness level, physical performance, quality of life, and less depression and fatigue. Exercise is part of a healthy lifestyle and will help in weight control and emotional health. There are exercise programs that are targeted at cancer survivors but not all of them will meet the needs of someone at risk for lymphedema.

My goal is for cancer survivors to participate in individually structured and group exercise programs at all cancer centers or facilities close to their homes.

Article reprinted with permission from Carole J. Michaels.


Carol J. Michaels is the founder and creator of Recovery Fitness® LLC, located in Short Hills, New Jersey. Her programs are designed to help cancer survivors in recovery through exercise programs. Carol, an award winning fitness and exercise specialist, has over 17 years of experience as a fitness professional and as a cancer exercise specialist.

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Change, Habits, Comfort Zones and the Power of Fear

I am a creature of habit. I have always struggled with change throughout my life. I fought it and rarely embraced it until I was forced to acknowledge I was on the wrong path and needed to make a change. In my personal life, I held onto my marriage long after it ended creating unnecessary pain and anguish for all of us. I have learned that to RESPOND to the changes in my life is a far less traumatic way to live than always REACTING to the “fluid” circumstances and uncertainties of life.

Comfort zones, habits, and fear – the “Big 3” of life’s impediments to lasting and positive change in our lives need to be embraced for what they are: “False Evidence Appearing Real” – FEAR.  I see this today as I have seen it repeatedly over the past 2 decades with my clients. We seem to end up being FORCED to change our ways rather than willingly and knowingly taking the steps necessary to move us forward to a more fulfilling life. Let’s take a look at a model for change that has begun to work for me.

The principle behind change is that the universe is always in a state of flux. Nothing in this reality remains the same – especially as we age. One of my former teachers stated that “the only constant in the natural order is change” and yet we fight the changes in our lives and often label them “bad” or “good”. Even positive change brings new stresses into our lives – stresses that can fuel our creative “juices” and enable us and empower us to grow in ways that we could barely imagine. Being willing – and ready – to embrace change allows us to imagine with feeling what is possible. This can create new paths to a future that can embolden and encourage not only ourselves but others as well.

We all have to understand that we can’t control what is NOT ours to control and “let go” while embracing what it is that we DO have the power to influence. The next steps in my journey are being written RIGHT NOW as I type these words. The same holds true for each of us so let’s be BOLD and embrace change as a friend and see what can happen when we partner with change for a higher purpose.

Habits and comfort zones rely on each other to keep us from fulfilling our promise. I have lived for years with the notion that I didn’t possess the “right stuff” to leave a lasting mark on this world.

My daughter Lisa is a “big thinker” and strives for excellence in all aspects of her life even as she has had to struggle over the past three years with life’s inevitable challenges at a very crucial time in her life. I am proud to say that she is confident and hopeful and continues to trust her instincts making me feel very proud of her at this critical moment in time in her life. She has what I didn’t have at her age – an indomitable spirit that continues to believe in her own innate ability and talent. To her comfort zones are only “resting places” – not residences.

I have learned that my fears were of my own making and today I know that we can only improve our lot in life if we are willing to risk acting “in spite of our fears”.  Remember that fear is nothing more than “false evidence appearing real” and our clients need that reassurance every day as they attempt to change something significant in their lives.

We need to KNOW deep inside ourselves that we indeed CAN make a difference and move our clients – and all those we want to serve – one step closer to their OWN new reality. May we each benefit from the changes that we are experiencing right NOW in our OWN lives so that we can help others achieve their own victories as well!

Article reprinted with permission from Nicholas Prukop. 


Nicholas Prukop is an ACE Certified Personal Trainer & a Health Coach and fitness professional with over 25 years of experience. His passion for health and fitness comes from his boyhood in Hawaii, where he grew up a swimmer on Maui. He found his calling in writing his first book “Healthy Aging & You: Your Journey to Becoming Happy, Healthy & Fit” and since then he has dedicated himself to empowering, inspiring and enabling people of all ages to reach for the best that is within them and become who they are meant to be – happy, healthy and fit – and be a part of a world where each person can contribute their own unique gifts to life.

seniors at gym

Treat the Person, Not the Scan

“MRI’s are just anatomic pictures of structures. They do NOT tell me if someone is having pain from MRI findings. I tell patients that it is similar to having your portrait taken. The picture just shows what you look like, not how you are feeling.”

Dr. Derek Ochiai

“For example, many people have “stuff’ on their scans that can sound scary, even if these things are relatively normal and not closely connected to pain. This includes things like bulging discs and degenerated discs, which have a lot in common with grey hair and wrinkles – they are more common as we get older, without being dangerous.

Unfortunately, people with back pain are often told that these things indicate their back is damaged, and this can lead to further fear and distress or lead people with back pain to rush for procedures like surgery when they are not needed. Therefore, you should think twice before getting a scan.”

Kieran O’Sullivan, PT

“MRI scans show two patients with herniated lumbar discs.  One is a small herniation; one is a large herniation.

Q: Which patient needs surgery?

A: Neither.  Both patients have minor symptoms and are doing well with physiotherapy and anti-inflammatory medications.

“Treat the patient, not the MRI”

–Ali A. Baaj, MD

I hope you find encouragement in the previous quotes. What is to be inferred from them?

You can be injured, have structural or tissue damage to the muscle-skeletal system, and not have very much pain or discomfort – sometimes no pain at all!

Let me repeat – be encouraged by this!

The message that tissue damage must always result in pain can be wrong.

This is not an indictment of X-Ray and MRI scans and the accompanying radiological reports. They are certainly valuable tools. For example: one of my colleagues on a recent Facebook post shared that an MRI showed that her shoulder joint doesn’t properly fit together due to repeated dislocations and that she is prone to future dislocations.

Of course, this is valuable information. It can help us understand whether we should, and if so how, to exercise the shoulder for strength training. It also sets up the expectation for outcomes for any process employed to help the individual.

On the same post, another colleague mentioned that a scan of his neck showed a herniated cervical disc was pressing on a nerve root. The scan took place after the numbness in his left arm had already disappeared. He mentioned he never had any pain in his neck or arm.

Should scans be done every-time someone is complaining of pain? Physicians have to make this decision on a regular basis often knowing that the scan might show something, or it might not. Whether or not what the scan shows has anything to do with the patient’s complaint is another matter.

It’s a conundrum for the doctor and the patient. Of course, each wants to know the cause … the reason for their pain. The pain needs to be blamed on something specific that can be seen. It has to be given a name like arthritis, tendonitis, or herniation. Unfortunately, the scan can’t show that whatever image is produced is what is causing the pain directly.

So, the insistence by the patient or doctor to get a scan is balanced against the hesitation to order a scan because it is expensive and may not shed any light on the problem, or possibly prompt a surgery that isn’t necessary.

The patient may leave the doctor’s office discouraged. They don’t want surgery, they don’t want to take drugs if they can avoid it, but they can’t live the rest of their life with chronic musculoskeletal pain. Drugs and surgery may even compound the problem by creating new issues.

It’s time to ask a few questions: What else can someone do to help the situation? Is there a more conservative approach to try before taking the risks of drugs and surgery?

Yes.

The answer – exercise.

Too many people have given up on trying to work conservatively via exercise to move better in order to feel better by looking for quick fixes that may carry negative long-term consequences. (can anyone say opioid epidemic?)

If you are feeling discouraged by musculoskeletal pain and are trying to avoid drugs and surgery – try exercise. Get a thorough assessment and have a professional develop, and implement, a personalized and precise exercise-based strategy that is unique to your needs.

Remember those quotes in the beginning of this blog, “Treat the Person, Not the Scan!”


Charlie Rowe, CMSS joined Physicians Fitness in the fall of 2007 after spending 9 years as the Senior Personal Trainer at Oak Hill Country Club in Rochester, New York. He has also worked within an outpatient Physical Therapy Clinic coordinating care with the Physical Therapist since joining Physicians Fitness. Charlie has earned the Cooper Clinic’s Certified Personal Trainer, the NSCA’s Certified Strength and Conditioning Specialist, the American College of Sports Medicine Certified Health Fitness Specialist, Resistance Training Specialist Master Level, and American Council on Exercise Certified Orthopedic Exercise Specialist Certifications. 

gym training, young man and his father

Allostasis and Exercise Dosing

Three sets of ten repetitions of pushups.

How long should repetition be?

How much rest should occur between each repetition?

How much rest should occur between each set?

How should the push up be performed?

How would a trainer determine the dose of this exercise was appropriate?

How would a trainer know that the total amount of exercise for a given exercise session was tolerated well by the client?

The dosing of exercise can be an uncertain process with lots of assumptions and guesswork involved. Often the trial and error nature of prescribing a dose of exercise can lead to a client not feeling so good… either during the session, or after. It is definitely no fun to have a client start feeling unwell during a session, or come back following a session only to report a couple days of misery due to soreness and malaise.

An understanding of the relationship between homeostasis and allostasis can inform the exercise prescription dose.

Homeostasis (n.) the tendency toward a stable equilibrium between elements of a system, especially as maintained by physiological processes. The inherent inclination of the body to seek, and maintain, an internal condition of balance, equilibrium, and ease, within its internal environment, even when faced with external changes. Energy conservation and efficiency. Normative. Homeo=same and stasis=not moving.

Allostasis (n.) the intrinsic process by which the body responds to stressors to regain homeostasis. Maintaining stability through change. Adaptive system responses. Coping.

System element excursion in reaction to a stimulus/demand.

It is critical that the exercise professional take a thorough personal health history in order to gather information that directs physical assessment process. Past and current medical conditions, prior injuries and surgeries, life stressors, and activity history can give insights into the overall state of the clients system. This insight may give rise to precautions to physical assessment, and create a conservative frame for asking the client to undergo the physical stress of exercise, both systemically and locally.

A physical assessment can give quantified data points, and qualitative information, that leads to a better understanding of the client’s bodily tolerance potential to mechanical and chemical stressors experienced during and after exercise. This is referred to as the Allostatic Load of the client.

Allostatic Load (n.) the accumulative damage of the body’s cells as an individual is exposed to repeated acute and/or chronic stressors with inefficient regulation of the responses within cells. It represents the physiological consequences/costs of exposure to fluctuating or heightened neural or neuroendocrine responses that result from repeated acute or chronic stressors. This leads to maladaptive system responses. Protective responses that are on too long, not down regulated properly, or cycles of normal hormone change throughout the day, or the response didn’t come on line at all to govern the process of change.

Allostatic Load can accumulate and the overexposure to neural, endocrine, and immune stress mediators can have adverse effects on various organ systems, and their response and return to subsequent stressors, leading to dysfunction and disease. (5)

Join Greg Mack for a webinar for more on this topic, Allostasis and Dosing Exercise


Greg Mack is a gold-certified ACE Medical Exercise Specialist and an ACE Certified Personal Trainer. He is the founder and CEO of the corporation Fitness Opportunities. Inc. dba as Physicians Fitness and Exercise Professional Education. He is also a founding partner in the Muscle System Consortia. Greg has operated out of chiropractic clinics, outpatient physical therapy clinics, a community hospital, large gyms and health clubs, as well operating private studios. His experience in working in such diverse venues enhanced his awareness of the wide gulf that exists between the medical community and fitness facilities, particularly for those individuals trying to recover from, and manage, a diagnosed disease. 

REFERENCES

  1. Bruce S. McEwen and Peter J. Gianaros, Stress and Allostasis-Induced Brain Plasticity, Annu Rev Med. 2011; 62: 431–445. doi:10.1146/annurev-med-052209-100430.
  2. Douglas S. Ramsay and Stephen C. Woods, Clarifying the Roles of Homeostasis and Allostasis in Physiological Regulation, Psychol Rev. 2014 April ; 121(2): 225–247. doi:10.1037/a0035942.
  3. Julie Bienertová-Vašků, Filip Zlámal, Ivo Nečesánek, David Konečný, Anna Vasku Calculating Stress: From Entropy to a Thermodynamic Concept of Health and Disease, Department of Pathological Physiology, Faculty of Medicine, Masaryk University, Kamenice 5 A18, Brno, 625, 00, Czech Republic.
  4. Barbara L. Ganzel, Pamela A. Morris, Elaine Wethington, Allostasis and the human brain: Integrating models of stress from the social and life sciences, Psychol Rev. 2010 January ; 117(1): 134–174. doi:10.1037/a0017773.
  5. Allostatic Load and Allostasis: Summary prepared by Bruce McEwen and Teresa Seeman in collaboration with the Allostatic Load Working Group. Last revised August, 2009.
  6. Bruce S. McEwen, PhD, Stressed or stressed out: What is the difference? Laboratory of Neuroendocrinology, The Rockefeller University, New York, NY.
Parkinson's disease

Why Parkinson’s Doesn’t Have To Win

An exercise management program specifically designed to attack Parkinson’s disease can help you reduce falls, improve energy, and restore function so you can live a normal, independent, and productive life.

Medical exercise and medical fitness professionals can guide you in using exercise to recover a happy, fulfilling, independent life with this condition.

I know this because I have witnessed exercise win. I have seen people claim victory. I have seen them take their life back from the thief called Parkinson’s (keep reading and I will share a story with a great ending)

The Condition

Parkinson's disease

Just to familiarize you, Parkinson’s is a progressive neurologic disorder that affects 1% of the population over 50. The condition progressively destroys cells in the brain that produce dopamine, a neurotransmitter controlling movement. Parkinson’s is characterized by tremors, postural instability, impaired movement, rigidity, a shuffling walk, difficulty moving the body, and speech impairment.

The Parkinson’s posture is characterized by an excessive forward head drop, rounded shoulders, forward trunk lean, and side to side shuffling. This posture is very taxing on the body and leaves its afflicted depleted of strength, energy, and confidence in their body.

Falls are a major concern with Parkinson’s disease as the body loses its ability to “catch” itself if it starts to fall. A person will experience decreased reaction time, and a feeling of “slowness”, making it very easy to fall and sustain serious injury.

If I just described your daily struggle, there is GOOD NEWS!

Medical Exercise

An exercise management program specifically designed to attack Parkinson’s disease can help you reduce falls, improve energy, and restore function so you can live a normal, independent, and productive life.

Let’s discuss the components of an effective exercise program for Parkinson’s and how it can benefit you or your loved one.

Range of Motion or Flexibility Training

Parkinson’s disease (PD), reduces the tone (or pull) of the extensor muscles (helps you stand upright). Consequently, when walking, the PD client takes shorter steps and his/her posture is stooped with bent arms, bent knees, and a forward falling head. Over time, this flexion posture (leaning forward) results in further weakening of the extensor muscles (helps you stand upright), and it becomes more difficult to fully stand upright. Joint and muscle stiffness discourages movement, and eventually, the tissue around the joint shortens and restricts movement. Flexibility training improves joint function, reduces stiffness, and improves mobility.

I recommend you focus on the following areas for stretching:

  • Ankle plantar flexion
  • Rotation & lateral flexion of the pelvis
  • Cervical & thoracic extension, rotation, lateral flexion
  • Outer hamstrings
  • Elbow extension and supination
  • Finger flexion and extension

Resistance Training

Gentle strengthening exercises for your extensor muscles (muscles that hold you upright) are super important because they counteract the flexion (forward lean) tendency seen in PD. Extensor muscles of the body include calf (gastrocnemius), anterior thigh (quadriceps), buttocks (gluteals), back (spinal extensors), back of the upper arm (triceps), mid-back (posterior shoulder girdle) and back of the neck (neck extensors). With this, the muscles included in hip extension, external rotation, and abduction are vitally important to improving balance and gait and preventing falls.

The benefits of improving your muscle strength and endurance include:

  • Increased ability to perform Activities of Daily Living
  • Increased independence and self-efficacy
  • Increased lean body mass
  • Maintained or increased bone mineral density
  • Counteraction of the Parkinson’s posture
  • Enabling you to feel better, stand taller, and function more effectively
  • Strengthening muscles and joints, helping you stand upright and move

Cardiorespiratory training

Rigidity can reduce your ability to inhale and exhale your breath. Additionally, PD may cause decreased chest expansion, slowed movements, fatigue, and poor endurance during prolonged activity. Aerobic activity has been shown to be extremely beneficial for improving cardiovascular and respiratory fitness, as well as the generalized health of the PD client. You want to perform aerobic (or cardiorespiratory) exercises involving large muscle groups to increase your heart rate, thereby improving cardiorespiratory function. Aerobic exercise is most beneficial when started early in the disease process.

Some great ways to perform CV exercise include:

  • Walking
  • Stationary biking
  • Elliptical
  • Swimming (aqua aerobics)
  • Yoga
  • Pilates
  • Low-impact dance

Balance & Postural Training

Incorporating postural and balance training into your exercise program cannot be emphasized enough. Parkinson’s pain, stiffness, and lack of muscle strength disrupts your ability to perform efficient, controlled, and coordinated movements like walking. Awkward movement and postural patterns, like side shuffling, will require more energy and will increase your fatigue, resulting in decreased body stability and increased risk of falling.People with PD may develop new postural problems elicited by the disease, or the disease may exacerbate old postural problems. Poor posture fatigues the body. Injury can occur if proper body mechanics are not utilized. Therefore, it is very important that you learn what healthy posture is and how to maintain it throughout your daily activities and during exercise.

Postural training is highly beneficial as it:

  • conserves your energy
  • prevents falling
  • reconnects you with your body

trevor-parkinsons1Postural exercises should focus on increasing your awareness of proper posture and teaching you how to achieve and maintain correct body alignment with all exercise. Proper body mechanics should be a component of the total exercise program. Your program should emphasize sitting, standing, and walking tall. Include techniques for bed mobility tasks, getting in and out of chairs, descending and rising from the floor, and exercises involving proper use of the back muscles in tasks of daily living/lifting, etc.

Body awareness is another component of posture training. This means learning how to observe and listen to your body. People who are aware of their bodies are more likely to recognize incorrect positioning and movements that could unnecessarily stress a joint, increase muscle tension, or increase risk of falling. They are also better able to avoid overexertion.

Prior to activity, you should go through an alignment checklist from foot to neck focusing unloading your joints and using the right muscles to stand. You can practice this in front of a mirror to visually learn how to adjust your body.

Check out this great diagram (right) from the Mayo clinic that illustrates some postural checkpoints to focus on during walking.

Activities that enhance postural awareness go a long way toward improving your ability to recognize and correct postural problems.

Victory

As you read at the beginning of this article, Parkinson’s attempts to steal freedom people by overwhelming them with frustration, grief, or fear of living as a slave to a disease for the rest of their lives. However, as you can see, exercise can set you free. Exercise can teach your body to move right again, and exercise can teach you the tools you need to fight back and reclaim your freedom.


Trevor Wicken has been practicing as a Medical Exercise Practitioner for almost two decades and has a Bachelors degree in Sports Medicine and a Masters Degree in Exercise Science. He is certified as an elite trainer through NASM and has spent his entire career passionately helping people to use exercise and movement to reduce pain, prevent injury, and manage medical conditions. 

Seniors with trainer in gym at sport lifting barbell

4 Tips to Help Your Clients Reduce Their Risk of Falls

No matter how fit and healthy your older clients are, there is one thing that can change their lives forever: a bad fall. Every year, almost 1/3 of older adults fall and many cause injuries that will affect them the rest of their lives.

As a fitness professional, you need to be well-prepared to deliver the most effective fall prevention exercise programming to your clients. You can find excellent guidance on assessment and program design at www.mobilitymatters.fit. But you also should be providing advice to your clients on how to reduce their fall risk in other ways.

Have them do these and keep them on their feet!

1. Many falls happen outside where there are lots of potential hazards. Advise your clients to avoid walking on loose gravel, metallic/painted surfaces and cracked sidewalks and avoid being outdoors in bad weather (e.g., rain, sleet, snow). Appointments can always be rescheduled, but a trip to the ER should never be the reason!

2. Indoors, advise your clients to make sure that their path from the bedroom to the bathroom is free from obstructions (e.g., pet toys, rumpled rugs) prior to going to bed at night – that way a trip to the bathroom will not include a trip and a fall!

3. Advise your older female clients to never wear high heeled shoes outdoors. Put their heels in a canvas tote bag and walk outside in sneakers or flats instead. Nobody looks good falling, no matter how stylish the shoes!

4. In the bathroom, advise your older clients to line the floor of their shower/tub with textured adhesive strips. These are less likely to cause a slip or a trip than a rubber bath mat that might slip or bunch up. They also give a nice pedicure!

Are you a fitness professional interested in learning more on this topic? Check out Dr. Thompson’s 4 hour course with PTontheNet, Essentials of Older Adult Exercise Assessment and Program Design for Preventing Falls.


Christian Thompson, PhD is an Associate Professor in the Department of Kinesiology at the University of San Francisco and founder of Mobility Matters, an exercise assessment and program design platform designed to help fitness professionals and clinicians work with older adults. Christian has published scientific articles on exercise programming for older adults in peer-reviewed journals such as Medicine and Science in Sports and Exercise, Journal of Aging and Physical Activity, and Journal of Applied Research.

Surgery word cloud

Can I Avoid Surgery?

Did the title of this article capture your attention?  It should because surgery, no matter how big or small, is serious business. The type of surgery this article is speaking to is orthopedic surgery. This means surgery due to pain, disease, and dysfunction in your muscles, tendons, ligaments, bones, and joints.

Maybe you, or someone you care about, have been told that surgery is necessary.  You have done what the doctor suggested.  You tried Physical Therapy.  You went beyond that, and tried massage, acupuncture, chiropractic, drugs, and other alternative interventions. Why would avoiding a surgery even come into your mind? You are in pain, the doctor said you need it and that should be the end of the discussion right?

It’s a tough decision with uncertain consequences. Second and third opinions are recommended.

There might be several reasons why you want to avoid it; the thought of someone going in and “cutting you” (surgery is really a controlled injury), the risks associated with being put under anesthesia, the long recovery time and disruption to your life routine post surgery, you know someone that had surgery and months later are still not feeling much better, or they may be suffering complications from the surgery itself.

You have doubts.

Maybe you have read the recent research that concluded that a very common surgical procedure on knees actually showed more long term harm than good. (1)

Have you read the research that shows that there are many individuals with a diagnosable orthopedic disease that don’t report pain?  And there is research that shows that some report pain and nothing can be found wrong that directly explains the pain. (2) (3)

Maybe you will need the surgery. But is there one more conservative non-surgical alternative that you haven’t tried yet?

There is… Exercise.

But wait, you already did exercises at the physical therapy clinic. Even the chiropractor gave you some stretches and rubber bands to tug on and that didn’t work.

Here is the problem. All exercise is not created equal. What may work for one person doesn’t work for another.  Why is that?

Because every pain situation, just like people, is unique.

Pain is a word. When you choose to use the word pain to describe a sensation in your body you are clearly elevating the level of concern you have for the sensation.

Pain is not a thing like a brick, cat, glove, or car. Pain is the brain’s conclusion about all of the information it is receiving and processing from within the body moment-to-moment.

If you are considering surgery because you are experiencing a sensation that you choose to use the word pain to describe, then in a sense you are having surgery to remove the pain right? Which is weird because pain isn’t a thing to be removed, as it is simply a word chosen to describe a subjective conclusion based on bodily information. So a surgeon doesn’t remove pain with a scalpel, they remove the body part that they think is causing the pain. Sometimes this works great. Sometimes it doesn’t. See previous references.

What the surgeon is doing, what the drugs are doing, what the spinal manipulations are doing, are changing, or at least trying to change, the information that the body is producing to see if changing the information that way will lead to a new conclusion of the brain.

Change the information and possibly change the conclusion.

Back to the exercise thing.

What is exercise? It is stimulation to, and of, the body that changes the information within it. Sometimes those changes are short term and sometimes they can be of a longer term.

But you tried exercise in physical therapy and with the chiropractor and it didn’t help.

As stated earlier not all exercise is equal. Often exercises are just given to work on the area of the body that hurts. This might not be the best way to change the information. Exercise has very specific influences on the body depending on HOW you do it. The old adage “Just Do It” is painfully inaccurate advice. We need to know the quantity but also need to know the quality of your experience with different exercises.

Pain is a subjective experience that, at least right now, does not have an objective measurement like temperature, pressure, and distance. Your pain is totally unique to you and cannot be experienced by anyone else. Pain has a component of quality associated with it. It certainly can have a cause like when you break a bone, cut of your skin, tear a muscle, or sprain a ligament. But sometimes the cause is not so clear-cut.

So what am I proposing? What could be the thing that you haven’t tried yet?

A different approach. A totally different strategy. A more precise HOW.

I am talking about exercise that is highly catered and highly specific to your unique body.

Your body has its own unique history, a unique genetic profile, a unique combination of diseases and dysfunction, all of which confluence towards a unique problem. This requires a completely unique solution. A completely unique HOW.

This unique strategy and HOW is based on some simple concepts.

  1. All physical exercise uses the Muscular System in some form or another.
  2. The Muscular System receives and produces information form the nervous system.
  3. Muscles control you in three primary ways:
    • By contracting to maintain your joint positions,
    • By contracting to change your joint positions by lengthening,
    • By contracting to change your joint positions by shortening.
  4. Your body is a system that by definition means that all of the body parts are interconnected, interacting, and interdependent.
  5. A system’s control over information, and the stability of that information, can be assessed by perturbing it – by knocking it off course a bit – to see if it can make the necessary course corrections in order to stay in control.
  6. You should be the center of attention – not the exercise. You should not be made to conform to the exercise – the exercise should be made to conform to you.

If number 4 is true then it stands to reason that any part of your body’s information generation and processing can affect any other part’s information.  You may good at contraction shortening but are not so good at contraction lengthening.

If number 5 is true then a good way to see if you actually have control and assess the information control is my assessing your ability to do number 3.

Given the fact that your body is completely unique from any other body, this means that any strategy and HOW must be created to explore your unique information control system and any influences between parts. See number 6.

This is what Muscle System Specialists are trained to do. To systematically explore your information control by assessing your muscles’ ability to hold joint positions and change joint positions via lengthening or shortening contractions. This tells us about the quality of you information generation and processing.

The challenge is to find those places and conditions. You have roughly 600+ muscles and are capable of being in a dizzying array of positions and motions.

It’s okay – we have a process to explore your unique body’s abilities and start discovering the solutions it needs in order to change its control, to change the quality of information within it that just might lead to a change a reduction in pain.

Can you avoid surgery? Maybe. You have to decide if it’s worth some time and effort to exhaust conservative non-surgical options. Always speak with your doctors regarding this important decision.


Greg Mack is a gold-certified ACE Medical Exercise Specialist and an ACE Certified Personal Trainer. He is the founder and CEO of the corporation Fitness Opportunities. Inc. dba as Physicians Fitness and Exercise Professional Education. He is also a founding partner in the Muscle System Consortia. Greg has operated out of chiropractic clinics, outpatient physical therapy clinics, a community hospital, large gyms, and health clubs, as well operating private studios. His experience in working in such diverse venues enhanced his awareness of the wide gulf that exists between the medical community and fitness facilities, particularly for those individuals trying to recover from, and manage, a diagnosed disease. 

Charlie Rowe, CMSS joined Physicians Fitness in the fall of 2007 after spending 9 years as the Senior Personal Trainer at Oak Hill Country Club in Rochester, New York. He has also worked within an outpatient Physical Therapy Clinic coordinating care with the Physical Therapist since joining Physicians Fitness. Charlie has earned the Cooper Clinic’s Certified Personal Trainer, the NSCA’s Certified Strength and Conditioning Specialist, the American College of Sports Medicine Certified Health Fitness Specialist, Resistance Training Specialist Master Level, and American Council on Exercise Certified Orthopedic Exercise Specialist Certifications. 

References

  • Thorlund, J., et al, Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms, BMJ 2015;350:h2747 doi: 10.1136/bmj.h2747
  • Ave Marie, L., Why Most People Are Wrong About Injuries and Pain – SimpliFaster Blog, 12/24/2018
  • Brinjikji, W., et al, Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations, Apr 2015 www.ajnr.org
Kama-Squat-article

Gait and Alignment

Many times when I run in Central Park, I see some elite runners. They look like gazelles. However, sometimes, I will see runners who have knees turned in, toes turned the opposite way, or simply just POUNDING on their feet.

When I teach Yoga, or even strength training, I advocate aligning the hip bone (asis joint) with the knee, and the 2nd toe.

i.e., Squats.

Often trainers will tell students to “bring their feet hip width apart” and perhaps, having read too many magazines with models who are super thin, they bring their feet so wide that they are BEYOND the alignment they could possible sit in or walk in. Imagine the MANSPREAD on the subway. Over time, if clients keep doing “squats” with their feet so beyond the width of their hips, it puts undo strain on the ACL, ankles, and causes many muscle imbalances.

In a squat, the goal is NOT to “go lower”.

A member once wrote a nasty comment via the gym website that “I didn’t go low enough” in my squat. What is “low enough”? If you are compromising form, or bending your back over more to make up for the fact that knees can only bend so much, then this is counterproductive.

When squatting, you should “crease” the hip joint (hip flexors) and imagine a chair being pulled out for you. Reach for the chair with your butt while bending your knees. The chest may tilt slightly forward, but the movement is NOT initiated by bending the upper body into forward flexion. Imagine if you were wearing all white, dry clean only clothing, and were carrying a tray of martinis (or red sauce). You would have a mess if you bent forward with your upper body. Therefore, keep your chest high, hold the platter high, and only angle forward as needed. This way all the work goes into the quads and glutes, and not into the back.

Exercise Samples (L to R): One leg step up; one leg dead lift; squat to one leg

Another drill I like to teach is a step-to 1 leg squat. Take a step to your right, balance on the right leg, and perform 1-3 squats. Then repeat by stepping left. To advance this, take a little hop, and then do 1-3 1 legged squats.

1 leg step ups (pictured above): place 1 foot on a bench laterally. The step should have 2 risers on each side if you are between 5’ and 5’4, and maybe 3 risers if you are above 5’6, and 4 risers if above 6’ tall. Press the weight into the foot that is on the bench and full stand up on this 1 leg. Then sit back down into the squat stance with both knees bent (one will be on the floor).

1 leg dead lifts  (pictured above): based on warrior 3: 1 leg is very straight without locking. Like a seesaw, pitch forward by lifting the free leg as high as it can go, but do not round the back, or drop the chest. I also look forward and keep my chest slightly lifted. Recover to upright by raising the gaze. Repeat 4-8 reps per leg.

Sit, stand, raise lower…this is a combination 1 leg squat into 1 leg deadlift (warrior 3). Repeat 4-8 reps.

Practicing 1 legged drills will make it so that when you perform drills such as squats on 2 legs, you will remember that if you were to take 1 leg off the ground, your stance/width should be based on this idea.

This will give you better form for running, and even walking.

The hip, knee, and 2nd toe should always REMAIN FRIENDS in every exercise for better alignment, and pain-free workouts.


Kama Linden has been teaching fitness for over 2 decades. She has taught strength, step, pilates, vinyasa yoga, senior fitness, and has worked with clients and students of all ages and fitness levels. She is certified by AFAA Group Exercise and NASM CPT, as well as 200 hour Yoga. She has a BFA in Dance from University of the ARTS.  Her new book, “Healthy Things You Can Do In Front of the TV” is now on sale on amazon.com, BN.com, and Kindle. Visit Kama’s website, bodyfriendlyoga.com, and kamalinden.com.