I think when some people read that word they have the same feelings I get when I see on my to do list “clean house” or even worse “organize paperwork”.  I just DO NOT want to do it.  I know I should.  I know that  I will be happy with the end result, but I resist it like crazy.

I took me a long time to understand that people feel differently about exercise than I do, and I still struggle with it sometimes.  I think some of it may be in the choice of words.  I love to exercise, but when I think about it, that’s not how I describe it.  For me it’s training.  It’s training to be faster for next race season, to be faster than I was last time I raced, to push myself harder and to get a better result.  To find ways to get the most out of myself, when it would be so easy to just coast a little.   That motivates me every day.

There are many pieces to the puzzle that will make me faster.  The mental and physical challenges that I face while trying to get the best out of myself get me excited, and give a purpose to my “exercise”.   But, take those goals away, and I can be relatively lazy.  That’s what finally helped me to understand why exercising just to exercise doesn’t motivate people.  

Common wisdom says “well, just make it a habit, like brushing your teeth”.  I think that works for some disciplined people, and there are a lot of books and websites (very well done for the most part) on forming habits and having willpower, but in the end if the reason for doing it isn’t strong enough, or the enjoyment isn’t there, it becomes one other thing that “I have to do”.  When “exercise” joins a long list of other tasks, things that put food on the table or take care of family, it’s easy to let it slide if the desire isn’t there.

The problem is though, that the less we do, usually becomes the less we can do.  I have so many patients who come to see me and often don’t realize how limited they have become until we find it during their assessment, or something changes.  I recently treated a woman in her late 70’s to help restore the mobility and function of her right shoulder following surgery.  The treatment of course included exercise, but it wasn’t a hard or long routine and it focused primarily on her right shoulder.  She told me toward the end of her treatment with me, that for the first time in many years she could actually go to the mall and shop with her daughter.  This was one of her favorite things to do, and something that she hadn’t been able to do without stopping frequently to rest, needing to use a wheel chair because she became so tired, or going home after only an hour or so.  She actually walked around the whole mall and enjoyed herself, all because she did some exercise for her right shoulder.

I think one of the big problems with exercise is that we make it a big hairy monster task that is this “thing we have to do”.  We think, “well I have to drive to the gym, or I have to do this tape, or this workout routine, and I need to dress, and shower and change and do all of this stuff to exercise.” So it becomes too much to do, takes too much time, or too much energy, and it gets skipped.

When I was first a PT I was guilty of giving my patients these long, detailed home exercise programs.  I had all of these wonderful exercises and always felt that more was better.  I felt that I was shortchanging the person if they didn’t take home at least three pages.  When they came back for their next visit, sometimes they would have done them all, sometimes a few, and then there were those who didn’t do any…but always happily told me “at least I was honest”.  (topic for another day, but I always think..why is that a good thing?)

Some of the time this was because I didn’t do a great job of selling the importance of exercising.  I think more often than not, however, I just overwhelmed them with another task on the to do list.  When they were already hurting, or limited in their time and energy, this was really too much.   I have since learned that in most cases, less is better.

Unless they ask for more, I will usually only give out at most 4 exercises.   On occasion though I have negotiated it down to one.   I would rather have someone do one thing, do it well and do it often than do nothing.   I’m a firm believer in people taking responsibility for their own health (also a topic for another day), but I realize the need to meet people where they are now.

I also call it something else. It’s not an exercise, it’s an activity that you do every day; whenever you talk on the phone, stand on one foot for as long as you can; whenever you get out of a chair, do it without using your hands and stand up and sit down 5x (or 3x or 2x) before walking away; set up your elastic bands in your kitchen doorway, every time you walk by you have to do 10 pull backs.

Whatever.  The point is to make it part of the daily routine, not a big “thing” that has to get done.  In the end you’ve gone a long way toward keeping yourself moving and benefiting your health, without the mental burden of another thing to do.

But, if you decide you do want to take on a crazy goal like a marathon or a triathlon, I’m still know how to coach “more” too!

Ok, let me clarify that I don’t necessarily like to take tests, I just like the data that I get from them.

When we test we get a baseline.  We find out where things stand right now.  This could be something as simple as taking your blood pressure or pulse, or your weight, or something more complex like a memory or math test.  We get a place to start from and more importantly, we can measure the effectiveness of anything we implement to change the test result in the future.

If you want to lose weight and you try eating differently for a week you can weigh yourself again and see if your plan worked.  If you don’t have information from a first test then you have no way to know if your efforts were effective.

When I race, I’m always trying to get faster.  One of the challenges of measuring this in a race is that each race is different.  I can try and use the same race from year to year but even on the same course  wind or rain or some other factor can the parameters enough to affect the outcome.

This brings up an important point about tests.  They need to be designed in such a way that the variables that could affect an outcome are minimized, and the test needs to measure what you think it is going to measure.

Going back to my racing example if I race a 3 mile race that is flat and then a month later race a 3 mile race over hills, if my time on the second race is slower does that mean that I didn’t get faster? If I race a flat 3 mile course and then race it again a month later but this time there is a strong wind and my time is slower is my training not working?  We can’t get a true answer because the test variables were too different, and even though I was evaluating the effectiveness of my training by racing the same distance, the test was too different to give me good data.

When I look at how someone moves, while I can get a good sense of how things are going just by looking at them walk, stand from sitting and climb a few steps this doesn’t give me all the information I need.  As I’ve discussed before, the body gets very used to doing what we ask (or don’t ask) it to do every day, but is this the best way to perform the task?  Are we potentially overusing a body part that then might get injured?  Just because you can perform these simple tasks, what happens if you try to do something out of your normal routine? Like yard work, a big day of shopping or even a long day of cooking?  If you are an athlete, how do I know you are ready to go back to your sport? Or if you want to start a new sport or activity, how can we assess that you won’t get hurt?

There are some well established and basic tests that we use in the clinic and that I use with any athlete that I work with.   I use them because I want to know how well you move now, and I want to have an objective way to measure your improvement.  I want to be able to know if what we are doing is working or if we need to try something different.  I want to know if you are ready to progress to something more advanced, and I want to know if I can safely send you back to your sport or job with minimal risk that you will get hurt.   I want you to be able to see and feel your improvement, or I may want to show you where you still need work.  I

Unfortunately I don’t think we test our movement like we should and could.  Using my example of blood pressure from above, when we go to the doctor for an annual checkup this is often the first thing that gets tested (usually just after we are weighed which may have an unintended effect on our BP).   If you have an abnormal reading, the doctor can immediately make a recommendation that can prevent a problem in the future.  You will usually follow up with the doctor again in a 3-6 month time frame to see if the recommendation is working.  Changes can be made if not.

But when do we ever look at movement?  And why isn’t this equally if not more important than getting my blood pressure tested?  I will give a specific but very typical example from a recent patient.   This individual is in his late 40s and has been an avid hiker for many years.  Last year after having some knee pain and undergoing arthroscopic knee surgery to take care of a small meniscal tear he found that he had couldn’t do some of his favorite hikes as he recovered from the surgery.  He therefore didn’t hike often and became more sedentary.  As winter came he became even less active as he found it even more challenging to get out in the colder weather.  When spring came he decided to try a little hiking but found that it was a struggle and now his other knee hurt.  So he never really got back to hiking over the summer.

He came to see me yesterday because his knee hurts now when he stands up from sitting, when he goes up and down stairs and even when he rolls over in bed.  He finds that he loses his balance very easily, tells me he has put on some weight and just really doesn’t do the things he likes to any more.

Over the course of his physical therapy this gentleman will  improvement in his balance, function and movement and have the option to return to his hiking if he wishes.  However, if he hadn’t actively sought treatment for his knee, which in his mind was surgery before his doctor suggested PT first, but instead decided to live with his knee pain, his function would likely have declined.

If it hurts to climb stairs he would likely avoid it decreasing his ability to get around.  If his balance is off he would likely avoid situations that challenged it, made it worse, and then been prone to falling.  If being sedentary was increasing his weight, it is likely that this would continue.  Being sedentary is linked with many health risk factors completely unrelated to being able to get around and he might find that these developed or worsened. He might find that he stopped doing things he liked to do because it was too hard to do them.  Ultimately, because one of the most effective ways to manage the problems associated with knee osteo-arthritis is through exercise, he may end up having to go through a knee joint replacement surgery.

Sound dramatic? It’s not really.  When I take the history of a new patient this type of decline is quite common.

What if say even 6 months ago he had come to see me for an evaluation of his movement as part of an “annual checkup”?  Using the functional movement tests I work with I would have found the physical elements that impaired his hip, knee and ankle movement, his balance and his ability to hike.  I would have given him a simple program to start with, I would have recommended a 3 month follow up retest to see if it was working, and I would have made changes if needed.

I might have saved him a lost summer of hiking, helped him be more active in general, kept some of his weight off and minimized or prevented the pain he is feeling now.

Something to consider…and, yeah, that’s why I like tests.

Going back to my patient from last time..

Unfortunately a few laps up and down our hallway didn’t miraculously restore her to pain free walking.  What it did do though is show her that she was able to make a change that reduced her pain, and that she could do an activity that she really enjoyed..walking.   She wasn’t “broken” and, with a little help and guidance from me, she had the power to “get back to normal”.

The steps we took included mobilizing her hip, ankle and, perhaps surprisingly, her thoracic spine (upper back).  I showed her some hip strengthening exercises, stretches for her hip ankle and upper back, and several balance exercises.  Once she had some more flexibility and strength in these under used areas, we started to practice walking.

Initially she walked and I gave her cues to think about.  This worked fairly well but not great. The most effective thing however, was getting her to change her walking speed.  She had become so careful of her walking that she moved with a slow, very controlled and stiff gait.  My cuing didn’t help.  Once I had her try walking faster though, suddenly things evened out.  She automatically aligned her feet better, rotated he body and swung her arms in a way that effectively balanced her momentum, and was able to walk with 80% less ankle pain.  She also described the sensation as being “less like pain and more like a tired feeling”.   Perfect!  Now she was making those underused muscles do their job again.

Now we had something to work with.  Now her homework was to walk fast.  Spend some time each day walking quickly up and down her hallway at home,  When she could, walk quickly in the hallway at work.  If she got tired rest, but do her best to keep up the pace.  She had a favorite loop that she used to walk in the evening.  We started back to doing laps of that.  Only one to start because the increased speed tired her quickly, but as of this week she is up to three, and she spent a day out shopping and walking with friends.  Something she had avoided but really missed over the past few months.

So why did this work?  In her case, she had put so much thought into how to move to protect her ankle that it was difficult to change her new gait pattern with more conscious actions.  But when I had her stop thinking about how to place each foot and  think of only going faster, her old patterns of movement started to appear.  Automatic patterns that we were able to bring out by avoiding focusing on the parts and instead doing the whole movement, but in a way that stimulated her reflexive gait pattern.  Something that she once did naturally, but had forgotten.  We just had to trigger that reflexive pattern again, and keep triggering it until it became the new normal.  So far so good.

 

Going back to my patient from last time..

Unfortunately a few laps up and down our hallway didn’t miraculously restore her to pain free walking.  What it did do though is show her that she was able to make a change that reduced her pain, and that she could do an activity that she really enjoyed..walking.   She wasn’t “broken” and, with a little help and guidance from me, she had the power to “get back to normal”.

The steps we took included mobilizing her hip, ankle and, perhaps surprisingly, her thoracic spine (upper back).  I showed her some hip strengthening exercises, stretches for her hip ankle and upper back, and several balance exercises.  Once she had some more flexibility and strength in these under used areas, we started to practice walking.

Initially she walked and I gave her cues to think about.  This worked fairly well but not great. The most effective thing however, was getting her to change her walking speed.  She had become so careful of her walking that she moved with a slow, very controlled and stiff gait.  My cuing didn’t help.  Once I had her try walking faster though, suddenly things evened out.  She automatically aligned her feet better, rotated he body and swung her arms in a way that effectively balanced her momentum, and was able to walk with 80% less ankle pain.  She also described the sensation as being “less like pain and more like a tired feeling”.   Perfect!  Now she was making those underused muscles do their job again.

Now we had something to work with.  Now her homework was to walk fast.  Spend some time each day walking quickly up and down her hallway at home,  When she could, walk quickly in the hallway at work.  If she got tired rest, but do her best to keep up the pace.  She had a favorite loop that she used to walk in the evening.  We started back to doing laps of that.  Only one to start because the increased speed tired her quickly, but as of this week she is up to three, and she spent a day out shopping and walking with friends.  Something she had avoided but really missed over the past few months.

So why did this work?  In her case, she had put so much thought into how to move to protect her ankle that it was difficult to change her new gait pattern with more conscious actions.  But when I had her stop thinking about how to place each foot and  think of only going faster, her old patterns of movement started to appear.  Automatic patterns that we were able to bring out by avoiding focusing on the parts and instead doing the whole movement, but in a way that stimulated her reflexive gait pattern.  Something that she once did naturally, but had forgotten.  We just had to trigger that reflexive pattern again, and keep triggering it until it became the new normal.  So far so good.

 

As I continue my own quest to become a better runner I do a lot of reading about what makes us move most efficiently.  How can we best take advantage of the systems in our bodies that are designed to propel us forward with the least amount of active effort?

There are several reflexive systems that work by responding to a stretch.  In other words we allow a muscle to get loaded or elongated by movement, often just by letting gravity do it’s thing, and it reacts by reflexively shortening an assisting us in completing the move we wanted to make.

A simple example is in the way that we jump or even try to lift something heavy.  We don’t just pop off the ground, or grab something and just lift it, or at least we don’t get very far if we do.  Instead we sort of drop down a little, to get a little extra oomph, and then we push up.  What’s happening is that we are elongating those muscles that are going to give us that extra push and letting them reflexively shorten.

As a runner, one of the biggest aids to forward movement is our Achilles tendon and calf muscles.  When our foot lands on the ground and our ankle flexes, we are elongating that muscle group.  This in turn stimulates these muscles to reflexively shorten and push us forward.  The faster and more effectively we can load up this muscle, the faster and farther we move forward with that step.

As we move further up the body, the next most effective muscle group for propulsion is those around our hip.  The muscles that strongly flex one hip forward stimulate a reflexive hip extension, or backward push, of the other hip and leg.  This will give us a big push forward.

Often however, we don’t effectively make use of these powerful reflexive movements.  Either we have lost the mobility of our joints and muscles and we are unable to or we have developed ways of moving that over ride these innate responses.  We are trying to do something consciously that is better and faster done unconsciously (or sub-consciously as I don’t mean for you to go to sleep).

The problem with how to re learn to take advantage of our powerful reflexive movement systems is that we can develop ” paralysis by analysis”, or essentially try and think our way back to moving something that does better without conscious input.

So what to do?

Sometimes we have to use the movement itself to retrain this ability, but rather than focus on trying to activate a specific muscle, we focus on trying to do something differently.

What do I mean?

Well, using myself as an example, a cue that I found very helpful in my running is to think to drive one knee up and forward.  This was a completely new idea for me and something much different than I had been trying.  The effect has been that my opposite hip and leg are now really driving me forward.  The difference is that this forward propulsion feels relaxed and powerful and no where near as tiring as when I think to try and actively push off with my hip to propel me forward.  The difference is that the push is now reflexive as opposed to active.

The interesting part is how much thought it takes to think “drive forward”, which is essentially an effortless move and the leg is not meeting any resistance, but I need to remember that I am learning a new movement pattern which, though I probably did this naturally as a child, I’ve forgotten.

Another example comes from a patient of mine.  She came to see me for peroneal tendinitis or essentially pain and swelling on the outside of her ankle.  She was unable to walk for any length of time without pain and had given up hiking and walking with her family.

After talking to her and examining her foot, ankle and hip mobility I found that her symptoms began not long after she had had a bunion surgery to realign her big toe.  After surgery, due to the pain and stiffness in her toe she began to walk on the outside edge of her foot to avoid putting weight through her stiff and painful toe.  Unfortunately our bodies are designed to use our big toe to push off when we walk.

This wouldn’t have been such a problem if she had stretched out her toe and gradually worked to put weight through it to restore her normal mechanics.  Instead however she continued to walk on the outside of her foot for many months.  In fact when I first talked with  her she completely dismissed the bunion surgery as being related until I asked her to walk and apply pressure over her big toe.  She couldn’t do it without pain, and it was very difficult to even orient her foot correctly as, after months of walking with her foot turned out and rolled to the side, her hip had become very tight.   Interestingly she had developed low back pain on the same side in recent months.

Even though we think we can come up with our own awesome new way to move, and our bodies will usually try to do what we ask, when we think we are smarter than mother nature, we will usually pay for it in some way with an injury or inefficiency in the way we move.

Now, even though we uncovered some additional issues, the best part was that once she walked for a few laps up and down the hall way, forcing herself to put weight through her big toe as she pushed off, her outside ankle pain lessened significantly.   The challenge became how do we get back to normal?

That’s for next time…

 

 

 

I recently participated in a small group discussion about the direction physical therapy was heading in the current health care market. As a group we brainstormed answers to a variety of questions, including ways to broaden our appeal to prospective patients.  As we talked I realized that we were all coming from this as insiders.  Meaning we all understood what physical therapy was, what value we provided to our patients and what benefit we could provide to different groups.

All of us were experienced therapists who were enthusiastic about what we did and enjoyed the opportunity to provide our patients with a positive experience.  Most of us were able to detail successful outcomes and times where we were able to turn a negative into a positive situation for a patient.  I think those were some of our most valued experiences.  We could all name patients who sent us their friends and family members and who returned with their own issues.  Again this type of community was something we treasured and worked hard to develop.

What struck me though was that we were kind of preaching to the choir.  These patients understood the value of physical therapy.  The clinicians of our group possessed skill sets that restored function and the ability to move to their patients, almost in a way, giving them their life back.  We knew what physical therapy could do.

But what about the people who don’t understand what physical therapy is or why a visit to a PT could benefit them.  Who think well of course I can’t walk that far any more, or climb all those stairs or carry my grandchild or my groceries, or take up running or swimming or bowling…I’m not as young as I used to be.   Or who sit 8 hours at a desk, sit behind the wheel for another two and wonder why their back or shoulders hurt, but just accept it as a part of aging.

Or my brother in law who loves to ski, hike and ride his bicycle who had plantar fasciitis for a year and a stiff and occasionally swollen ankle, and whose doctor told him “well at 55 what do you expect”.  If he didn’t have a sister in law who was a PT and he were to decide that, “yeah, I guess I should slow down and not do all of these things any more because maybe I will get worse” is he better off sitting around more?  And in 10 years will he move any better?  Not likely.

Sure he can do his job, and take care of his family and he has other hobbies, but should his world get smaller because he doesn’t know that he has a choice?  That he could see a PT for an assessment of his current ability to move, and get some direction about how to take care of himself.  That he could come back again in a few months or a year, just like he goes to see his dentist or doctor, so that we can screen him again.   That maybe the stiff ankle he has is something he can treat now so that 10 years from now he can teach his son to ski.

What if we could teach people that the real value of physical therapy isn’t just treating them when they have an injury, but in screening them for a problem before they develop an injury?  Or that having trouble getting out of a chair, or up from the ground, or climbing a step isn’t necessarily permanent or a sign of age, but rather that their body just needs to be reminded how to do it?

Physical therapists understand how the body moves.  That’s what we were trained in.  But like the way we typically practice medicine in our country, we tend to see people only when they have a problem.  I think our greatest opportunity is in seeing those who could move better, or who are primed for an injury because they don’t move well, BEFORE they have a problem.