Archive for Exercise

Restoring Movement to the Neck

By Peter Fabian · Comments (2)
Thursday, February 2nd, 2012

The Neck

The neck is about one of our most used connections of the spine (and well used in our lexicon)  It is designed to be mobile and capable of great feats of movement and stability.  Just remember the days you’ve arisen out of bed–even before getting up–you notice how stiff you became over night.   Sometimes we say life is a pain in the neck.  Some folks even still neck around a little.

The neck is just not an anatomical structure to be described of bones and soft tissues.  It is a highly functioning arm of the nervous system and ourselves.  Here I am concerned with looking at how to restore movement in the lower neck (in a particular direction).

Mechanical problems

In my practice of Physical Therapy, many people who come in with shoulder and neck problems usually have a problem in moving their lower neck and upper back spine.  This area seems to become easily rigid.  We often see degenerative changes of the spinal segments at the segments just above this juncture of neck and upper back.  We often label seven neck segments with the top one starting as number one.  So the fifth and sixth segment are very popular in showing these degenerative changes.  To me this means that the area below is not participating in allowing movement to continue through these lower segments.  By the way, we don’t just move our necks.  Our bodies don’t move the neck.  Our movements take place in the spine.  Our patho-anatomical  medical approach (getting a diagnosis of a problem based soley on the anatomy that has a dis-ease vs including a functional evaluation or how it is working in daily usage) can distort our perspective of how we look at how what is going on ie the problem.

Of course, the  direction of mobility problem can be different for different causes and different people.  Here I wish to share my observations of the problem at moving through this juncture of the neck (cervical spine) and upper back (upper thoracic spine).  This junction is easily referred to as the cervical-thoracic junction or C/T junction.

What I find is that many people do not have very good side bending of the lower neck.  They often over move in the segments above.  Also when you observe those with pain and dysfunction of the neck and shoulder complex, it is worth evaluating how well they are side bending at this lower neck to C/T area.

Of course there are problems of stability in the mid neck and also upper neck.  There are sometimes mobility problems of the upper cervical region as well.  Note the junctional areas of the spine are very important in transmitting forces THROUGH the area (versus into the area).

Example of Moving the Lower Neck Spine

Here is a short video I did in working with someone.  I hope it will explain a bit about how you might start to work on learning to move this area.  Note it spends most of the time trying to coach one to move the lower area while learning to stabilize the above area.  It seems un-natural for many who have a movement deficit in this area.

Remember the learning is not just about correcting and moving better.  Ideally one must spend a good amount of time feeling and practicing these directions.  Often it takes some coaching.  A mirror can be invaluable in this type of training.

Conclusion

Enjoy the practice.  Those who don’t move this lower neck area well will be rewarded with proper practice.  You will find that once you can create some movement here sometimes your shoulder and neck problems become less.

Try it out and let me know what you find.

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Popular Misconceptions of Breathing

By Peter Fabian · Comments (7)
Thursday, June 30th, 2011

Breathing

We breathe and we live (or is it the other way around).  There are many excellent resources on breathing.  This article will focus on some of the popular misconceptions of the diaphragm in breathing.

Popular misconceptions (taught world wide and in current anatomy texts)

  1. Some people speak of chest breathing versus diaphragm breathing.  Does this mean that if you breathe with your chest you are not using the diaphragm?  If you are moving air into and out of your lungs and still alert for longer than 30 seconds, then your diaphragm is moving.  You will use your diaphragm essentially all the time you move air, whether you see your chest or belly primarily moving.
  2. Only the central portion of the diaphragm moves in breathing.  Really?
  3. The diaphragm is only active on inspiration.  Expiration is essentially passive.  Hmm-mm.

We will be primarily addressing the second and third misconception listed above.

Brief Anatomy of the Diaphragm

It is a dome shaped muscle when at rest or after the expiration/exhalation phase of breathing.

Here are it’s distal (furthest away from the center-line of the body) attachments:

  • Costal or ribs number 7-12
  • Lumbar vertabrae number 1-3
  • Xypho-Sternal aspect

Here is the proximal (close to center-line of the body) attachment:

  • Central tendon

Now there are more complete descriptions of these attachments in most anatomy texts that you can review in the library and on the web.  For now I want you to think about this division of distal and proximal attachments for the diaphragm.

Muscular attachments and directions of contraction

The diaphragm is one of the few muscles that does not attach one bone to another.  The face is another exception to this popular occurrence of muscular anatomy.  Keep in mind that contraction of the diaphragm is occurring between the proximal and distal attachments.  It is not occurring between the ribs and the spine.  Please keep this picture in your mind.  That means that when it contracts in inspiration it is shortening the distance between the proximal attachment (central tendon) and distal attachments.  Therefore in simple terms one end is coming closer to the other end.  (Although in reality they are both moving to different degrees)

Here in inspiration as the diaphragm contracts you could see that the central tendon would be pulled down.  This downward movement of the central tendon causes the lungs to fill with air.  Some people only describe the movement of the central tendon in inspiration.  This is only partially complete.

Let’s deviate for a moment to looking at the action of your bicep muscles in isolation.  Here the biceps connects the forearm bone to the upper arm bone (essentially).  The action is to bend the elbow.  (Only partially true).  So if you bring your hand (distal part) to your shoulder (proximal part), the bicep is moving them closer.  This is true only if the shoulder is fixed in space and the hand is free to move (like when you lift up a gallon of milk).  If your hand (distal) is fixed to an overhead bar or tree limb and you contract the bicep muscle it brings your shoulder (proximal) closer to the fixed hand (the ole pullup).  Similar actions but different parts (attachments) are moving while other parts (attachments) are fixed.

Also notice that the bicep muscle is active in lifting AND lowering in both cases.  Let’s take the example of the lifting glass gallon of milk up with you hand.  As the milk/hand comes closer to the shoulder the bicep is actively shortening in it’s (concentric) contraction.  If the bicep muscle were essentially passive in returning the hand away from the shoulder (in this case the act of lifting), then the glass gallon would possible slam into the table below.  This may be a bit laborious for some to read, but stay with it if you can keep your mind focused here.  Lowering of that gallon of milk can be observed with the bulging of the bicep muscle seen in both directions.  The opposing tricep muscle here is essentially inactive.  This is true also in the pullup example.  The same muscle is active in raising and lowering.  (This dual action will be the same in the diaphragm)

The bicep is actually active in lifting and lowering of the milk/hand.  This is respectively the concentric (shortening activity) and the eccentric (lengthening activity) of the muscle.  Let me labor this point further.  There are still authors and teachers who teach that muscles can only contract in one direction (often stated about the diaphragm).  They say it takes a second muscle or force to activate the second direction.  Of course the force of gravity is always present.  But to say that the diaphragm is passive in exhalation is an error.

Diaphragmatic function in inspiration and expiration

The central nervous system sends a signal via the phrenic nerve (the anatomical origin exits through the neck via the chest cavity to the diaphragm) to activate the diaphragm.  The diaphragm is involved in both concentric contraction and eccentric contraction.  The latter has been poorly described if at all.  I feel that this error is due to very poor functional knowledge of the way things actually work.  These explanations of contraction and then relaxation lead one to speak of one phase being active and the other passive.  This idea becomes erroneous and the propagated to the detriment of proper functional training of the diaphragm.

The diaphragm can fix either the proximal or distal end and move it’s opposite.

  1. In inspiration, if the rib and sternal attachments are fixed (by the action of the abdominal and costal muscles), the action of contraction of the diaphragm will lower the central tendon.  We then see the belly protrude forward.  Often this type of inspiration/inhalation is referred to as belly breathing.
  2. Another style of inspiration is when the central tendon is held in a static position (often by an increase in intra-abdominal pressure, which impedes the central tendon from descending).  Then the action of diaphragmatic contraction will cause the ribs to elevate and expand the interior dimension.  Often this style of three dimensional costal breathing of the lower rib cage is referred to as diaphragmatic breathing.
  3. Another style would be a combination of these proximal and distal attachments being held in part and allowed to move in part also.
  4. In expiration, the diaphragm is returning to it’s resting/starting position of a dome like appearance.  The diaphragm is just not flaccid during this phase, as often suggested by the word passive exhalation.

Eccentric phase of the diaphragm

When (in expiration/exhalation) the diaphragm returns, it is still contracting (in it’s lengthening return to rest).   Let’s look at setu bandasana.  This is the bridge pose in yoga where you lie on your back with your knees bend with feet standing on the ground.

When you inspire, you can see that the diaphragm must push against the weight of the abdominal contents.  Literally the diaphragm muscle is lifting this weight of the internal organs in this pose.  It actually is quite strengthening for the diaphragm, as are all inverted postures/asanas.  Now when you exhale, often slowly, the return of the diaphragm muscle if it was passive, would be a rapid release of the abdomen.  This erroneous belief of a passive diaphragm in this case would create a dramatic “whoosh” of exhaled air.  We know this is not what regularly happens, but quite the opposite.  This slow release is because the diaphragm is actively lowering the belly contents as it returns back to it’s starting position higher up in the chest cavity.

This eccentric phase of the diaphragm is occurring on all positions.  It can be more easily appreciated in inverted postures.

Orchestration of breathing

There are many styles and names of various ways we inhale and exhale.  We can orchestrate the different patterns of breathing through our positions and activations/inhibitions of all the muscles involved.  There are many other important muscles of breathing.  The internal and external intercostals will not be discussed in any detail.  They are extremely important along with the abdominal muscles, especially the obliques in helping to choreograph the visible expansion and contraction of the chest and belly volumes.

Just realize that in breathing the diaphragm is always involved in moving the air (if we are conscious for more that 30 sec).  Even in upper chest breathing (vs just saying chest breathing), the diaphragm is responsible for the intake of air.  In paradoxical breathing, where the chest expands and the belly is pulled up and inward, the diaphragm is still the prime mover.  In this style of breathing, radiography has shown even an elevation of the diaphragm.  Realize that the distal costal attachments are pulling outwards to such an extreme extent that the diaphragm is still contracting even though it is slightly doming up in the chest cavity.

Functional Training

So what!  Literally if you are still reading you may be wondering something similar.  If not OK!  Either way at this time we should look at the so what factor.  Knowing that the diaphragm is active in both phases of breathing will definitely affect your training of breathing.  Breathing for most people is inefficient.  So many people are suffering unnecessarily because they are not breathing well.

Also people are not re-training their breathing patterns properly.  We must include this eccentric phase of the diaphragm in our training.  I think we do in some ways now when we prescribe for people to breath slowly.  The exhalation phase that is active can lead to greater awareness of the breath flow.  Knowing that you are actively working both phases of the breath from the diaphragm will translate into better training regimens.  Adding resistance to the eccentric phase of breathing is very important.  Many people have a very weak diaphragm.  So the use of an abdominal sandbag or using inverted positions becomes very important.  Also I really like the Makarasana position or crocodile pose to help here.  The Himalayan Tradition in teaching proper diaphragmatic breathing commonly uses this asana.

Conclusion

Now when you train your breathing patterns include this active exhalation model of the diaphragm.  See if this concept helps focus and enhances your training.  Let me know what you find out.

The best in your training efforts.

Please contact me if I can be of further assistance.

Peter

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Fitness is a Lie

By Peter Fabian · Comments (0)
Monday, May 30th, 2011

The Great Lie

  • Get fit and loose fat
  • Fitness improves your health
  • Increase your longevity with exercise

Give Me a Break

We put our hopes and dreams into ideas.  Fitness can become just an idea.  These supposed lies of fitness could be true as well as not.  There are parts to each of the above that are true and other parts that are misconstrued.  Let’s take a break from whether it is true.  The discussion is specious.  Does this mean we shouldn’t strive to be fit.  Again there is this aspect of talking about it vs getting it done.   The key at this moment is “go” not talk about it.  (now before you leave for your workout…)

Next Step

Best thing to do is stop discussing this idea and start practicing it.  There is a ton of information out there on different programs to help you achieve your goals in becoming better at moving.  This is what fitness does.  It helps you move better.

Everything in our physiology is movement related.  We send signals of back and forth within our body, both chemical, electrical and mechanical.  We push and pull air and fluids throughout our vessels and channels.  We move things inside and outside.  Our thoughts and emotions move into and out of our awareness.  We are a constant complex marvel of an internal and external ballet of choreographed movements.

All this internal movement is summoned up in our expression and dance of movement with our outside ecology.  These exercises we do and the functions we perform in our daily lives and the kinds of relationships we have or don’t have are the final expressions of our symphony of movements.

Fitness Guidelines

  1. Start a regular practice involving large body movements.
    1. Spinal movements
    2. Shoulder girdle movements including the whole shoulder complex
    3. Hip girdle movements including the lower extremities
  2. Include a systematic variety of different types of movements
    1. Endurance both aerobic and anaerobic forms
    2. Stability and strength
    3. Flexible and fluid
    4. Power
    5. Agility and balance
    6. Coordination and motor control
    7. Skill and FUN aspects
  3. Yoga
    1. Develop a philosophy of life
    2. Live both the life of the inner worlds WITH the life of the outer worlds
    3. Be truly happy and know yourself
    4. Skill set of practices
      1. Meditation and concentration practices
      2. Breath training
      3. Internal dialogue
  4. Diet and nutrition
    1. Develop regular eating habits
    2. Proper food selection and supplementation
    3. Proper elimination
  5. Sleep
    1. Regular
    2. Sufficient amount
  6. Sex
    1. Healthy expression
    2. Significant indicator of hormonal balance
  7. Etc
    1. In case I left out anything, please add here

Now What

Do some of you remember Jim Fixx.  Back in 1984, he was on the popular front of running and getting fit.  He had a 2 pack/day cigarette habit and was out of shape.  He stopped smoking, ate better and took up running.  He was the iconic symbol of a fit man when suddenly he died of a heart attack while jogging.  I remember this incident well.  I had bought his book and thought what a great thing for fitness that he was doing.   After his death there was a whip lash effect on this fitness craze of the day.  Some of course used this sad story to incorrectly label the efforts of fitness.

Being fit does not protect you from disease or life.  It does allow you to move better through life, no matter what you have to deal with.  The key again is movement.  Fitness isn’t something that you can hold in your hand as this or that.  But if you have done your practices regularly, then you will be able to live above most that do not.

We all will have some of today’s diseases for a variety of reasons.  Some of us will be heavier.  Some us will be skinnier.  Etc.  Being able to move our minds and bodies well will allow recovery and return to our lives with greater ease.

Look closely at what you want in your life.  Develop a practice to reach those goals.

What you can train, you can attain!

If you are involved in training, congratulations!  Consider reviewing your program.  Look at the above guidelines.  Which areas are you doing well in.  Are there areas that you leave out?  Maybe you don’t even consider them.  It would be another article to speak more directly about using some of these guidelines that may be under utilized (or mis-used) by some in the fitness arena.  Leave a comment about this topic.

If you haven’t started training regularly, then re-evaluate where you are in relation to your goals.  Maybe get some goals and/or redefine them.  Start with a simple plan and then take action on it.

Expect to train and practice for a long time.   Many fitness gurus and research speak of short term training programs.  There is value to including short term effects.   The real value in practice and training is over the long term.  It is always surprising to me how much change happens from year to year.  Most are familiar with the change of degradation from year to year.  The changes I find that are most sustainable and profound actually take place over many, many years.

Now for some, a longer view is a kin to a prison sentence, at least emotionally.  OK, that isn’t uncommon.  It is just unproductive.  This evaluation of the value of long term training actually allows for all of us to attain whatever it is that we are training.  This statement kind of reminds me of a money back guarantee.

Just don’t be planting carrot seeds and expecting apple blossoms.  I’m not kidding.  Many people say this type of training just doesn’t work.  Often these critics do not even participate.  They are the arm chair quarterbacks or the box seat critics.  You have to be moving and doing (before you re-hang around being).

But again the main point is that what ever we do, what ever we eat, what ever we think/feel becomes what we are.  If we have a particular result, it is due to all that we have done or not done that leads up to this result.  Again this can become a challenge to survive/manage/overcome or an obstacle that seems insurmountable.

Develop the fitness of the mind and body.  Engage fully in life.  Practice!

Best of the best in your endeavors–peter

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Shoulder Stabilization in Asana/Posture and Movement

By Peter Fabian · Comments (2)
Tuesday, May 17th, 2011

Shoulder Stabilization in Posture and Movement

In Yoga and many times in athletics/sports, we are often looking at physical flexibility.  This is great in the proper context.  Flexibility which is certainly stressed in yoga asanas has it’s compliment in stability.  We often talk a good line about balancing the body.  Often in practice we don’t notice what kind of balance we are creating or have created.  Since I often hear instructors in yoga class repetitively encouraging a student to go farther into the asana, I wish to focus on this incomplete perspective.

We will look at a case example from my Physical Therapy clinic.  Before moving into looking at this specific example of shoulder instability, let’s speak more of this flexibility vs instability issue.  Is it that one is better than another.  (of course it is and of course it is not)

Posture or Asana Guidelines

This is old material for many who know it, but a brief review will be stated.  The first of the three Yoga Sutras of Patanjali on asana starts out as:

Sthira-sukham asanam

Asana or posture is steady/stable and easeful/comfortable.  I don’t know how many teachers and students who can recite this and more, still persist in having someone focus over and over again in trying to stretch further.  Many people will look at a picture of someone who has tremendous physical flexibility, and they will effort to accomplish more range of movement.  (Just like in the picture of their mind)

This perspective of overdoing the flexibility aspect of asana is not being balanced out by proper training of the needed stability.  There must be good reasons why such an authoritative text like the Yoga Sutras has started out with stability and not about flexibility per se.  (I know the context is stability of the mind–but we are starting with the body part of the mind here)

Developmental Guidelines

When babies start to move around, what is the first thing they do?  In one way they start just moving.  They seem to come equipped with great flexibility, right? (Wouldn’t some of us love to have that now days.)  Well they don’t get very far until they develop significant stability.  They do a ton of core work on their backs while seemingly flaying around their limbs for example.  I will not get into the large amount of work they do sucking and orienting their eyes and head, etc.  I just want to focus on this idea and observation–they don’t get up and get around until they develop their stability.

So if someone has the proper mobility then stability comes in conjunction to complete many of the functional movement patterns or exercise/sport  patterns that we are involved in.  What if we don’t have the flexibility, let’s say for the a particular asana.

We need to have movement.  What is the relationship with movement and stability?  Does one come before another?  Well—it depends.  (great words of wisdom : ))

Flexibility Problems and Of Course Stability Problems

Flexibility and Stability are both needed.  It is the prescription of how, when, and where–including dosage amounts and timings.

For the past several weeks I have been seeing a client for shoulder and neck pain.  Basically when he raised his arm above shoulder level in abduction, he has a painful arc of movement from about 110-150 degrees.  Also this is his limit of movement on first examination.  He can stretch it farther into the ends of range to 160, but it is just more painful in this case (not a true painful arc, per se).  His neck movements were slightly limited in rotation and side bending away from the affected side.  Mainly stiff lower cervical segments as a group.  Also his thoracic spine rotation was markedly restricted bilaterally.

All his movements demonstrated poor sequencing of the scapular component.  He was very weak in scapular retraction against resisted rowing movements, especially on his affected side.   (The gleno-humeral joint was  also anteriorly subluxed slightly)  He was unable to retract or move his scapula’s together with resisted pulling movements when his forearms were more vertical.

I often use a mini band at this point to see if they can maintain their forearms in more of a vertical position as they pull the band apart and try to retract the shoulders.

Often they are grabbing this mini-band with their hands vs just wrapped around their wrists.  You can see here that the band is at the top of the chest level.  If you try to have them start at their nose level and then try to pull it apart–you will often see them only able to pull it while allowing it to come to their chest level again.  Their scapular stabilizers with abduction of the arms are quite weak.  The classic testing of shoulder stability with the elbows at the sides of the trunk are for very weak folks.  Much of compromised work is with the hands/arms raised over his head.

Flexibility and Stability Retesting

Once I found both a flexibility and a stability problem, I will start to stimulate one area like the above scapular retraction with the mini bands.  (As this scapular component could be at the base of his flexibility problem–as the shoulder blade is literally the base of the arm AND it was the most asymmetrical problem).   Then I will retest their original complaint.  In this case, he had pain with limited shoulder abduction.  He immediately showed improvement.  So then just for an experiment in his case, I tried doing some gleno-humeral (shoulder ball and socket) mobilization and mobility exercises.  He didn’t respond as well upon retesting.  I  also tried improving his thoracic rotation.  We used combined active movements of rotation and side bending of his trunk in sitting.  He improved in shoulder abduction a few degrees, but not nearly the improvement as seen with the direct scapular resistance.

This particular fellow is rock climber and surfer, etc.  He is very active and very strong in other ways.  In other words, when I asked him to do a push up, he just dropped to the floor and pushed away with no problem.  Please note that in this push up position, he locked his upper arms in close to his side.  His scapula’s were quite stable, with no winging or instability.  Very impressive.

Note that his instability (and seemingly inflexibility) is when his arm and hand are above his head.

Stability Rehab

This client case is just to emphasize that some people will have a lack of movement.  Their lack of movement does not always respond to stretching.  In this particular case it made no difference, except it was actually more uncomfortable with end range stretching.

He has responded well to starting with side plank positions.  He is fairly unstable and has very weak endurance in this side plank position.  The forward plank did not demonstrate enough change.  The bulk of his program that has proved most helpful has been with these pulling movements at different angles.  We often focus on holding the pulling movement and then working on eccentric/concentric contractions of this movement pattern.  We change the angles over time, trying to find the weakest and most unstable position.  We back away from it slightly and work before that place and after that place and then through that place that is difficult.  He still uses thoracic mobility exercise to his advantage too.

Limitation of Yoga Asana

He has done very well.  It is interesting to note that in traditional Yoga Asanas:

…most asanas develop forward pressure movements involving the upper body

He was originally trying stretch it out for weeks and weeks.  There wasn’t much change.  All forward pressure movements did not significantly help him either.

Summary

Realize this is a case example–speaking to the importance of assessing both mobility and stability.  Certain protocols/sports/movement paradigms are biased in direction of movements and particular activities.  These are constraints that can lead to significant imbalances.  It is not that something is bad or good for you directly.  There has to be an evaluation of what are your weaknesses and strengths.  Often we are involved in activities that strengthen our strengths and do not do much for our weaknesses.

I know that in other people, they have more of a mobility restriction in their particular case.  Therefore work more on mobility.  Remember it is identifying the problem(s) and then a key is to RETEST.  This retest provides the feedback.  It isn’t this paradigm vs that paradigm.  These topics of controversy, if they truly are, only should lead to examination not to reverential following.

Strengthening your ability to observe is paramount.  Also you must ask a lot of questions.  Be systematic in your focus of questions and answers–(most really are not–their mind immediately jumps away to a more familiar aspect of their inquiry–more to say about this in another post)

OK, make some comments.  Share what you find works.  Let’s build a community together.

Strong Mind and Body–Peter


 

 

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Myth of Maximum Heart Rate

By Peter Fabian · Comments (2)
Friday, April 1st, 2011

Question

What should my target heart rate be for safe exercise now that I’m reaching into my 60′s? or now that I’m ….?

Answer Part 1

There has been a consensus from people in medicine and in the various fields of exercise training that your maximum heart is determined by the following formula:

220 minus your age =’s Maximum Heart Rate

Then you take a percentage of that to arrive at your target heart rate for training.  Let’s first look at this formula stated above.

Background

This formula has been too casually utilized.  It has been promulgated as being scientific and over time has become the erroneous guideline for many in determining individual training levels.

It was founded in 1970 by Dr William Haskell.  There is a very good article in the New York Times that challenges this myth of maximum heart rate.  Below are excerpts from it:

The common formula was devised in 1970 by Dr. William Haskell, then a young physician in the federal Public Health Service and his mentor, Dr. Samuel Fox, who led the service’s program on heart disease. They were trying to determine how strenuously heart disease patients could exercise…

The subjects were never meant to be a representative sample of the population, said Dr. Haskell, who is now a professor of medicine at Stanford. Most were under 55 and some were smokers or had heart disease…

…At that point, Dr. Fox suggested a formula: maximum heart rate equals 220 minus age.

But the formula quickly entered the medical literature. Even though it was almost always presented as an average maximum rate, the absolute numbers took on an air of received wisdom in part, medical scientists said, because the time was right.

Answer Part 2

The American College of Cardiologists and the American College of Sports Medicine have come out with different guidelines.  I have seen that the American Heart Association used in the past the old formula.  I don’t know if they are still recommending this 220 minus age, equals your maximum heart rate.

Many have used the Karvonen Formula–See this link for an easy and quick calculation (and calculator)

Heart rate = ((Max HR-Resting HR)*%X/100)+Resting HR. (where %X =%MAX)

There is a great summary on a Wiki page here.  It provides more information than many would want.  It has other measurements and of course you can find the cited references.  Nice job.

So where does that leave us.

Answer Part 3

OK, whenever there are at least three answers proposed, be careful.  That means here, be careful!  I think that we don’t have a simple answer.  Also, we just don’t really know.  So in light of doing a treadmill test or similar at a human performance testing laboratory–what do we do?

We could use our common sense (or uncommon sense, as the case may be).  Take measure of who is asking.  What kind of condition are they in, any medical concerns–use a doctor to rule out medical problems.  What is their exercise history both recent and past composed of. Etc.

I personally like the Karvonen Formula or one of the other similar ones (they seem to differ in the range of standard deviations allowed).  In addition, I also like the Scale of Perceived Exertion.  This scale has shown good reliability with different groups of people–but it has doubt for some populations (caveat emptor).  Many people have derived their own modified Borg Scale.  Different groups have assigned different numbers meaning different levels of exertion.  (here and here for example)  Most importantly find your own subjective report that you can use consistently to gauge your work effort.  Be smart and be aware always.  Don’t use scales of any kind without retesting.

This retesting is important.  By retesting I mean how do you feel after exercising at your level of exertion.  How long does it take for you to recover–both in immediate heart rate (and breathing rate) and in the following days.  How you are sleeping and waking are always good barometers to pay attention to in determining how stressed you have become or not.  Also consider your mood swings and general level of energy.  This evaluation is always seen in our relationships with both are family/friends and in difficult situations especially.

Summary

Training is never done in isolation to how ones heart rate only is responding.  One needs to pay attention.  This attention would benefit by having a check list (hmmm another article someday)

Hopefully some of you will read this article and add what you have found to be important in determining your level of work.  Add your comments below.

Good training–may our hearts expand and receive the benefits of training beyond the base physiological parameters of regular exercise prescription.

 


 

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Shoulder Pain: Case Example Using Mini-Bands

By Peter Fabian · Comments (2)
Tuesday, February 22nd, 2011

Background

Shoulder problems are one of the big money makers for people in the medical field.  As with many problems there are many factors and different categories of these problems.  This statement of shoulder pain is a very poor title for discussion.  It is the common moniker that many of us use for a wide variety of different problems.  In other words, shoulder pain does not even describe the problem, only the symptom.  Only subsequent questioning and discussions can bring clarity to what is the problem.  Shoulder pain can be referred pain from other sources like the neck, ribs, heart and lungs and many other problems.  These origins of the shoulder pain don’t even have to be in the neighborhood of the shoulder.

Here I just wish to talk about a particular case illustrating some basic principles of movement and stability of the shoulder complex and using mini bands.   If you are experiencing painful shoulders, please do not limit your assessment to what is given below.  Remember what is said in the above paragraph.  First ask other questions.  If there is any doubt in your mind have your doctor clear you first before embarking on trying out a musculoskeletal approach only.

Case Example

This young man who works a sedentary job and participates in weekly yoga class had been noticing increasing discomfort  of both shoulders but especially the left one.  Simple lifting the arms above the head would reproduce his symptoms.  They would get better on the right with continued movements but not on the left.

A brief assessment showed the following.  His posture looked casually very erect.  (Although is head was slightly forward and his thoraco-lumbar area was over extended, and his scapula’s winged bilaterally).  His neck demonstrated limited rotation and sidebending bilaterally especially to the left, his more affected side.  His lower neck spinal mobility was more restricted in these movements.  His shoulder mobility was with a flexion deviation in abduction. End ranges in abduction and external or outward rotation were slightly limited.   Resisted testing was weaker in extension and external rotation with arm above the head.

His mid to lower thoracic mobility was restricted in rotation–his mid to upper thoracic  was restricted more in extension.

In all his shoulder mobility testing, he demonstrated poor initiation of the scapula, especially on his affected, left side

Basic Approach

We worked on basic joints and glands (calisthenic type) exercises and foam roller to help restore some of his spinal mobility.  He improved so that his mobility was more normalized in his spine and shoulder.  His most provocative test now was his resistance to external rotation of his left shoulder when his hand was above his head.

It is interesting to note that in the classic muscle test position of external rotation with his elbow at his side, he had no problem.  I find it always helpful to hunt around to see if different positions will provoke his symptoms.  Also during these movements the scapula had a lag or latency in it’s sequential recruitment.

Mini Bands

Since he was essentially not activating his scapula enough in order to move his arm, work on this provided the changes he needed.  By working on basic pulling activities and cueing the scapula to perform better he was able to complete his recovery.

One problem I find in recommending exercises is compliance.  The simpler and easier the exercise the more compliance you will have.  This is a real struggle for me as there are so many areas that a person needs to learn about to move effectively.  If you can start the movement and break it into pieces, you can sometimes deal with this compliance issue effectively over several sessions of training.

This photo shows the 9 inch long loop called the mini band in action.  Here we started with simple setting of the posterior shoulder muscles.  We can emphasize scapular retraction while loading more of the external rotators to act as stabilizers.  This movement reminds me of the ole chest expanders we used as kids.  (Hoping to become like Charles Atlas and rule on the beaches).

Mini bands are great.  I constantly refer my clients to an online store called Perform Better.com.  Here is the link to their mini-bands.  They are a closed loop and give you what thera-band still gives (sans the knot, tying the ends together).   I just find I use these a lot more and they are so easy, portable and just fit the bill so well.  (no I don’t have any financial relationship with this company–except when I give them my money for their products)

We used a variation of this set up that is shown in the above photo.  What you see here is the mini-band looped around his wrists while pulling on another band (monster band, listed under mini-bands in the above link)–this monster band is 20 inches vs 9 inches in the mini-band.  You can use them separately or together as shown here.

One of the advantages of using a closed loop to do any type of rowing movement is that you can develop two directions at once.  This combined movement is very good for activating the stabilizers in this case.  You see on regular rowing you work on mainly retraction/extension of the shoulder.  Here with a closed loop (and the addition of the mini band) you emphasize this external rotation with a variation of horizontal abduction.  Turning on multiple planes of movement will really drive the shoulder complex to be more stable with proper cueing.

Another advantage to this arrangement is that it is very simple to set up and take down.  Space and equipment considerations are minimal.  Just get in there and do the work.

Progressions

The mini bands come in a variety of resistance.  I often have my clients purchase the yellow, green and blue mini bands.  Also buying the 20 inch loop (called a monster band with in the mini band section), will give you a large variety to try many different things.

  1. First I will start with a yellow or green band in the upper body for sedentary folks
  2. Next I will add the two bands as in the second photo
  3. For people who have issues in grip–whether arthritic hands or other problems, you can easily use the loops around the forearms
  4. Also the loops placed more proximal will reduce the force needed–this makes it very doable for anyone–I even use these ideas with a 93 yo woman who is progressive working just with the mini bands and also a 40 inch loop.
  5. This rowing movement for those who have issues of rotatory instability with the arms above their heads need to further progress.
    1. We start from simple rowing movements where the elbows are pulled closer to the sides while the forearms are more parallel to the floor
    2. Next we work into getting around a 90/90 degree position of shoulder abduction with external rotation while the elbows are around 90 degrees
    3. I’m not too strict here about the 90/90, just having them move towards this position and have their forearms more vertical works quite well

Summary

Retesting will clearly show if we are in the right direction.  I will immediately retest their provocative movement pattern.  If it is better, that is stronger, better movement of the scapula/humerus and thoracic spine–I know this has been a good choice.

There are of course many ways to deal with this problem of instability.  Try out this variation if you haven’t.  Let me know what you find.

Best in training.

As always, contact me if I can be of further assistance–Peter

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Effective Exercise

By Peter Fabian · Comments (0)
Tuesday, January 11th, 2011

Strong Mind and Body

Do we get the best results from our exercise selections?  How do we select which exercise to perform?  Besides matching the proper exercise for the problem we have, what else is important?

Is being effective due to:

  • The proper selection of the correct exercise?  or
  • How we do that exercise/movement?

Effective Exercise

First we must congratulate ourselves because we are doing exercises.  Next we have usually identified some reason for putting down the remote and/or getting out of bed.  Now let’s move quickly on to someone who wants to perform their particular task or skilled movement better.  It could be that they want to jump higher, cut quicker on the field, get into better shape/condition or simple perform a yoga posture that is particularly challenging.  Let’s take the latter case to illustrate several of these points on how to effectively exercise.  (We are expanding the definition of exercise and bending the definition of yoga asana here to make some points, knowing that the purists may start off disagreeing too early here)

Yoga Asana–Chakrasana

This is not a complete description of how to do Chakrasana.  We are using this posture/asana as an example of some one who wishes to do an exercise or asana effectively.  (This example could be extrapolated into many of the “corrective exercises” being given and performed today.

Let’s start with looking at a typical example of someone wanting to be more flexible.  They have taken up Yoga asanas in a class.  At some point the teacher has progressed to this pose called Chakrasana or wheel.  It is fairly vigorous for many, as can be seen by the picture above.  Again this could be an example of someone wanting to jump higher and get stronger in their legs who at some point starts doing one leg squats.  It really doesn’t matter the movement activity by itself.  It is again looking at how to exercise effectively.

Truly in exercise/movements it would be best if we knew ourselves well.  (Know thyself–OK, end of philosophy).

  • Where do we move well–actually where and in which directions do we have ease and dis-ease
  • What movements are strong/stable/powerful and have endurance (both in mobility and in stability)
  • Which tasks and/or skills do we prefer and which ones do we stay away from
  • Do we move smoothly and in a coordinated fashion
  • Do we breathe or frequently hold the breath with frequent efforting
  • Can we stay focused and pleasant in our mind or just the opposite

These are just some of the aspects or questions to ask in order to get to know HOW we move and therefore better know ourselves.  Knowing ourselves better will allow us to move better.  We can take full advantage then of the exercises or movements being selected.

Maybe Chakrasana (or single leg squats) are not the best exercise at the moment.  Maybe the way in which we do them is not allowing the benefits of those movements to create the tremendous results that await us.

Where (location and direction) and how do we move well (and where/how we don’t)

We need to look at large patterns of movement.  We want to see and feel how the body moves in all directions from the major areas of the body while performing a variety of movement patterns/tasks/skills.

  • Bending and reaching
  • Twisting
  • Pushing and pulling
  • Squatting and kneeling
  • Rolling and crawling
  • Sitting and standing
  • Walking, running, hopping and jumping

Where in the body do we move a lot and where are we stiffer.  Often this inquiry stops here.  It is insufficient.  The shoulders may be tight in lifting them above our head but have a lot of movement in the opposite direction.  Especially important is to notice difference from side to side and up to down.  Maybe our hips are able to extend (backward bend) well but our shoulders cannot open in that same direction.  Maybe one shoulder does more opening that the other–do you see that in Chakrasana then you would create a rotation of the trunk.

Look at the picture again and you see that the hips are opening well in backward bending.  The lower back spine is bending a lot.  The rib spine or thoracic spine is not backward bending at all in the mid to upper back.  The shoulders are also tight in this same direction.

Isn’t it interesting to note that this person is doing the general direction of this Wheel pose.  It is just HOW they are doing it that is of note here.  Therefore they will be over using hips and low back (and neck) and under using shoulders and mid-upper back (and wrists).

What if we knew where we moved and didn’t.  This might totally change what we do and how we do it.  Of course the results would be vastly different.  Our learning then and what we pay attention to would be expanded.  The changes across many different systems could be facilitated (musculoskeletal, fascial, nervous system, respiratory, immune, etc)

What movements are strong/stable/powerful

Again looking at this picture, we can ask several questions.  I know it would be better if we actually had a video.  Then truly we could appreciate the movement qualities better.  This picture and discussion will at least highlight the points of this article.

Looking at the two ends of this Wheel pose–which end, the leg or arm end, looks most stable?  You can see how the weight of the body is carried behind the arms.  Are the shoulders weak or only stiff?  or both?  Address whatever is involved with a more appropriate regression of this pose first.  Identify weakness and lack of stability of the shoulder complex with the arm above the shoulder level.  There are many ways of doing these tests/movement regressions.  We will not go into that detail here.

Looking at the middle of the body and seeing how the front of the lower back (the belly) over lengthens.  The lower back  over shortens.  How much of this over extension of the low back is a mobility problem of the thoracic spine in extension?  (or/and does it involve lack of stabilization of the anterior belly region.)

First you would have to decrease the challenge of this activity.  Take them out of trying to do this asana.  Place them on the floor and have them roll from belly to back with only the arms and head.  Do they activate their belly enough to transmit the rolling through the trunk from the arms.  Could their shoulders and thoracic spine be so stiff as to even impede this movement. Further investigation would be warranted.  This again is just to highlight a perspective of looking and asking questions.

By looking at more of these larger movement patterns, it will become clearer.

Which tasks and/or skills do we prefer and which ones do we stay away from

I wonder if this person loves to do backward bending movements where the shoulders are not flexed near their end ranges (that is over head position, above shoulder level).  So let’s make up a scenario that I see frequently in the clinic.  They would do  easily cobra or lying on their stomachs with arms by their sides.  Even Camel pose (tall kneeling and bending backwards to place hands on heels) would be available.  Any superman type position or boat pose would be done with substitution and difficulty.  They would never practice hand stand as it is too tiring.

If this lack of using the extremities over the head (in Chakrasana) causes such stress, then it may need to be regressed or made easier.

This easier movement may allow the proper awareness and adjustments to overusing and underusing that is being outlined here.

Do we move smoothly and in a coordinated fashion

This examination of coordination and agility reinforces many of the above observations.  Again whatever we move well and strongly, those are things we do.  We always use what we have even when trying to do something else.

Let me digress from this example to talk more of our preferences and avoidance’s in general movement.  We use the same patterns of movements and habits even in opposite directions.  It is not unusual to see someone who is trying to sit on the floor and has a lot of left knee pain (for example–in a cross leg, sukhasana pose).  Sometimes in looking at them you see their weight shifted to their left hip, although they are leaning a bit to their right.  You find they are in right sidebending of their trunk.  When you ask them to sit on a chair and turn right and left they still have most of their weight on their left sit bone.  In other words they do their movements of rotation and still maintain their right side bending of their trunk.  Their coordination remains dysfunctional even though you would give them a movement to change it.

This latter dysfunction a very important point to discover.  Our movement habits often remain and don’t change just because we are doing some corrective asana or exercise.  The WAY we move becomes also very important.

Do we breathe or frequently hold the breath

OK, breathing is so important.  It is a barometer of our mind and nervous system.  Sure at the beginning one may fine this breath rhythm disturbed.  The habitual and repetitive nature of an interrupted breath is very detrimental to our learning and proper response to the exercise.  A jerky breath relates to a jerky focus of the mind and all the other negative effects in all systems.

Try moving only so far as the breath can flow well.  This does not mean that you can’t cause strain.  That is ridiculous.  As one continues to do repetitions or hold the pose, the breath should be noted to start to flow well.  Otherwise there is not practice.  One is just violently stimulating the system.  Of course you have some changes even with the breath always being strained.  This abnormal breath rhythm though is very limiting and over the long term is detrimental to health and well being.

Can we stay focused and pleasant in our mind

Alright, take off the music headphones.  Pay attention to what you are doing and what you are feeling.  A good barometer like the breath is to ask whether you are pleasant in your mind.  GEEZ, you mean we have to be smiling all the time.  OK, less drama here.  Just note what happens to your overall sense of tensing and effort when you notice that your mind is not pleasant.  Whenever I ask this question in class or to individuals, I never fail to see an easing of tension, even a  : o )

Also when the mind is more pleasant–often you will notice an ease in the movements.  Try it just like you would try breathing with more awareness and ease.

Whew

So now when you exercise, you can ask more questions.  Effective exercise is creating the proper effect you want and/or that is available in the stimulation of the movement done well.  Effective exercise involves BOTH the selection of the right exercise the proper way of moving–

  • The Body
  • The Breath
  • The Mind

So before and during your next exercise session, take time to pay attention.  Use the movements to create opportunities to sense and breath.  Train hard up to your capacities.  To know your capacities, you must practice a lot.  You would benefit by coaching or skilled guidance.  Try using these principles–pick one, like having a pleasant mind.  Then go find a skilled coach/teacher and get some quality feedback.

Best of luck in your effective exercise.

Feel free to comment or contact me directly for a consultation.

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