The Clinic is a Trojan Horse for Exercise

“In the 21st century, health care is increasingly about long-term condition management and thus about health behavior change” [1]

Inactivity is a major worldwide problem. The World Health Organization (WHO) lists “physical inactivity” as the fourth leading risk factor for mortality [2]. Unfortunately, the rates of exercise participation are shockingly low. In the U.S. it is estimated that less than 30% of adults meet current exercise recommendations [3].

We, as physical therapists, are uniquely suited to combat this problem. The PT clinic is the perfect Trojan Horse to get clients exercising regularly.

Why PT’s Should Promote Exercise

Promoting exercise doesn’t just improve general health-there are musculoskeletal benefits that may prevent the need for PT in the first place.* Exercise, specifically resistance training, has preventative musculoskeletal health benefits including: preserving cartilage, preserving/increasing bone mineral density, improving tendon stiffness (a good thing for tendon function), and reducing frailty (which relates closely to fall risk) [4].

However, beyond the preventative benefits of exercise, many of the conditions we treat require long term management. Physical therapists no longer just treat acute injuries. For the chronic conditions we are increasingly working with, patients need tools like exercise, to manage pain and improve function.

The Unique Advantages of PT’s to Promote Exercise

PT is one of the few healthcare professions that spends massive amounts of time with patients. A PT might see a patient for several weeks for 30-60 minutes per session. On the other hand, a physician might only see a patient for an annual checkup for 10-20 minutes.

With so much time spent with patients we are able to:

-Understand and change beliefs about exercise like “lifting weights is dangerous” or “just swim because it’s low impact”. We not only have the time to discuss these beliefs, but the context of the clinic can help patients feel “safe” while exercising. Patients can gradually build up confidence exercising in the clinic in order to exercise independently upon discharge from PT.

Design exercise programs that fit a patient’s life. We get to know our patients well. We deeply understand their exercise preferences and the constraints of their life. So we can create exercise programs that a patient will actually stick to.

For example, I would love all patients to have gym access. However, this is not always possible. For some patients a bodyweight exercise program would have to suffice. Sometimes, the “optimal program” is the program that patient will stick to long term.  

-Help patients build support to exercise. Having support from loved ones and social groups helps many patients stick with exercise. As PT’s we often meet patients’ loved ones and can talk directly with them about how to exercise long term. For example, we often need the buy-in of loved ones to help a patient get exercise equipment, make time to exercise, and to motivate them.

However, even if we don’t meet a patient’s loved ones, we can still help them build support for exercise. We can help them involve their loved ones in exercise. Or we can even help them connect to groups to make exercise social.

But won’t this take away from “treatment” time?

We shouldn’t see exercises for fitness as distinct from exercises for “treatment”.  Many rehab exercises are quite similar to general strength and conditioning exercises. For example, with rotator cuff tendinopathy, we often use isolated strengthening exercises and then progress towards compound movements like pushups and rows. With the right dosage of load and volume, the same exercises that were once rehab exercises become general strengthening exercises.

The clinic need not be only a place for PT “treatment”. The clinic can be the Trojan Horse to empower patients to transform their health through exercise.  

*We cannot truly “prevent” injury or pain, but we can reduce the risk of injury. I use the word “prevent” since “reduce risk of injury” is too verbose.

References:

1. Rollnick S, Miller WR, Butler CC (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: The Guilford Press.

2. GLOBAL HEALTH RISKS GLOBAL HEALTH RISKS WHO Mortality and burden of disease attributable to selected major risks. (2009). Retrieved November 19, 2020, from https://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf

3. Piercy, K. L., Troiano, R. P., Ballard, R. M., Carlson, S. A., Fulton, J. E., Galuska, D. A., George, S. M., & Olson, R. D. (2018). The Physical Activity Guidelines for Americans. JAMA320(19), 2020–2028. https://doi.org/10.1001/jama.2018.14854

4. Maestroni, L., Read, P., Bishop, C., Papadopoulos, K., Suchomel, T. J., Comfort, P., & Turner, A. (2020). The Benefits of Strength Training on Musculoskeletal System Health: Practical Applications for Interdisciplinary Care. Sports medicine (Auckland, N.Z.)50(8), 1431–1450. https://doi.org/10.1007/s40279-020-01309-5

Cues Gone Wrong-“Shoulders Down and Back”

Cues Gone Wrong-“Shoulders Down and Back”

“Shoulders down and back”. This cue is practically gospel in the world of physical therapy. And it has seeped into the world of fitness as the “safest position” for the shoulders.

Unfortunately, this cue is overused and creates confusion when misapplied.

While shadowing as a PT student, I recall watching a PT cue a patient doing dumbbell overhead presses. They kept telling the patient to keep their shoulders “down and back”. The patient struggled and struggled. Over the next few weeks the patient would lament, “I just can’t seem to get it”. At the time I thought the patient just needed more practice. I’ve since learned that the patient couldn’t keep their shoulders down and back while overhead pressing, because that’s not what the shoulders do in an overhead press.  

In this article I’ll discuss the use (and misuse) of this cue in pressing exercises.

What is this cue intended to do?

This cue is intended to create scapular retraction (squeezing the shoulder blades towards the spine) and depression (bringing the shoulder blades towards the pockets, away from the ears).

When does this cue apply?

The bench press and its variants.

In the bench press creating a back arch allows the user to lift more weight. This back arch creates various mechanical efficiencies: a smaller range of motion (ROM) for the bar, improved leverage in the lift1, and “tightness” or stability that allows the user to generate more force.

Shoulders down and back can help the user to create that arch, thereby allowing them to lift more weight.

When does this cue NOT apply?

The overhead press.

Trying to keep the shoulders down and back when lifting overhead is contradictory to the motion of the scapula.

When the arm lifts overhead, the scapula rotates upwards. It is estimated that 1/3 of the range of motion lifting overhead comes from this scapular upward rotation2.

Further, this scapular upward rotation is created by the synergistic actions of the trapezius muscles and the serratus anterior2 . So using the upper trapezius is actually necessary to lift overhead with full ROM.

Figure 2: Scapular Upward Rotation
Source: https://www.zachdechant.com/the-other-shrug/

As a self-experiment, lift your arm overhead. Then pin your shoulders “down and back” and try lifting again. There will be significantly less ROM because pinning the shoulders down and back limits scapular movement, which limits full shoulder ROM.

The pushup is another exercise where the shoulders should not be held down and back. During the upward, concentric phase of the pushup, the scapula protract (move away from the spine, see figure 1 above). That protraction is accomplished mostly with the serratus anterior. Trying to cue shoulders down and back is contradictory to that “natural motion” of the pushup.

Why do the pushup and bench press have different cues?

First, the bench press is derived from the sport of powerlifting where the goal is to lift the maximum amount of weight. As discussed above, arching allows the user to lift more weight.

Second, in a bench press the support from the bench gives the scapulae a surface to brace against. In the pushup, there is no external stability, so the serratus anterior has to create the platform for pushing.

Cues have a time and place. The right cue applied to the wrong lift creates confusion and frustration. “Shoulders down and back” has its place in the bench press, but generally should not be encouraged in the overhead press or pushup.

References:

  1. Rippetoe, M., & Kilgore, L. (2011). Starting strength: basic barbell training. 3rd ed. Wichita Falls, TX: Aasgaard Co.

2. Levangie, P. K., & Norkin, C. C. (2005). Joint structure and function: A comprehensive analysis. Philadelphia, PA: F.A. Davis Co.

Why Eating Out is Healthy

Humans are social creatures. Think of the worst punishment that people reference in prison: solitary confinement. We NEED to be around people. I’ve always understood this intellectually, but I often lose sight of it by focusing on other areas like health and school instead. However, I’ve realized that mental and physical health depend A LOT on socializing, perhaps as much as food and exercise affect health.

For example, when I was into the Paleo diet and eating “clean” I rarely shared food with anyone because I was consuming a very limited diet. Yes, I was eating a “clean” diet but I was missing a huge aspect of socializing, which is sharing food with people. Only recently, I realized that there are so many health benefits to socializing that are worth the small intake of junk food.

Consider what is “healthier”: the perfect kale salad with wild-caught salmon and extra-virgin-blessed by a rabbi-organic olive oil eaten alone in your apartment OR a white bread sandwich eaten with friends with a few good laughs sprinkled on top? I would argue the sandwich is actually “healthier”. The sandwich with friends has a lot of benefits: laughing, walking to the café, getting outside, developing deeper connections, and other effects we haven’t discovered. I suspect scientific research will show these effects in the coming years. In fact, some research suggests that simply hugging may decrease levels of cortisol (a stress hormone).

Of course, you can always choose healthier options when eating out and suggest more athletic social activities. But if your filter for social activities is only what fits into the “healthy lifestyle” you follow, your activities will be limited. And unless you are a professional athlete (meaning your income depends on your athletic ability), it probably is not worth it. Basing all socializing on a fitness/health activity, such as Crossfit, means if you get injured, then your social life will be severely hindered. Plus when you meet people outside of that group, it will be harder to connect since you are used to only talking to people in Crossfit. An exercise group should just be just one of the many tribes you are part of.

So as much as eating well and exercise are part of being “healthy”, regular doses of in-person socializing are the supplement most of us need more of.

Monday Morning Lunch vs Wedding Cake Moments

Most people fall into two extremes of eating: paying no attention to their diet, consuming every bite of junk food that comes their way OR obsessing about diet as if they were training for the Olympics. The problem is that neither way of eating is productive for most people.

From my personal life and observations as a trainer, I believe it is helpful to separate your diet into: what you eat for Monday morning lunch and “wedding cake moments”.

Monday morning lunch is a meal that repeats over and over. It’s not very memorable. These are routine meals and as such should be as healthy as possible. Habitually rewarding yourself with treats at such routine meals gradually adds unnecessary calories and fat to the body. Also, this creates the unhelpful habit of expecting treats regularly. I am not saying never have a cookie or chips, but such treats are actually more enjoyable when they are infrequent and should be reserved for…

“Wedding cake moments” How often do you go to a wedding? Once or twice a year. How often is it your mother’s birthday? There are some special events that come up very infrequently but are important for another part of one’s health, which is relationships. Don’t be the guy/gal at a wedding so obsessive about their diet that they refuse to eat a slice of wedding cake. Unless you are a professional bodybuilder, a piece of cake a few times per year won’t make much of a difference in your body. Now this doesn’t mean that every single office party or Friday night with friends warrants pizza and another round of drinks! And of course sometimes we slip up and may eat a bit of junk food. However, the stress and anxiety from expecting dietary perfection is just not worth it. Just get back on track towards your standard fuel, because really in the big picture it doesn’t matter that much.

So stick with the Monday Morning Lunch routine most of the time, but allow yourself those “Wedding cake moments”. You can have your cake (being healthy and lean), and eat it too (infrequently, at truly special events).