Breath. Breath is the common denominator for understanding how pilates can enhance the pelvic floor’s function. Reciprocally, using your pelvic floor correctly can deepen your connection to your pilates practice.
Let’s take a look at how to optimize your breath in the first place. A deep, three dimensional breath utilizes your diaphragm to its fullest extent. When you inhale, your diaphragm contracts forming a dome shape under the rib cage while simultaneously lengthening the pelvic floor creating a cylindrical shape within your torso.
There are two options for the rib cage while you take this inhale. Option one involves flaring the ribs outward during the breath. Option two involves narrowing the ribs slightly down towards your ASIS (hip bones). When we breathe with a more neutral, tapered rib cage, we utilize the second option for rib placement, thus finding our Zone of Apposition (ZOA). Breathing within the ZOA provides us with the most efficient breath we can take. Once the ribs are placed properly over the pelvis, we’re able to create the cylindrical shape within the torso and the relationship between the diaphragm and the pelvic floor is optimized!
Pilates is rooted in core strengthening principles that directly correlate to breath and the ZOA. In order to keep your ribs from flaring, ultimately keeping you from finding the ZOA, you need to have a sense of abdominal control. There are a handful of ways to find the ZOA, but one of my favorite cues to use with clients is to “narrow your ribs toward your naval.” Try this on your own either lying down, sitting, or standing, and notice what happens to your abs as soon as you taper, or narrow, your ribs toward your naval. You should feel some muscle tone over your stomach. AKA your abs kicking in!
Once you’ve achieved proper rib placement, ab engagement, and optimal breath, layering various exercises into your program will be much more attainable. It requires a good amount of body awareness to be able to coordinate these three major concepts before advancing through your pilates practice. It’s also important to concentrate on how your pelvic floor is reacting to your breath and movement. In footwork, for example, you start in neutral spine and exhale as you press the carriage out feeling a slight contraction in the pelvic floor. On the inhale, knees bend pulling the carriage back to it’s starting position while the tailbone drops slightly and the sits bones widen allowing you to lengthen the pelvic floor. (Prime example of moving within your ZOA).
As you can see, the pelvic floor plays a huge role in breath and core activation which is the root foundation of all your pilates and basic core exercises! If this interests you, or utterly confuses you, schedule a pilates session with me at Beyond Basics!
Exercise in ever tightening spandex while making frequent public toilet stops, or binge on Netflix and cronuts? Pregnancy is a great equalizer. Not even Kate Middleton can escape the hormones that can cause pregnant women to suffer from mood swings, fatigue, nausea, and achiness. Those symptoms—and modern culture—frequently encourage pregnant women to decrease movement and everyday activities. However, there is resounding support in academic literature that recreational physical activity during pregnancy is beneficial to both mother and baby.
While the pregnant woman is best suited to monitor what is beneficial for her body and baby during pregnancy, adequate information to make that decision is not always readily available. Yet around 600 studies published between the mid-1980s and mid-1990s corroborate that exercise during pregnancy is not harmful by measure of fetal birth weight, mode of delivery, preterm delivery, Apgar scores, and acute fetal well-being (1-3). What’s more, the American College of Obstetricians and Gynecologists (4) removed the limitations for intense exercises back in 1985 (5) and a literature review showed that bed rest was not beneficial for pregnancy complications. Still, 95% of ob-gyns continue to prescribe activity restrictions to certain pregnant mothers (6).
Clearer guidelines are needed for how pregnant women can decrease injury while maintaining performance and the well-being of mother and baby. While running is only one mode of boosting fetal and maternal health, many women, especially here in New York, embrace it as a key part of their overall wellness. As a recreational runner myself, I was disappointed during my first pregnancy with the foggy information regarding how to run safely during pregnancy. I found myself as a self-case study, correlating the physiological and biomechanical pregnancy changes with a shift in running mechanics. At the third trimester, I had a suspicion that I should replace running with the elliptical and restorative yoga.
The scientific literature specific to running during pregnancy is extremely limited, and in its absence, I’ve used findings for “moderate to strenuous” physical activity, in addition to clinical knowledge of pregnancy related changes in the body and running patterns to develop the recommendations below. Recently, a group of researchers published a series of five papers and combined recent literature about higher level physical activity during pregnancy for application in appropriate populations (7-8).
Pregnancy and exercise:
Pregnancy may seem like a counter-intuitive time to start an exercise program. However, research shows that 150 minutes/week of moderate exercise (9) for inactive and relatively sedentary women, and moderate to strenuous exercise for active women, has strong health benefits for both fetus and mother. Moderate exercise is recognized as 5-6 on the Rate of Perceived Exertion (RPE), 40-59% HRR (Heart Rate Reserve = Heart rate max – Heart rate resting). Moderate to strenuous is described as 7-8 RPE, 60-84% HRR (1). So while growing a baby is not a good time to start a running program, it is a good time to increase an appropriate level of physical activity or continue an established running program. Some of the benefits of appropriately prescribed exercise are correlated to (10-16):
· Healthier gestational weight gain, which protects against complications like cesarean delivery, hypertension, preeclampsia, and gestational diabetes
· Improved general healthy behaviors
· Improved psychological wellbeing – reduction in depression and anxiety, improved self-esteem, particularly for women who were previously inactive
· Improved ability of the placenta to deliver oxygen
· Increased amniotic fluid
· Healthier fetal birth weights that correlate to changes in leptin levels that continue to correlate with a healthier body fat and muscle ratio at the age of 5
· Increased gestational age
· Decreased rate of pregnancy complications, although one study showed higher use of physician assisted delivery (10)
· Faster delivery and decreased chance of Cesarean delivery in a setting that supports natural birth (11)
· Higher Apgar scores
· Lower fetal heart rate and increased fetal heart-rate variability
· Improved neonatal orientation
· Higher general intelligence and oral language skills at the age of 5
· Improved ability of baby to self-soothe after birth, (i.e. longer stretches of night sleep)
Strenuous activity is correlated to a higher rate of miscarriage during the implantation phase of pregnancy—about 20-23 days after the last menstrual cycle. Elevated body core temperature (above 103 degrees Fahrenheit), which can be caused by strenuous activities like marathon running or exercising in hot and humid weather, can increase the risk of fetal neural tube abnormalities during its development, 35-42 days after last menstrual period. Exercising for 60 minutes in a comfortable environment will not raise core temperature above 100 degrees Fahrenheit.
The pregnant woman’s heart rate should not exceed 90% of her maximal heart rate. Because of physiological changes, the pregnant runner will underestimate her heart rate based on the typical rate of perceived exertion or talk test. For this reason, the pregnant runner should modify the run intensity knowing that her heart is working harder than she perceives or wear a heart rate monitor using the HRmax = 220-age, unless she has access to laboratory equipment that can calculate HRmax without full exhaustion.
The American College of Obstetrics and Gynecology, (ACOG) has set absolute and relative contraindications to aerobic exercise during pregnancy (4).
· Hemodynamically significant heart disease
· Restrictive lung disease
· Incompetent cervix or cerclage
· Multiple gestation at risk of premature labor
· Persistent second or third trimester bleeding
· Placenta previa after 26 weeks of gestation
· Premature labor during the current pregnancy
· Ruptured membranes
· Preeclampsia or pregnancy-induced hypertension
· Severe anemia (different than mild anemia)
· Unevaluated maternal cardiac arrhythmia
· Chronic bronchitis
· Poorly controlled type 1 diabetes
· Extreme morbid obesity
· Extreme underweight (BMI <12)
· History of extremely sedentary lifestyle
· Intrauterine growth restriction in current pregnancy
· Poorly controlled hypertension
· Orthopedic limitations
· Poorly controlled seizure disorder
· Poorly controlled hyperthyroidism
· Heavy smoker
Low back and pelvic girdle pain/instability, knee/hip pain, pelvic heaviness, sharp pains in the pelvic floor, urinary leakage, and regular ankle sprains are all signs that it may be time to modify running as exercise. In the clinic, I am often asked about pelvic floor symptoms, particularly urinary leakage during pregnancy, and specifically with running.
I like to think of these warning signs as a force transfer problem—something in the system is not working well. For stress incontinence and pelvic heaviness, it’s the inability of the pelvic floor to generate enough force to keep things up against the up-chain forces of running (2.5x while accepting weight after the flight phase) and down-chain forces of steadily increasing body weight + baby’s weight (around 20% of pre-pregnancy weight). But post-partum is not as simple as the forces that are generated from running or the ability to do a Kegel. Elite athletes and non-exercisers have about the same rate of post-partum incontinence. However, postpartum symptoms are more likely if exercise also caused urinary leakage during pregnancy (16).
The pregnant body is a little more complicated:
It needs to taken into account, that the 10-fold increase of relaxin and progesterone that might be responsible for more instability as forces from the ground traveling up into the falling arches of the feet, adduction of the knee, internal rotation of the hip, through the pelvic floor and gapping of the sacroiliac joint. As the fetus and breasts grow, the body’s center of gravity shifts forward, the ribs flare, and the pelvis tilts forward. While the gluteus maximus and calf muscles are getting stronger to propel the pregnant body forward, the front of the body gains significantly more mass. When this happens, the front of the diaphragm and the front of the pelvic floor are positioned so more forces are going through the front of the pelvic floor than the back. This requires more support of the bladder through the pelvic floor. As the pelvis widens, foot step width increases in walking (17), but decreases in running during the single stance phase, requiring more pelvic control. In other words, the pregnant runner’s leg strength, particularly the hip stabilizing muscles, gluteus medius and minimus, need to be exponentially stronger than in the non-pregnant runner to account for additional weight, forward weight shift, and ligamentous laxity. I primarily talk about the deficit of the gluteus group because of what I see clinically, but depending on when the woman is experiencing pain or pelvic floor instability symptoms, other muscles may also need attention.
The usual period of pain experienced by pregnant runner’s initial strike to single stance, corresponds with the biomechanical gapping of the sacroiliac joint. Alleviating such issues will require force absorption and muscle activation through the quadriceps, medial hamstrings, calf muscles, tibialis anterior, TFL, adductor magnus, iliopsoas, and gluteus medius/minimus. Symptoms of lower extremity and lumbopelvic pain, pelvic heaviness, or sharp pains in the pelvic floor have similar biomechanical and physiological causes as urinary leakage. They should be treated in a similar manner whether controlling the upward and downward loads by:
· decreasing speed of running – correlated to double flight phase, which increases upward pressures
· decreasing vertical displacement
· landing with a midfoot strike to increase shock absorption (18)
· increasing arm swing/thoracic movement – dispersing upward forces and facilitating the respiratory and pelvic floor piston
· decreasing daily physical exertion that causes increased abdominal pressure
· increasing external support with (sacroiliac joint) SIJ belts or foot orthotics – decreasing the body’s instability
· maintaining hip flexor mobility – controlling forward pelvic tilt, movement throughout the day out of sitting posture, hip flexor stretches, shifting weight back through heels, diaphragmatic vs. back breathing
An orthopedic physical therapist specializing in pelvic floor dysfunction and in prenatal and postpartum care will be able to give more specific recommendations, since each woman’s symptoms are a little different.
Expected running changes in pregnancy:
For previous recreational to elite runners, about 70% will continue to run at some point in the pregnancy with only 1/3 continuing into the third trimester. They usually cut the running volume and intensity by 50% compared to non-pregnancy training. For those who stopped running during pregnancy, over half elected to do so because of self-monitoring symptoms of wellness, about one quarter stopped due to physician’s advice, and the remainder stopped for fear of a miscarriage. Whether choosing to continue or stop running during pregnancy, most women had returned to running by 2 months postpartum, and without negative impact on breastfeeding (19).
Speed will decline as instability increases, so that the body has less time with both feet off the ground. Ankle sprains may happen intermittently because of changes in foot position, possible increased swelling, and laxity in the ankle ligaments. Resting heart rate increases 15-20%. Breathing might be more labored during running because of increased sensitivity to carbon dioxide (particularly in early pregnancy) and decreased lung capacity/rib excursion (in late pregnancy). Pregnancy-related mild anemia, which decreases available blood oxygen, affects more than 40% of pregnant women and may show up as accelerated fatigue and increased respiratory rate during running. Be sure that fatigue is not related to severe anemia or hypothyroidism, particularly in persistent symptoms. The pregnant body will improve its ability to thermoregulate with increased sweating to dissipate more heat.
Clothes won’t fit like they once did, especially the spandex. Find some appropriately fitting, breathable, loose exercise clothing that does not excessively compress around the stomach. Urinary urgency and frequency are common limitations in running as the pregnancy progresses, which requires some planning and increased water intake.
Running during pregnancy presents an opportunity to do something overwhelmingly beneficial for both mother and baby, with the added incentive of tuning into the body’s remarkable capacities. While physical activity, running or otherwise, will look different during pregnancy, the goals are similar for a healthy lifestyle. Be kind to yourself—body, mind, and spirit. You and your baby will be thankful. Happy trails. Please leave any comments or questions here!
Joanna is currently taking new patients at our downtown office.
Phone: (212)- 267- 0240
1. Szymanski LM, Satin AJ. Exercise during pregnancy: fetal responses to current public health guidelines. Obstetrics and gynecology. 2012 Mar;119(3):603.
2. Physical Activity Guidelines Advisory Committee. Physical Guidelines Advisory Committee Report, 2008. Wasington, DC: U.S. Department of Health and Human Services: 2008.
3. Barakat R, Stirling JR, Lucia A. Does exercise training during pregnancy affect gestational age? A randomised controlled trial. British Journal of Sports Medicine. 2008 Aug 1;42(8):674-8.
4. American College of Obstetricians and Gynecologists. Physical activity and exercise during pregnancy and the postpartum period. Committee Opinion No. 650. Obstet Gynecol. 2015;126(6):e135-142.
5. Artal R, O’toole M. Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period. British journal of sports medicine. 2003 Feb 1;37(1):6-12.
6. Bigelow C, Stone J. Bed rest in pregnancy. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine. 2011 Mar 1;78(2):291-302.
7. Bø K, Artal R, Barakat R, Brown W, Davies GA, Dooley M, Evenson KR, Haakstad LA, Henriksson-Larsen K, Kayser B, Kinnunen TI. Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 1—exercise in women planning pregnancy and those who are pregnant. Br J Sports Med. 2016 May 1;50(10):571-89.
8. Bø K, Artal R, Barakat R, Brown W, Dooley M, Evenson KR, Haakstad LA, Larsen K, Kayser B, Kinnunen TI, Mottola MF. Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 2—the effect of exercise on the fetus, labour and birth. Br J Sports Med. 2016 Sep 22:bjsports-2016.
9. US Department of Health and Human Services. 2008 Physical Activity Guidelines for Americans. Department of Health and Human Services. Washington, DC: 2008.
10. Kuhrt K, Harmon M, Hezelgrave NL, Seed PT, Shennan AH. Is recreational running associated with earlier delivery and lower birth weight in women who continue to run during pregnancy? An international retrospective cohort study of running habits of 1293 female runners during pregnancy. BMJ open sport & exercise medicine. 2018 Mar 1;4(1):e000296.
11. Erdelyi GJ. Gynecology survey of female atheletes. J Sports Med Phys Fitness. 1962;2:174-179.
12. Prather H, Spitznagle T, Hunt D. Benefits of exercise during pregnancy. PM&R. 2012 Nov 1;4(11):845-50.[Ine
14. Clapp JH, Capeless E. The VO2max of recreational atheletes before and after pregnancy. Med Sci Sports Exerci. 1991;23:1128-33
15. Gjestland K, Bø K, Owe KM, Eberhard-Gran M. Do pregnant women follow exercise guidelines? Prevalence data among 3482 women, and prediction of low-back pain, pelvic girdle pain and depression. Br J Sports Med. 2012 Aug 1:bjsports-2012.
16. Bø K, Sundgot‐Borgen J. Are former female elite athletes more likely to experience urinary incontinence later in life than non‐athletes?. Scandinavian journal of medicine & science in sports. 2010 Feb 1;20(1):100-4.
17. Gilleard WL. Trunk motion and gait characteristics of pregnant women when walking: report of a longitudinal study with a control group. BMC pregnancy and childbirth. 2013 Dec;13(1):71.
18. Nicola TL, Jewison DJ. The anatomy and biomechanics of running. Clinics in sports medicine. 2012 Apr 1;31(2):187-201.
19. Tenforde AS, Toth KE, Langen E, Fredericson M, Sainani KL. Running habits of competitive runners during pregnancy and breastfeeding. Sports health. 2015 Mar;7(2):172-6.
May is arthritis awareness month. Arthritis can come in many different forms. It can be a result of wear and tear or it can be a response to an autoimmune condition. There are many different types of arthritis, but the fact remains that in all of these different types of arthritis, once the damage to the joint is done, it is done. Currently, we have no way of repairing the joint outside of joint replacement. You may be thinking, if the damage is done, why bother spending my precious time and money in physical therapy? The reason is that physical therapy and lifestyle management can make a huge difference towards reducing your pain, improving your function, and even preventing the progression of joint break down. Physical therapy has been proven to help reduce pain and increase function, and in many cases, avoid surgery.
Physical therapists are movement experts. It seems obvious that they should be the providers directly involved in restoring function to individuals with diseases of the joints. For both rheumatoid conditions as well as osteoarthritis, physical activity is considered the first line intervention for improving pain and function. This is not to say that exercise will replace disease modifying arthritis drugs (DMARDs) in cases of rheumatoid arthritis. It is saying treatment is not complete until you address the strength, pain, and range of motion problems that occur with arthritis.
Physical therapy will not change the conditions of joints that have been damaged by arthritis; however, physical therapy is paramount to improving the prognosis of arthritis by helping to improve the strength around the joint, range of motion, and stability of the joint to prevent further cartilage and joint break down. Physical therapy can also have a marked effect on the pain and function, and can open up your world to things that were once too painful. In a meta-analysis study conducted by Sampath and colleagues, two common physical therapy techniques, manual therapy (work on the joints) and exercise therapy were examined to assess the efficacy of these techniques on pain and function in individuals with arthritis. The study found strong evidence that exercise therapy and manual therapy were good at reducing pain and improving function in people with arthritis.
Physical therapy is so worth the investment. It is an investment in your comfort, the ability to do the things you love, and commonly helps people stave off needing a joint replacement. Full disclosure, I’m partial to our clinic, Beyond Basics Physical Therapy (understatement of the year, I know). What makes us so special is that we have the manual therapy, exercise and orthopedic experts. We all come from various orthopedic (joint and muscle PT) backgrounds including the Postural Restoration Institute (PRI) and the Institute of Physical Art (IPA) and many of us have earned advance orthopedic certifications such as the Certified Functional Manual Therapist (CFMT), Certified Orthopedic Specialist (OCS), and Postural Restoration Certification (PRC) distinctions. What this means is our therapists have the knowledge and skill set to go above and beyond the basics in our hour long treatments to treat you head to toe, improving the way your body moves and more importantly, how it feels. Click here to read more about the ins and outs of the CFMT certification and how it can take you to the a place of less pain and more function here.
Another thing to keep in mind is your weight. When it comes to management of arthritic conditions, additional pounds put additional stress on your joints and can hasten the progression of joint break down. Losing pounds can be a big task when your joints are not feeling their best. Your physical therapist can guide you through exercises that are efficient for weight loss and do not exacerbate your symptoms. We also can provide a valuable link to get you set up with proper nutritional support to help manage weight.
Once the damage is done by arthritis it is done; however, that does not mean you are condemned to pain, decrease function and continued deterioration. Get physical therapy today for pain relief and to get moving again!
We have two clinics. One in Midtown Manhattan and one Downtown. We also offer Pilates and personal training at our clinics, which can help get you back into an exercise routine.
Give us a call today to find out more:
212- 267-0240 (Downtown)
Heidari B, Rheumatoid Arthritis: Early diagnosis and treatment outcomes. J Capsian Internal Med. 2011: 2(1) 161-70
Hootman J, Murphy L, Omura J, et Al. Health care provider counselling for physical activity among adults with arthritis. Morbidity and Mortality Weekly Report. 2018; 66(51-52) 1398-1401
Sampath K, Mani R, Miyamori T, et al. The effect of manual therapy or exercise therapy or both in people with hip osteoarthritis: a systematic review and meta-analysis. Clinical Rehab. 2016; 3-(12) 1141-55
Wang Y, Lombard C, Hussain S, et al.Effect of a low-intensity, self-management lifestyle intervention on knee pain in community- based young to middle-aged rural women: a cluster randomised controlled trial. Arthritis Research & Therapy. 2018; 20(74)
Pilates vs. Yoga Kierstin Elliott, Certiﬁed in Stott Pilates
As a pilates instructor, I am often asked the question, “How is pilates diﬀerent from yoga?” Although there are many similarities between the two practices, such as developing strength and ﬂexibility, the diﬀerences are quite substantial.
Yoga is an ancient practice that has long been established throughout Indian culture. One major factor that sets yoga apart from pilates is the spiritual element. For many, yoga promotes an environment of self awareness in mind, body, and spirit. Although there are various styles of yoga, ranging from the lively ﬂow of Vinyasa to the meditative holds of Yin, you have the freedom to explore and evolve the limitations of your body and mind within the practice.
Pilates is a more recent method of movement created by Joseph Pilates as a form of rehabilitation and was introduced to the States in 1920. Pilates wanted to create a practice in which injured soldiers could quickly rehab with bio-mechanics. Therefore, the apparatus’ used in the practice such as the Cadillac and Reformer, closely resemble hospital beds with springs, pulleys, and slings. Pilates is focused primarily on restoring the natural curves of the spine using these 8 founding principles: breath, concentration, control, centering, ﬂow, alignment, precision and relaxation.
Both pilates and yoga oﬀer numerous health beneﬁts for the mind and body in addition to complimenting each other quite well. If you are looking for a more spiritual or meditative connection through movement, yoga is the choice for you. If you are looking to strengthen your core and improve posture, pilates will be right up your alley. Give them both a try and see what makes the most sense for your body. Finding a practice that not only feels good, but one that you also enjoy, is important for maintaining consistency and progress. Only with commitment and dedication to your practice will you discover the stronger, healthier, and happier version of you!
Kierstin Elliot currently teaches Pilates at Beyond Basics Physical, Flex, Kinespirit, and offers in home training. Call the office at Beyond Basics at 212-354-2622 for more information on Kierstin!
If you have perused our website, you might have noticed that here at Beyond Basics, we have many physical therapists who have a CFMT certification, or are in the process of completing one. Now the question lies, what is a CFMT? How is this approach unique? How can this approach be of benefit to me?
The acronym CFMT stands for Certified Functional Manual Therapist. This certification is through the Institute of Physical Art (IPA), which is an organization founded by two physical therapists, Gregg and Vicky Johnson.
With the CFMT approach, we evaluate and treat every individual’s mechanical capacity (how your tissues and joints move), neuromuscular function (how your system stabilizes itself, and the coordination of muscle activation), and motor control (how an individual moves and performs daily tasks). Furthermore, we assess and retrain how these three individual components interact to ensure each person can return to the tasks/activities they need and love to do.
What this means is, when a new patient walks through our door, we don’t just focus on one small area, such as only the knee in which you report pain. Instead, we will look at the big picture by assessing your strength, amount of limb and segmental motion available to you, posture and alignment, and movement, which can be as simple as getting out of a chair, or a higher level activity such as running, weight lifting or other sport-related activity. This will allow us to get a thorough impression of what impairments you might have, and will help us determine what the cause of your symptoms and functional limitations is (what is the driver?). From here we can figure out the most effective approach to your treatment, and will apply progressive interventions that help to ensure continued benefits from each session. We have found that this approach commonly gets you back to your activity or sport faster!
Now you may be asking yourself, “Well this sounds interesting, but why does it matter?” Looking at the whole person and treating your system overall, allows us to make lasting changes, not only to a specific body part that is causing problems for you, but also with your habits of how you hold yourself and move. By becoming more aware of your body and moving with more efficiency, you will find day-to-day activities, and even sporting activities, are easier for you to perform. Furthermore, and most importantly, if you are able to move and live in a more efficient way, you are decreasing the risk of future injury.
So whether you are experiencing incontinence, pelvic pain, low back pain, or a shoulder injury, having a knowledgeable therapist work with you, can make a significant impact on your function and quality of life.
Shoulder pain is a fairly common issue amongst adults, with a reported lifetime incidence of up to 70% in various countries and estimates of cost burden up to $7 billion a year for treatments of it.
Subacromial shoulder pain is defined as pain that originates from the subacromial space, which is a very small area between part of the shoulder blade called the acromion (“roof of the shoulder”), and the shoulder joint (the glenohumeral joint). In this area lies the rotator cuff tendons and the subacromial bursa (a fluid filled sack that helps minimize friction on these tendons). Subacromial shoulder pain is commonly located on the top and outside of the shoulder, and is often aggravated by overhead activity. The pain from this area is typically caused by inflammation and/or tearing of the rotator cuff tendons, as they are pinched/rubbed against the underside of the acromion.
There have been multiple research studies that have looked into the benefit of surgery for the treatment of subacromial shoulder pain. Today, we will be focusing on one article that looks at the effect of arthroscopic subacromial decompression (a common surgery for pain by removing tissue), as compared to a placebo surgery (no tissue actually removed), and no treatment. Here is a quick summary of the study:
313 patients were randomly assigned to treatment groups: 106 to decompression surgery, 103 to arthroscopy only, and 104 to no treatment. For the decompression surgery, surgeons removed soft tissue and other structures within the subacromial space, a nearby ligament, and removal of any bone spurs. For the arthroscopy, structures were inspected and irrigated, but nothing was removed or repaired. Following surgery, both groups (decompression and arthroscopy) received appropriate post-operative care, including follow-ups with the surgeons, as well as physical therapy. Those participants assigned to the no-treatment group attended one reassessment appointment with a shoulder specialist, 3 months after entering the study, but with no planned intervention. The pre- and post-test findings were mainly based on a functional shoulder measure.
The findings in this study turned out to be very interesting, although perhaps not what the authors originally intended. Not because both surgical groups reported higher scores on the functional measure, as compared to the no-treatment group, which is something that one can expect when an intervention is appropriately applied. The main take home message from this study is not even that researchers reported participants in both surgical groups ended the study with similar outcomes. A major plot twist in this article is that both surgical groups were given physical therapy post-operatively. Remember, the group who received arthroscopy did not actually have any structures repaired or removed, yet this group made statistically significant gains after all intervention were completed, that matched, if not bested, the results of an actual surgical intervention. How could this occur? We must consider the common denominator – physical therapy! Physical therapy is the only thing that both groups had in common, so it is safe to assert that it likely played a significant role in the improvement of shoulder pain.
If that isn’t convincing enough, let’s now focus on a research article that takes a closer look at the impact of physical therapy for patients with subacromial impingement syndrome. This article published in 2012 looked at a specific exercise routine vs generalized exercise for 102 patients in Sweden, who had already failed conservative treatments for their shoulder pain, and would likely become candidates for surgery due to their continued pain. Participants in both groups received a subacromial injection of corticosteroids two weeks prior to the commencement of any exercise. The control group received general exercises that including shoulder and neck movements and stretches. The experimental group was given six exercises to perform, which included eccentric strengthening of the rotator cuff, meaning these muscles were actively controlling resistance while lengthening, stabilizing exercises of the shoulder blade, and stretching of the back of the shoulder. After performing these exercises two times per day for up to 12 weeks, and attending one physical therapy session per week, these patients reported significant improvements in functional measures for the shoulder, as compared to the control group. The authors also reported that significantly fewer participants from the specific exercise group opted for surgery after the trial was over (20%), as compared to 63% from the control group. This study not only shows that physical therapy is beneficial for decreasing subacromial shoulder pain, but it also proves that when it is tailored specifically toward the needs of an individual condition or presentation, it can still be effective even after a person has failed conservative treatment.
In summary, subacromial shoulder pain is a very common condition, that can successfully be treated with physical therapy, even if conservative treatments have previously failed to relieve symptoms. The emphasis must be on finding the correct intervention program that meets the needs of each individual patient. If you or someone you know is dealing with shoulder pain, whether it is new or old, you could benefit from a tailored physical therapy program. Here at Beyond Basics Physical Therapy, all of our therapists have extensive training and are experts in orthopedic and sports-related injuries, and will work one-on-one with you to develop a rehab program that helps you achieve your goals, so make and appointment today!
1. Cadogan A, Laslett M, Hing WA, McNair PJ, Coates MH. 2011. A prospective study of shoulder pain in primary care: prevalence of imaged pathology and response to guided diagnostic blocks. BMC Musculoskeltal Disorders, 12 (119).
4. Beard DJ, Rees JL, Cook JA, et al. 2017. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet, 17 (32457), doi: 10.1016/S0140-6736.
5. Holmgren T, Hallgren HB, Oberg B, et al. 2012. Effect of specific exercise on need for surgery in patients with subacromial impingement syndrome: a randomized controlled study. BMJ, 344 (787), doi: 10.1136//bmj.e787.
It’s that time of year again. We are all nobly setting out on our self improvement journeys. Resolutions are often deeply personal goals we set for ourselves and can involve spiritual, physical, and emotional aspects. Overwhelmingly, one of the most common goals people have is weight loss. The desire to lose weight often goes beyond aesthetic. People can be motivated to reduce pain in their joints, improve heart health, and to have more energy. As physical therapists we see the harms of the burden of carrying around extra weight on aching joints as well as the fallout from initiating a program with a little too much vim and vigor.
Goal settingis something almost every article on New Year’s resolutions addresses, for good reason. Goal setting properly is imperative to success. We can think of goal setting in two ways. Sometimes we think of goal setting like a wishlist, “it would be great if I achieved x”. These kind of goals are great for getting you to look at the final picture, but provide no direction on how to get to your end result. Writing down a goal to lose 10 pounds is all well and good, but without a solid plan, you are left without any real steps to put in motion.
In goal setting I suggest you borrow some tools from us physical therapists. When we assess patients we develop short and long term goals to get them to their ultimate fitness and health goals. The short term goals we make, allow us to zero in on small and discrete changes we can make towards the ultimate goal.
Think about what habits you currently are doing that are holding you back from weight loss. Are you having an extra glass of wine at night you could cut out, are you not getting enough sleep, so working out seems impossible? Break things up into small behavioral changes to concentrate on. Keep in mind goals can also be positive, what things are you currently doing that are helping you on your path that you would like to continue doing. It’s important to recognize where you are being an absolute rockstar already and use that positive energy towards things that might be harder to change.
Track your goals and think about how often you want to make sure you are doing them. Personally, I find it helpful to track my goals to see if I am generally sticking to them. There are apps out there, that you can install on your phone that will help track your success in sticking to your goals. I use a free app called “Productive”. It allows me to make a recurring checklist for my goals. You can use the app to schedule out what time of day you would like to do your goals, how many days a week you’ll do them, and provides stats on how regularly you are achieving them.
Finally, it is important to be realistic with your goals. Goals that are too easy or too hard are less likely to get you where you want to be. Allow yourself some flexibility, to keep your journey less of a burden. Over time, check in with your goals you may find you have outgrown them or they are unrealistic. It is perfectly okay to tailor as you go.
We all know diet plays a major key in weight loss. A friend to the clinic, Nutritionist, Jessica Drummond will often say, “ You cannot exercise your way out of a bad diet”. Poor diets can stymie any exercise plan.
Dietary needs vary widely from individual to individual, but overall it’s best to avoid highly processed foods. These foods tend to be chalk a block with salt and easily digestible sugars that can spike appetite. No good.
Be wary of fad diets and health crazes. Gluten free foods are all the rage right now. I, myself am gluten free for health reasons, but if you do not have celiac disease or non celiac gluten sensitivity, reaching for the gluten free pizza or cookie is not the wisest choice as a weight loss strategy. In addition to usually being more expensive, gluten free options, like cookies, bread, and pizza often are higher in calories than their “glutenful” counterparts. It only took a quick stroll over to my refrigerator to prove this point. I compared a slice of traditional bread next to a gluten free slice. As you can see in the photo below, the traditional bread is larger than the gluten free bread. Not only do you get more food for serving with the traditional bread, the traditional bread has 20 fewer calories per serving than the gluten free bread. This goes to show that regardless of your dietary needs, consuming foods that are not processed like sweet potatoes, quinoa, and rice, over processed food like bread, is a good way to avoid hidden calories.
Gluten free: left, traditional: right
It is important that you eat enough to sustain your metabolism, your energy, and your mood, and furthermore, to allow your diet to be a sustainable change you can carry out long term to ensure success. There are apps on your phone that can help you track your calorie input, how many calories you have burned off, and what the composition of your macronutrients are. Macronutrients are protein, carbs, and fats. A diet higher in protein is generally used to help build muscles, which can in turn, burn more fat. These apps, like Myfitnesspal and Lose It! can give you target calorie intake for your desired weekly weight loss. It is important to set your target with some element of moderation so it is easier to stick to. Caloric restrictions that are too extreme can backfire by tanking your metabolism, energy, and triggering food binges.
Exercise is so important. In addition to helping you progress towards your weight loss goal, exercise has so many health benefits that will pay dividends well into the future. From stress reduction, cardiovascular health, bone health and more, exercise is an essential element of self care even for those who do not wish to lose weight.The
American Heart Association recommends adults exercise at a moderate intensity for at least 30 minutes five times a week or vigorous activity for 25 minutes 3 days a week. In addition to moderate to high intensity strengthening activity at least 2 days a week.
Finding the right exercise can be daunting. This is where having a physical therapist can be a tremendous advantage. Personally, I don’t believe in “the one best exercise”. Everybody is different and every body is different. Physical therapists are the movement specialists of the healthcare world. We can help you find good workouts for where your body is now, as well as strengthen your body so you can do the workout or event of your dreams while avoiding injury. Take a look at the series we wrote chronicling how physical therapy prepared my body for the rigors of the New York City Marathon and allowed me to complete it in record time, to see a great example of what physical therapy can do for you. I have included our blogs on physical therapy and exercise at the bottom of this article.
Once you have an idea of where to start and where you want to go, then slowly get started on trying out different routines. I once heard a quote from an exercise physiologist who said, “the best exercise is one you actually do”. So remember when starting your exercise program, it is okay to not like a certain exercise routine and move on. You might abhor the treadmill, but find tremendous joy in a Zumba class. Finding a workout that brings you joy, and at the very least, does not bring you dread is imperative. It’s kind of like dating, keep trying different routines until you find what works for you.
Once you find your dream routine, remember moderation. Allow yourself at least a day of recovery if you are a seasoned exercise veteran, and more if you are an exercise newbie. Rest not only prevents injury, but it gives the body time to get to the job of laying down more muscle fibers and making you stronger.
Injury can happen with new exercise routines and really, nothing is more frustrating than being super gung ho about a new program only to be sidelined with an injury. Again this is where having a good PT on your side really helps. Seeing us before starting exercise can help us spot both literal and figurative achilles heels in your posture, strength, and flexibility and will allow us to address these issues before they become mega impairments later on. We can help you decide when it is time to progress and how to do so safely. Additionally we can help you recover from an injury faster and prevent injury recurrence if you see us when you do have an injury.
Failure and Success
Repeat after me, “ I am a person, not a machine”. You will fail at certain elements of your plan. Notice I used “will” and not “may”. When you do overindulge, miss a workout, or whatever else. Remember it is a process and small failures do not indicate that you will fail in your ultimate goal of greater health. Nor is failure in any way an indicator of your worth as a human being, neither is the number on the scale, by the way. Progress will be slow, but you will likely get there if you are consistent. Failure is a good time to re-evaluate your goals. Maybe five workouts a week is completely unrealistic and maybe sticking with three is a much better balance. Regardless of what obstacles you face in your journey, remember to be kind to yourself, you are doing the best you can. Find what changes you can stick with and go from there. It can take a lot to change up your whole routine, but keep working at it and you will find success.
Check us out at BBPT!
Although we do specialize in orthopedic and pelvic floor physical therapy at Beyond Basics, we do so much more than that. All of our physical therapists are trained in orthopedic and sports rehab, and many of our therapists have earned prestigious orthopedic certifications like the OCS and CFMT. We can help you to figure out where to start, how to progress your exercises appropriately, and how to keep your body healthy so you can continue to achieve all of your goals.