Your Glutes: Movers and Stabilizers for optmal performance

Dear Friend,

Today's blog is about the importance of strong buttocks for human performance, whether for athletic performance, physical labor or simply Activities of Daily Living (ADL) and the  negative effects of gluteal weakness.
 
Anatomy:
Your buttocks are made up of three gluteal muscles, The Gluteus Maximus, the Gluteus Medius and the Gluteus Minimus.

The Gluteus Maximus is your strongest hip extensor, helping you get off the chair or toilet seat, lift up your grand child, safely climb stairs and manage curbs, and simply stand upright. Gluteus Medius and Minimus counter gravity's adductive forces at the hip through hip abduction and external thigh rotation and stabilize the hip during the swing phase of walking gait. Understanding the job discription of these muscles gives you already an idea of the negative effects that weaknesses in one or more of these muscles can mean to physical performance.

Causes of Gluteal Weakness:
In today's modern world an ever growing number of our population is spending their eight hour work day sitting on chairs in front of computers, returning home to a dinner table and later on to the TV couch and finishing the day off lying in bed. In other words twenty-two hours of most days they spend keeping their gluteals inactive (unloaded/inhibited), leading to atrophy of the gluteals and tightening of hip flexors. Other causes of gluteal weakness include:

• overuse of quadricep dominated exercises
• Muscular imbalances especially abdominals and back extensors
• Knee-, Hip- and/or Back Pain (secondary)
• Postural Deviations i.e. sway back or flat back

Effects of Gluteal Weakness on human performance:
Gluteal inhibition negatively effects performance, lumbar-pelvic-hip stability, postural alignment, and lower body strength causing often chronic pain and injuries whether it's on the athletic playing field or at home performing ADL. In athletics optimal postural alignment means more efficient movement, less muscular fatigue, less stress on joints and ligaments, and a more optimal transfer of energy while moving (more power). In older adults optimal posture reduces the chance of cumulative injuries due to static positions. Gluteal weakness is often the reason for a transfer from independent to assisted living. Conditions caused by weak gluteals:

• Hamstring Strains
• Low back pain
• Anterior knee and hip pain
• ACL (Anterior Crucial Ligament) sprains
• Ilio-Tibial Band Syndrome
• chronic ankle instability etc.

What came first, the egg or the chicken?
In many cases it's not clear whether gluteal weakness causes the condition or the condition causes the weakness. Example: An older adult suffering from osteo-arthritis in the knee might adopt pain related gait changes leading to gluteal inhibition. On the other hand, weak gluteals lead to hip and knee instability and an increase in wear and tear and therefore result in osteo-arthritis.

Treatment:
Studies show that gluteal inhibition/weakness can be successfully addressed and almost fully reversed within a few weeks through appropriate exercises, introducing regularly loaded activities. In order to re-activate the gluteals often functional hip mobility has to be restored first. Sit to Stand Stretch, Active Hamstring Stretches and isolated gluteal stretches i.e. Piriformis Stretch can help with mobility. The second phase should include simple gluteal activation exercises such as Bridging (2 to 1 leg), Clam Shell Exercises, Quadruped Hip Extensions, Fire Hydrant Exercise etc. This phase is followed by loaded exercises to increase/restore gluteal strength. Exercises such as Squats, Dead Lifts (progressing from bilateral to single leg and single plane to multi planar), Farmers Walks, Resisted Walking (sagital as well as frontal plane), and resisted Reverse Lunges promote great gluteal activation and contraction forces.

For detailed exercise descriptions please watch ViEW (Video Exercise Workshops) on "Gluteal Activation and Strength" by visiting our website: www.backinform.com

In summation: Weak Buttocks are a common occurrence in adults of all ages. Untreated, those weak buttocks can cause severe problems and injuries associated with lumbar-pelvic-hip instability and significantly reduce performance on the every day- and athletic playing fields. The good news is, that gluteal inhibition and weakness can be reversed through an appropriate exercise program.

If you need help recreating your buns of steel please give me a call!

A Sante,

Hartmut


Sources:
http://functionalresistancetraining.com/articles/re-activating-and-strengthening-the-gluteal-muscles
http://wannabebig.com/injury-rehab-and-stretching/how-gluteal-atrophy-effects-posture-performance/
http://www.shapefit.com/exercise/gluteal-amnesia.html
http://redefiningstrength.com/glute-activation-10-exercises/
http://www.higher-faster-sports.com/noglutes.html
http://drjohnrusin.com/top-5-glute-activation-techniques/
https://experiencelife.com/article/go-to-glutes/
http://www.brianmac.co.uk/glutes.htm
http://well.blogs.nytimes.com/2010/12/21/when-the-diagnosis-is-dead-butt-syndrome/?_r=1
http://www.healthline.com/human-body-maps/gluteus-maximus-muscle
http://physicaltherapy.about.com/od/humananatomy/a/Gluteus-Medius-Muscle.htm

Low Back Pain: Rest vs. Exercise

Dear friend,

in today's blog I will address a problem that approximately 80% of Americans are faced with at least once during their lifetime and that many live with day in day out: Low Back Pain (LBP) aka lumbago.

This blog will provide some insights into the most common causes and treatment options of LBP and investigate whether rest or activity is more helpful when dealing with acute or chronic back pain.


The most common causes in younger adults:

• Injury or overuse
  A sudden onset of pain and stiffness often after activity, a sudden movement or heavy lifting, is mostly caused by soft tissue injuries to muscles and ligaments in the back and along the spine such as muscle strains or sprains. Other causes that fall into the category of injury or overuse are injuries to the small facet joints of the spine or fractures of the bony processes of the spine (attachment points for muscles and tendons). Both types of injuries commonly heal on their own. A combination of rest, heat/ice applications, anti-inflammatory drugs and low back exercises improving spinal stability can be helpful treatment options.

• Nerve root compression
  An Acute or chronic nerve root compression can be caused by a variety of problems. Some of the more common causes in younger adults are:
• A herniated disc: As discs degenerate and break down, the inner core of the disc starts to leak out through the outer portion applying sudden pressure on nerve endings.
  
• Isthmic Spondylolethesis occurs when a vertebra slips forward causing instability and nerve root compression. The reason for the slippage is often a small fracture in a piece of bone that connects the two joints on the back side of the spinal segment. Th fracture typically happens during childhood, starting to cause trouble in young adulthood.
• Lumbar Degenerative Disc Disease: Even though this is a degenerative disease it often affects young adults in their early 20's. It refers to the breakdown of discs in between vertebrae leading to instability and inflammation.
• Sciatica: All of the previously mentioned causes of nerve root compression if effecting any of the major lumbar nerves can lead to Sciatica . Sciatica refers to radiating pain, weakness and numbness along the pathway of the nerves into the buttocks, legs and even feet. The pain can be worse in the feet and legs than in the back and is certainly more intense than the often dull aching pain resulting from strains or sprains.

The most common causes in older adults:
While older adults can experience the same pain related to the problems that apply to younger adults, they are more likely to experience chronic pain related to degenerative processes of the spine and it's joints.




Degenerative Processes

• Osteoarthritis effects most commonly the small joints of the spine, like the facet joints and the Sacro-Iliac joint between sacrum and ilium at the bottom of the spine. These degenerative joint changes (wear and tear on protective cartilage layers) can lead to inflammation of the joint area itself, causing instability, pain, and stiffness. In addition it can lead to the growth of bone spurs which again can apply pressure to the nerve roots. Osteoarthritis commonly effects other joints in the body as well, such as hips or knees causing gait changes leading to secondary pain in the low back due to compromised body mechanics.

• Spinal Stenosis refers to the degeneration of discs, vertebrae, muscles and tendons that make up the spinal column. This degenerative processes can lead to a choking (greek=stenosis) of the lumbar nerves causing increased leg pain with walking (pseudoclaudication) which improves almost immediately when sitting down.
   
• Osteoporosis is a condition in which the bone density degrades to the point of bone fractures. This condition is most common amongst post menopausal women. One of the most effected areas is the lumbar spine. Osteoporosis in the lumbar spine can result in compression fractures of the vertebra causing significant low back pain.

Less commonly found causes for low back pain worth mentioning are Ankylosing Spondylitis, bacterial infections and tumors of the spine.


Treatment Options:

• Heat and Cold applications are usually the first line of defense patients with low back pain are reaching for. Cold packs and ice have been hailed for many years as anti-inflammatory (antiphlogistic) and pain reducing (analgesic) treatment options. It is recommended to apply cold/ice for 15-20 minutes for the first 48 hours after injury. A newer line of thought questions the value of ice or cold packs as a form of anti-inflammatory treatment, because it leads to reduced blood circulation in the inflamed area, reducing the number of white blood cells (the body's natural defense against inflammation) at the source of inflammation. However the cold will numb nerve endings and reduce impulse transmission speed validating it's analgesic qualities. Try a damp cloth between skin and cold source for better conductivity and better results. If introducing ice as an anti inflammatory treatment I would recommend short ice massages. (Ice massage for LBP relief)  The short introduction of cold triggers greater blood flow to the area and lead to an increase in the number of inflammation fighting white blood cells.
  
  Heat applications are indicated if the source of discomfort stems primarily from muscle spasms. The heat will relax the muscles and promote healing. Don't use heat on injured areas that seem swollen and/or red.
  
  If circulatory issues or nerve damage are present do not use either form of treatment. Even though cold/ice is often recommended for the first 48 hours I suggest you try both, heat and ice and find out which provides greater relief.

• Topical lotions/cremes/rubs are in most cases not much more than a distraction from the pain as they commonly promote surface heat rather than penetrating heat. Those containing Capsaiscin, an extract from red chilli peppers, do effect nerve impulse transmission and can be a helpful addition to analgesic medicine in treating pain. Capsaiscin's effect is cumulative and therefore requires a prolonged period of usage before its full benefit is noticeable.
• Pain medications (Analgesics) reach from over the counter pills like Tylenol to powerful skin patches prescribed one at a time. In severe chronic back pain cases these types of analgesics are often combined with codein causing possibly addiction. Antiphlogistica include non-steroidal anti inflammatory drugs (NSAID) such as Advil, Aleve or Aspirin. NSAID address pain and inflammation. The last group of medications commonly administered for acute and chronic back pain are muscle relaxants. Muscle spasms appear quite often as a result of nerve root compression. Spasms add to pain, reduce circulation and slow the healing process. Muscle relaxants may cause drowsiness and should preferably be taken at bed time.
• Invasive Treatment Methods
  This form of treatment includes most often epidural injections; commonly a powerful mixture of an anti-inflammatory steroid (cortisone) and a local anesthetic used to calm nerve root irritation and reduce swelling.
• Physical Therapy
  In case of an acute injury such as a fracture or a herniated disc the RICE injury protocol as is typically the best choice. Rest, Ice, Compression and Elevation are indicated to prevent further damage/injury and manage irritation and inflammation. This protocol is most effective during the first 48-72 hours and typically followed up with passive Physical Therapy modalities such as cold/heat (see above), Iontophoresis, trans-cutaneous electrical nerve stimulation (TENS), and ultra sound.
  
  Iontophoresis is a modality in which steroids are delivered through the skin using an electrical current. A TENS unit is used to override painful nerve impulses to the brain reducing pain. Ultra sound is a form of deep heating soft tissue often successful in reducing acute pain and enhancing soft tissue healing.
  
  Education and Exercise
  A trained Physical Therapist, Physio-Therapist or Kinesiologist can help identify poor body mechanics or postural deviations, which may be contributing factors to your LBP. Together with the therapist you will develop learn to implement strategies that can help to improve those movement and/or postural issues. Learning about proper lifting techniques, a proper work station set-up, and postural awareness can positively influence the outcome of rehabilitation and secondary prevention.
  
  Postural deviations and poor body mechanics are often caused by a combination of a lack of muscular strength and shortened muscles leading to reduced range of motion in the large joints. Poor range of motion especially in the lumbar-pelvic-hip region of the body places undue stress on the spine, as it often requires the spine to compensate for immobility in hips and the sacroiliac joint. The combination of poor mobility and a significant lack of muscular strength leaves the spine vulnerable to injury and increased wear and tear. Physical Therapy will address these issues by leading you in an exercise program that will improve spinal stability and stretching exercises that will increase functional range of motion.

• Examples:
  Supine Floor Bridge: Lie on your back with your knees bend at a 90 degree angle and soles of feet firmly placed on the floor. Tighten your stomach and buttocks. Slowly raise your pelvis off the floor as far as you can, maintaining neutral spine throughout the movement. Hold at top for specified time and slowly return to floor. Careful if you have neck issues.
  
  
  
  
  Body Plank Prone: Lie down flat on your stomach. Tuck your toes under and place elbows next to your shoulders. Lift body off the floor supporting plank body position on toes and elbows. Keep stomach and buttocks tight to avoid sway back. Hold for specified time and slowly return to floor.
  
  
  
  
  
  
  Clam Shell Exercise: Lie down on your side, placing shoulder over shoulder, hip over hip, knee over knee, and ankle over ankle. Split off top knee keeping feet together and hip over hip (clam shell movement).
  
  
  
  
  
  
  
  
  Dead Bug Exercise: Lie down on your back, secure spine by contracting abdominals and glutes. Bend both hips and knees at 90 degrees and reach arms straight up towards ceiling. Lower right arm and left leg maintaining neutral spine. Return to starting position and use other diagonal.
  
  
  
  
  
  
  Hamstring Stretch: Lie on your back, both knees bent, feet on the floor. Straighten one leg out until you feel stretch on the back side of the thigh. Hold stretch for prescribed time and repeat with other leg.
  
  
  
  
  
  
  
  Kneeling Hip Flexor and Quadricep Stretch: Kneel down on one knee placing other foot in front. Tighten abdominals and glutes and push pelvis straight forward shifting body weight to front foot. You should feel stretch in front of hip and thigh. Hold stretch for prescribed time and repeat with opposite leg.
  
  
  
  Please consult your physician before starting any exercise program. Keep in mind that any exercise program should be designed with individual needs in mind and be instructed and supervised by a trained health professional.
• Rest or Exercise?
  Over the past four decades the rehabilitation protocol for LBP has clearly shifted from rest, sometimes total bed rest, to a more active path to recovery. Despite this change in approach the actual course of action is still determined by the cause of your back pain. Exercises can be beneficial and recommended, or strictly contraindicated if exercising carries a high risk for further damage. Generally the first course of action is to rest and have a physician assess the cause of your back pain and develop a treatment plan. Acute injuries such as compression fractures of the vertebra or spinous processes as well as a herniated disc require immediate rest to avoid further injury and possible nerve damage. Other problems such as strains and sprains of muscles and ligaments in the low back and along the spine often respond positive to gentle forms of stretching and low impact aerobic activities as both can be helpful in reducing muscle spasm. Regular exercises are of great importance in managing chronic back pain often caused by degenerative changes of the spine. Chronic back pain does require an individualized exercise program to stabilize and mobilize the spine as well as the lumbar-pelvic-hip region in order to reduce pain and improve function and movement. Secondary back pain is often the result of postural and gait deviations caused by osteoarthritis to other large joints such as knees and hips. In order to reduce the back pain an exercise program needs to manage the original cause first and later correct gait and posture.

Conclusion:
LBP is responding in most cases positive to exercising and often can be a valid alternative to surgical intervention. The starting point, the intensity, the progression as well as the choice of exercises should be determined by a team of Health Professionals experienced in the rehabilitation and management of LBP.

I hope this article is providing you with some helpful information in dealing with your own low back pain or that of a loved one. As always, your questions and comments are greatly appreciated.

A Sante,

Hartmut 


Sources:
http://www.nytimes.com/health/guides/symptoms/back-pain-low/exercise-and-physical-therapy.html
http://www.injurytreatment.com.au/search-injury-information/back-spine/lumbar-spine
http://www.webmd.com/back-pain/features/relieve-back-pain-with-core-strength-training
http://www.spine-health.com/wellness/exercise/back-strengthening-exercises
http://www.bigbackpain.com/back_pain_treatment.html
http://www.webmd.com/back-pain/tc/low-back-pain-prevention
http://www.webmd.com/back-pain/tc/low-back-pain-cause
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809228/
https://www.inkling.com/read/acsms-guidelines-exercise-testing-prescription-9th/chapter-8/low-back-pain
http://www.spine-health.com/blog/bed-rest-or-staying-active-better-low-back-pain-recovery
http://www.spine-health.com/treatment/physical-therapy/physical-therapy-low-back-pain-relief

Living and exercising with Prostate Cancer

Dear Friend,

a few days after the 12th anniversary of my father's passing, he had prostate cancer, and after a very close friend was recently diagnosed with the same disease I decided to dedicate this blog to all those who are or have been living with prostate cancer.

The prostate is a walnut sized gland between the bladder and the penis surrounding the urethra. It produces the seminal fluid that transports and nourishes the sperm.

Cancer of the prostate gland is one of the most common cancers in men. Even though the causes of the disease are still largely unknown we do know about risk factors that increase your chance to develop prostate cancer:

• Age: Prostate Cancer is most common in men over the age of 65 and cancer cells are found in nearly 80% of men by age 80.
• Ethnicity: Black male have an increased risk overall for developing prostate cancer and more aggressive forms of the disease in particular. Reasons unknown.
• Family history: Any man like myself who has a family history of prostate cancer is at a higher risk than those without family history.
• Obesity: Significantly overweight men who are diagnosed with prostate cancer show more often advanced disease which is much more difficult to treat.

Prostate cancer can in nature be slow growing or aggressive and be assigned one of four different stages. Stage 1: The Cancer is confined to a very small area in the prostate itself. Stage 2: The cancer is still small but maybe effecting both sides of the gland and/or deemed aggressive. Stage 3: The cancer has invaded other non prostate tissues surrounding the gland. Stage 4. prostate cancer cells are spreading throughout body by way of lymphatic system and blood stream and/or have grown into nearby organs.

The symptoms of prostate cancer often don't appear until the later stages:

• Difficulty urinating (initiation and reduced force)
• Blood traces in urin and/or semen
• Swollen legs
• Pelvic pain
• Bone pain

Should you experience any symptoms that concern you please see your doctor for a detailed diagnosis. The initial screening test is typically  a digital rectal exam (DRE) in which the doctor inserts a lubricated, gloved finger into the rectum to determine if your gland shows any abnormalities in texture, shape or size. In case of a positive DRE a prostate-specific antigen test (PSA) may be needed. This test analyzes your blood for a higher than normal level of PSA which could indicate an infection, enlargement, inflammation or cancer of the prostate gland.

The next step often includes ultrasound to produce a better visual diagnosis and a  needle biopsy to collect a tissue sample that can be checked for cancer cells. If it is determined that the cancer has spread, further diagnostics are used to define the exact situation and decide the treatment options.

The treatment of prostate cancer depends greatly on the speed with which the cancer is growing, the extend to which it has spread as well as your doctor weighing benefits versus side effects.

Treatment options include:

Radiation Therapy either via high powered energy beams applied from the outside or a low long-term dose of radiation treatment by inserting small radioactive seeds into the prostate gland near the tumor. Side effects are rare but in very few cases can lead to other forms of cancer associated with radiation.

Hormone Therapy targets the male hormone testosterone which helps cancer cells grow. Testosterone production can be stopped or limited through medications which prevent signals to the testicles to produce testosterone or through medications that prevent testosterone from reaching the cancer cells. A more radical and often faster way to reduce testosterone levels is the surgical removal of the testicles called orchiectomy. Side effects can include erectile dysfunction, loss of bone mass, weight gain, reduced sex drive and increased risk for heart attacks.

Prostatectomy is the surgical removal of the prostate gland, some of the surrounding tissues as well as nearby lymph-nodes. Side effects may include urinary incontinence and erectile dysfunction.

Freezing and thawing cancer cells via the use of gases that freeze and reheat the cancerous tissues and finally kill the cancer cells This form of therapy is still in developmental stages but complications have been significantly reduced over past years and presents a possible treatment option for those who did not respond to Radiation Therapy.

Chemotherapy is a very aggressive form of treatment most commonly used for  advanced stage prostate cancer (spread to other parts of body) or in patients that did not respond to Hormone Therapy. The medication that kills cancer cells is commonly taken either via pills or given intravenously. Unfortunately chemo therapy despite great progress still presents a lot of unwanted side effects in most patients.

As always it is better to prevent disease rather than having to treat it. The risk of developing prostate cancer can be reduced through a diet that is rich in fruits and vegetables and favors real healthy food choices over supplements. Nutrients and vitamins that have been linked to the prevention of prostate cancer are lycopene (found in tomatoes) as well as vitamin E and selenium. However supplements including these vitamins/minerals don't show the same success as foods naturally rich in vitamin E and selenium. In addition to a healthful diet regular exercising on most days of the week seems to cut the risk of prostate cancer even more. Screening healthy men for prostate cancer, who are not showing any symptoms of the disease, is somewhat controversial amongst the different medical organizations. To decide whether or not screening is appropriate for you please discuss your particular situation with your physician.

Exercise and prostate cancer
 As a Physio-Therapist and Personal Fitness Trainer I am of course especially interested in how far exercising can help reduce the risk of developing prostate cancer and how those with prostate cancer respond to exercise as an additional form of treatment other than the ones discussed previously.

It seems that the majority of studies performed between 1989 and today show a probable connection between increased physical activity and decreased prostate cancer risk. This reduced risk is explained by way of hormone level regulation, the prevention of obesity, improved immune functions, and the reduction of oxidative stress that are all positively influenced through regular exercising. Exercising also has a positive effect on those undergoing treatment for prostate cancer. One study suggests that men can reduce their risk of prostate cancer progression and increase their chance of survival by adding physical activity to their daily routine. These benefits can even be attained  with moderate levels of physical activity (15 minutes per day); however exercising vigorously for three or more hours per week seems to be of greater value and reduce all-cause mortality by 49% and prostate-cancer-specific mortality by 61%. Scientist are starting to understand why vigorous activities are more beneficial quoting it's positive effects on DNA repair and cell-cycle pathways as well as gene expression changes. They found upregulated genes that included well known tumor-suppressor-genes such as BRCA1 and BARCA2 in men with prostate cancer who participated in a vigorous exercise protocol for more than three hours per week.

I think it is safe to conclude that exercise does not only help in the prevention of prostate cancer, but can also positively change the outcome of the disease. More studies and research are needed to explain the correlation between exercise and prostate cancer in detail.


I hope this blog has been able to provide you with some interesting and helpful information. Please feel free to share my blog with anyone you might think would be interested, and as always your question and comments are greatly appreciated.

Wishing you and your loved ones good health,
Hartmut

Sources:
www.mayoclinic.com
www.cancer.gov
Program in Human Biology, Stanford University California
Medscape Medical News
American Society of Clinical Oncology