Chest Pain: Indigestion or Angina?

In today's blog I would like to share a recent experience I  had with one of my clients, hoping that sharing this story with you and elaborating on it will help you recognize the symptoms of coronary artery disease and prevent heart attack and possible death for yourself and others.

I recently started working with a new client, a male in his 70's, with a history of an ischemic brain infarct/stroke. At the start of our work-outs he had pretty much fully recovered from the event other than some lingering short term memory problems. His physician recommended a regular work-out regimen to reduce his elevated cholesterol levels, improve his stamina and help with the prevention of future strokes.

Three weeks into our relationship my client complained during a work-out session about frequent problems with heart burn or indigestion causing pain behind his sternum. He was experiencing these episodes several times during the day, but they never lasted very long. Lately the same episodes plagued him during our work-outs. When asking him whether he felt any acidic reflux he declined. Alarmed by his prior stroke and his elevated cholesterol levels I urged him and his daughter to schedule a stress test to eliminate the possibility of Angina. His primary care physician prescribed Anti Reflux medication and ordered a stress test ECG (better be safe than sorry). The stress test unfortunately confirmed my concerns. My client was indeed experiencing Angina, a common symptom of coronary artery disease caused by a reduced blood flow to the heart muscle. Angina is fairly common and often described as pressure in the chest or someone standing on the chest, but often mistaken for other health problems just like in this case.

Cardiologists differentiate between three types of Angina that I would like to introduce, and discuss their symptoms and characteristics.

• Stable Angina
• Unstable Angina
• Variant Angina (Prinzmetal's Angina)

The symptoms of all three types can vary and include:

1. Chest pain or discomfort
2. Pain in your arms, neck, jaw, shoulder or back accompanying chest pain
3. Nausea
4. Fatigue
5. Shortness of breath
6. Anxiety
7. Sweating
8. Dizziness

Commonly the perception is that Angina only effects the left arm, left side of jaw or left shoulder. That is a myth I would like to debunk. Both sides of the body can exhibit symptoms.

Stable Angina is the most common form of Angina and typically occurs during periods of elevated physical and/or emotional stress (Exercise, stair climbing, mental stress etc.).
Other Characteristics:
Predictable (patient knows how to and what triggers an event)
Consistent (chest pain is at least similar each time)
Short term (passes usually within 5 minutes or less)
Responds well to rest and Angina medication
Can feel like indigestion
Can spread to arms, back or other areas of the body (see above)

Unstable Angina is considered a medical emergency.
Characteristics:
Occurs even when resting
Change in the pattern of previously experienced Angina
Unpredictable/Unexpected
Long term (often 20 minutes or more)
Might not respond to rest and medication
Could indicate Heart Attack

Variant Angina is a very rare form of Angina accounting for only 2 percent of all Angina cases. This form is caused by a temporary coronary artery spasm reducing blood flow to the heart muscle.
Characteristics:
Occurs often during rest
Can be very severe
Might respond well to Angina medication

Your Cardiologist will order the right tests to diagnose your problem and develop a treatment plan that might include lifestyle changes, medications, medical procedures and surgery if needed.

I hope this information won't cause unnecessary panic or worry, but rather help saving lives. If you or someone else you know, or train, does experience any unexplained chest pains or other aforementioned symptoms please see a health care provider for further testing. If chest pain lasts longer than a few minutes and does not respond to rest and Angina medication don't hesitate to call 911 as it might indicate a heart attack.

In good health,
Hartmut

Source: Mayo Clinic Staff @ MayoClinic.com

Osteoporosis: maintain and recreate bone density

This blog is focusing on one of the most common health problems among my older female clients/patients, Osteoporosis.


Overview
Osteoporosis is the most common bone disease in women over 50 in the US. A loss of bone density occurs when the body doesn't form enough new bone or reabsorbs too much old bone or both. This is caused by a lack of calcium and phosphate, two minerals vital to bone formation. Other causes include:

• chronic rheumatoid arthritis
• corticosteroid use
• Hyperparathyroidism
• bed confinement
• Vitamin D deficiency
• alcohol abuse and more

Symptoms include bone pain, fractures without or little impact/trauma, stooped posture (hyper kyphosis) and significant loss in height (6 inches or more).

Bone density loss is commonly diagnosed by performing a bone density test. The dual energy x-ray absorptiometry scans are comparing the patients levels with those of a healthy young woman (T Score) and with those of the patient's peers (Z Score). Negative T-Scores indicate the loss of bone mass with values from -1.0 to -2.5 being diagnosed as Osteopenia (milder form) and values of -2.5 and lower being considered Osteoporosis.

A treatment plan is trying to stop further bone density loss, increase bone density and manage the associated pain. The patient is typically using calcium and vitamin D supplements and medications such as Fosamax, Actonel, Boniva, and Reclast that are designed to increase bone density. In addition patients with low bone densities need to be educated on the importance of impact exercising and be put on an appropriate exercise program


Why is weight bearing and loaded exercising important? Bone is considered a bradytrophic tissue, meaning it has very little or no direct blood supply. It absorbs nutrition like a sponge absorbs water. You squeeze the sponge for maximum absorption. Compressing the bone through weight bearing- and impact exercises accomplishes the same. Studies performed among women with Osteoporosis and Osteopenia showed significant better outcomes in those that were involved in exercise programs involving weight bearing exercises and loading stresses. It needs to be mentioned though that patients with severe Osteoporosis are at a very high risk for hip, wrist and vertebra fractures. High impact exercises have to be avoided at this stage. Exercising under the supervision of an experienced trainer or Physical Therapist is highly recommended.


Exercises I recommend to my patients include but are not limited to:

• Lunges
• Squats
• Step-ups
• Jumps (milder stages)
• Hip Abduction (short lever in severe cases)
• modified Push-Ups
• Supine Posterior Pelvic Tilts
• Supine Bridging etc.

I hope this blog is offering some insights into the problem of bone density loss and the importance of exercise to treat this disease. As always, please feel free to contact me with questions and comments. Please like BACK IN FORM on Facebook (www.facebook.com/backinform) and follow our tweet on Twitter.

A sante,

Hartmut

Piriformis Syndrome or Sciatica?

Many of my clients come to me asking for help after having been diagnosed with Piriformis Syndrome (PS) aka "Pseudo Sciatica". PS is caused by either a tight piriformis muscle or a spasm of the same causing irritation to the underlying Sciatic nerve. The term "Pseudo Sciatica" already indicates that it is hard to differentiate between true Sciatica and PS, as both cause the same symptoms (pain, tingling, burning, "electrical shock" sensations, and/or numbness down the leg, often all the way to the foot). Some recent studies contribute a tight piriformis or a piriformis spasm to the fact that the muscle is overworked due to weakness in gluteus medius and maximus (buttock muscles). True Sciatica is most commonly caused by the compression of one or more of its component nerve roots due to disc herniation or spinal degeneration in the lower lumbar region.

How can you actually tell the difference? There are two simple diagnostic exercises that give you a very good idea whether you are dealing with Sciatica or PS. If from a sitting position the patient/client straightens his/her painful leg and experiences an increase in pain you very likely are dealing with true Sciatica. If your client/patient pulls up his/her knee (painful side) from sitting position towards the same-side shoulder an increase in pain is only likely in severe Sciatica cases. If the same maneuver is performed towards the opposite shoulder and causes an increase in pain you most likely are looking at a client/patient with PS.

Can Exercise Therapy reduce the symptoms of Piriformis Syndrome?

Unfortunately there are no real scientific studies available that address this particular question. Treatment for PS has traditionally included physical modalities like heat, ice and ultrasound, stretching, and a combination of local anesthetic, corticosteroid and botulinum toxin injections into the piriformis muscle, muscle sheath, or sciatic nerve sheath. Furthermore Physical Therapy included soft tissue mobilization, positional release, and joint manipulation, performed two to three days per week over a three months period.

Recent case studies suggest that exercises strengthening the gluteus maximus and medius and help with movement reeducation can reduce PS symptoms dramatically and in some cases lead to a full symptom resolution within a couple of months.

Exercises recommended in these case studies and have shown improvement in my own PS clients included:

• Piriformis Stretches
• Resisted Side Step Abduction
• Supine Bridging
• Resisted Clam Shells
• Myofascial Release of Piriformis with Foam Roller
• Clock Lunges
• Clock Single Leg Hops

I hope I was able to shed a little light onto the problem of Piriformis Syndrome vs. Sciatica and my tips prove to be helpful to you or people you might train.

A Sante,
Hartmut

Low Back Pain during Pregnancy

Typically at the beginning of the year I write about New Year's Resolutions and how to keep them, how to chose the right club or trainer, or how to prepare foods that help you lose those extra Holiday pounds. This year I decided to go a different route. My education favors clearly the work with special populations and the rehabilitation of a variety of orthopedic, neurological and internal medicine conditions. So besides attacking main stream fitness issues I will dedicate a portion of my 2012 Blog to tips on rehab. My first blog is a tribute to all women who have gone or are currently going through the most incredible transformation: Pregnancy and the sometimes not so incredible side effects.

Low Back Pain is very common during pregnancy (50-70% of pregnant women) especially as changes in weight and center of gravity put added strain on your spine. As a Physio Therapist I want to know whether exercises can make a difference and if so which exercises to choose.

Weight gains during pregnancy (typically 25-35 lbs) have to be supported by mom's spine in addition the growing weight of the baby and uterus might place additional pressure on vessels and nerves in the pelvis and lumbar region. The growth of uterus and baby has also the effect that the body's center of gravity moves anterior drawing the lumbar spine often into hyper extension causing pressure and irritation to nerves exiting the spine in the lumbar region and pacing additional strain on muscles and tendons supporting body posture. Hormonal changes during pregnancy include an increase in relaxin, a hormone that relaxes muscles and tendons preparing the birth canal for the process of giving birth. This hormone unfortunately works also on muscles and tendons supporting mom's spine possibly leading to further exacerbation of already existing back pain. Last but not least, some pregnant women do experience muscle separation of the rectis abdominis (Straight abdominal muscle or six pack :-) along the center seam leading to a decrease in spinal postural stability.

Looking at research, there are four major studies out, that have evaluated this situation with different conclusions. Two of the studies did see increased value in adding lumbar stabilization exercises in order to treat low back pain in pregnant women, two studies found no significant difference between pregnant women who did engage in such exercises and those who did not. I concluded based on those four studies that pelvic lumbar stabilization exercises appear to be helpful certainly are not likely to cause additional pain and therefore to be recommended.

Simple low back stability exercises include, but are not limited to:

• Posterior Pelvic Tilt
• Hip Abduction
• Bridging
• Side Plank
• Hip/Leg Extension from Quadruped Position

any of these exercises can be modified to accomodate mom's prior experience with core stability training and her level of fitness.

I hope this little bit of info is helpful to all becoming moms and helps make your pregnancy a little easier.
Best wishes,

Hartmut Broring - M.S. Physio Therapy
Founder and President
Back In Form, Inc.

Happy and Healthy Holidays without the Expansion

Dear Reader,
With the first calorie slugfest behind us and the two biggest coming up I decided it was time to write about the challenge of expansion during the Holidays. The average American gains roughly five pounds between Thanksgiving and New Year’s. Studies show that most calories are not consumed on the specific Holiday itself, but that it is rather the seemingly endless holiday-parties and the grazing in between that add up. While weight loss programs during the holidays are almost certain to be doomed and unrealistic, maintaining your weight is not!

Here are a few tips for Healthy Holidays:

• Make an effort to continue your regular exercise program even in the middle of all the holiday bustle and hustle. Plan ahead by scheduling exercises around holiday commitments and then stick to the schedule! Exercising is the key to maintaining good health and a healthy weight.
  
• Don’t try to lose weight, just maintain your weight and you come out a winner.
  
• Don’t deprive yourself of holiday goodies such as eggnog, candied sweet potatoes and the occasional piece of chocolate. Instead choose small portions of those calorie laden foods and fill your plate with low fat choices such as fruit, vegetables.
  
•  Try to move your holiday get-togethers into a different arena or setting. Instead of indulging over a table of food, meet at the Holiday Ice Skating rink or at a Holiday Play such as the “Nutcracker”. Even Bowling can be a welcomed change to your holiday party routine.
  
• When invited to parties offer to bring a favorite low-calorie healthy alternative dish. That leaves you with at least one “safe” item available.
  
• Consume alcohol in moderate amounts. Alcohol is high in calories and can lead to overeating. Try to consume a glass of water for every glass of alcohol you consume! Also when at a party always keep a little in your class, that way the host won't refill every time he or she passes you.

I hope this handful of tips will make your Holiday Season a time to relax and enjoy the company of those you love and cherish without stressing over possible weight-gains!

Happy Holidays,
Hartmut

Updated Exercise Guidelines by American College of Sports Medicine (ACSM)

ACSM recently updated it's 1998 version of Exercise Guidelines. This post is trying to give you an overview of ACSM's current position regarding exercise quantity and quality.

 1. Health Benefits of Cardiorespiratory-, Strength and Resistance-, Flexibility- and Neuromotor Training

• reducing the risk of developing cardio-vascular disease
• improving insulin sensitivity
• improving cholesterol values, elevating HDL-
• reducing blood pressure values in hypertensive individuals
• enhancing mental outlook - improving mood disorders
• improving body-composition/weight-management
• preventing, improving or reversing osteoporosis/osteopinea
• preventing or improving osteoarthritis
• reducing risk of falling
• reducing risk for diabetes type 2 and metabolic syndrome
• reducing risk of stroke as well as breast and colon cancer

Overall it can be said that regular exercising not only decreases a persons risk of developing diseases that can significantly reduce his/her quality of life, but that it leads to increased levels of well-being.


2. Cardiorespiratory Training Guidelines (for apparently healthy adults)

• The ACSM recommends to train 3-5 days per week at moderate (Rate of Perceived Exertion (RPE) Scale: 12-13) to vigorous (RPE: 14-17) intensity levels.  This can be done on 5 days/week at moderate levels, 3 days at vigorous intensity, or 3-5 days at a combination of both levels. Moderate exercise levels should be performed for 30-60 minutes, vigorous exercise intensity should be performed for 20-60 minutes. These exercise sessions can be continuous or be broken up into multiple sessions during the same day. The cardiorespiratory training should be done purposeful and rhythmic involving all major muscle groups of the body. The training program should be gradually progressing in intensity, duration of each session, and frequency until set goals are achieved.

3. Strength Training Guidelines (for apparently healthy adults)

• The ACSM recommends to strengthen all major muscle groups 2-3 days per week with 48 hour rest intervals. The prescribed intensity depends on age, experience, and goals. In order to increase strength very light to light loads are recommended for novice older adult and novice sedentary adult exercisers. (40-50% of one Repetition Maximum)  moderate to hard loads (60-70% of 1-RM) are suggested for novice or intermediate adult exercisers and hard to very hard loads (80-100%of 1-RM) are reserved for experienced weight lifters. If trying to improve strength endurance light to moderate loads are recommended. For power training extremely light to light loads are suggested for older adults. Strength training is prescribed in repetitions, sets and rest. 10-15 repetitions and single sets to increase strength in novice and older adult exercisers. 8-12 repetitions and 2-4 sets to increase strength and power in most adults. 15-20 repetitions and 2 or more sets to improve muscular endurance. Each set should be followed by 2-3 minutes of rest.

4. Flexibility/Stretching Exercise Guidelines

• ACSM recommends to stretch all major muscle groups at least 2-3 days per week, with greater improvements being achieved through daily stretches. The stretch should be done in a static fashion to the point of light discomfort or a feeling of tightness in the muscle being stretched. Stretches should be held statically for 30-60 seconds for older adults and 10-30 seconds for most adults. Repeat each stretch 2-4 times per muscle for a total of 60 seconds per target muscle group.

5. Neuromotor Exercise Guidelines

• Neuromotor exercises are geared to improve balance, coordination, agility and gait and are therefore extremely beneficial especially for the older adult to prevent falls and maintain physical independence. ACSM recommends the inclusion of such types of exercises in the work-out routines on at least 2-3 days per week for 20-30 minutes. There are no known recommendations yet on intensity and volume. Keep in mind that more complex and difficult balance- and coordination exercises trigger greater heart rate and blood pressure responses.

 6. Comments

• This newly released ACSM statement is the largest evidence based guide (over 400 cited references of publications and studies) to health and fitness professionals in creating individualized exercise and training prescriptions for healthy adults of all ages. It highlights the importance of qualified leadership through well educated fitness professionals and it's positive impact on the exercise experience for all adults, especially the novice adult exerciser. If you have difficulties getting started on your journey to get healthier and improve the quality of your life please consider contacting a Personal Fitness Trainer to help you get on the right track.

À Santé

Hartmut Broring, M.S. Physio Therapy
Founder and President
Back In Form, Inc.

Fitness Tips for Tennis Players

To find out how to prepare for Tennis let’s look at the physical characteristics of the game and determine what attributes of physical performance should be addressed through training. Keep in mind: “we get fit to play a sport not playing a sport to get fit!” Tennis like most racquet sports is characterized by fast explosive movements like jumps and sprints. Recovery time in between points is usually rather short and total playing time varies between 30 and 180 minutes per match. There is a great amount of lateral movement as well as overhead racquet movement. Both movements carry an elevated risk for injury. A tennis player has to focus in his/her training therefore on a multitude of goals. Good muscular strength and flexibility help with injury prevention and explosive movement. Coordination and balance are important while chasing the ball with multidirectional runs. Anaerobic and aerobic capacity need to be trained parallel due to the stress placed on both energy systems with each point and the total length of the game.

Power and Explosiveness:
These anaerobe qualities can be trained in many different ways. I usually have my athletes go through sprint and plyometric drills and emphasize multi directional/planar exercises. I prefer to take the player off the court as much as possible in order to prevent overuse injuries due to the hard surface. Shuttle sprints over short distances, North, South East & West (forward sprints, lateral quick steps, reverse sprints), or Reaction Sprints (a partner throws a tennis ball over the athletes head, he turns sees the ball and retrieves it by sprint) are great ways of improving the sprint qualities and reaction time of tennis players. In addition I use medicine balls, reaction balls, agility ladders, elastic resistance, parachutes, hurdles, BOSU® and Plyometric Boxes to improve lower extremity power.

Muscular Strength
Tennis specific strength training should focus on balance and joint/core stability. That means you should avoid focusing on muscles of either front OR back of the body but rather engage in a work-out treating all muscle groups as equally important. In athletic performance training I prefer multi joint exercises over single joint exercises (typical for Body Building) as they are a better way of preventing muscular imbalances. I also introduce different plains of motion into exercises in order to emphasize joint stabilization in a multitude of directions. A few examples.: Forehand-Backhand Lunges; Chest Flys and Reverse Flys with multi directional lunges using elastic resistance or cable; Snatch, Cling and Jerk using moderate workloads; Medicine Ball Throws.
In addition I like to introduce my tennis players to a variety of exercises that help with overuse injury prevention. Exercises to stabilize the shoulder and prevent rotator cuff injuries such as internal/external shoulder rotation and “empty the can exercise”. Exercises to reduce lateral epicondylitis (aka tennis elbow) include wrist flexor/extensor stretches and strengthening of same muscle groups.

Flexibility:
Range of motion (ROM) is for a tennis player as vital as it is for most other athletes. A decrease in ROM due to tight muscles and tendons prohibits accurate biomechanics, diminishes your technique and reduces the accuracy and force with which you are hitting the ball. It furthermore leads to an increase in wear and tear on joints and muscles and therefore more time on the injury reserve list. Use dynamic stretching before your games in order to increase blood flow to the area and static stretching after your game to restore proper muscles length! Muscles groups in desperate need for stretching are hamstrings, quadriceps and gastrocnemius as well as pectoralis, rhomboids, trapezes and triceps.
I hope you find these tips helpful and wish you a lifetime of great tennis!

A Santé,
Hartmut Broring – M.S. Exercise Therapy