WHO NEEDS MAINTENANCE?
I can’t think of anything on earth that doesn’t need maintenance. My husband, Bill, points out that even the earth itself – soil – needs maintenance. Our cars, homes, tractors, power tools, and boats simply won’t perform at their best without regular attention. We can postpone maintenance for a bit but sooner or later upkeep has to be administered or the item will falter. I remember years ago a windstorm eradicated the power in our area for several days. Friends of ours were dismayed when their generator wouldn’t start. Never mind that they hadn’t cranked it up for 13 or so years – small wonder it failed them! Even the less tangible items like organizations and relationships won’t prosper without some form of attention and effort.
Similarly, it seems intuitive that our bodies need maintenance as well to thwart or diminish potential health issues: flossing and brushing, colonoscopies and mammograms are examples of routine maintenance and screenings directed at preventing problems or detecting them early. We’re even willing to spend over $30 billion dollars a year in the U.S. on herbals and supplements that continue to evade solid proof they are beneficial (you can read more about this here). For what it’s worth, I still take supplements. Just a few. Just in case. My husband Bill takes zilch – doesn’t believe in them. Yet while all this attention to bowels and breasts is admirable, many people completely overlook the connective tissue network, which constitutes roughly 45% of a man’s body weight and 35% for women. This complex network consists of bones, blood, adipose (a nice word for fat), muscles, and, of course, fascia. While integral to many life functions, the connective tissue network is also a vital component of the Movement System. Suffice it to say it’s a big and often overlooked element.
I’m going to assert my perspective that EVERYONE needs a body maintenance plan – no exceptions. Furthermore, I believe that the sooner it’s embraced in life the better. I find it intriguing the number of people who do not dedicate much attention to their body until they realize they can’t get up out of a chair. I remember giving a presentation to a group of various professionals meeting to discuss tactics for helping people “age in place,” or in other words be able to stay in their home. As you might imagine, the research shows that falls are a huge factor in determining where someone lives out their days. While everyone at the presentation easily agreed that prevention is key, the next question I posed to the group was not so straightforward: when is a good time to start thinking about preventing falls? Age 70? 60? 30? I would suggest a whole lot sooner than most people do. I believe that the 12 year old with popping knees may become a 30 year old with a torn meniscus, then a 65 year old with a knee replacement, then an 80 year old who’s falling down. I have heard this progression played out repeatedly as I document the history of numerous patients over the years. They call it pattern recognition. I don’t know about you but I want to avoid this pattern as much as I am able, and I want to help anyone who’s interested do the same.
While we can all likely agree that some form of body maintenance is prudent, what that looks like is subject to a plethora of opinions. Is keto or Atkins better? CrossFit or yoga? Power lifting or cardio? Water or land exercise? Low or high impact? Seems like nowadays everyone is acutely aware of how many steps comprise their day. Then there’s all the offerings in the realm of maintenance, prevention, and treatment such as massage, acupuncture, Rolfing, chiropractic, Graston, physical therapy, and so on. We are bombarded with information and options, making it difficult to navigate a best path. Surely some individuality comes into play here, reflecting personal preference, access, and baseline health status. But ultimately we need a plan, and need to begin it now instead of waiting until things start wearing out and hurting.
That’s what I’d like to propose: a PLAN, or at least some guidance, to help you make good choices that best direct your time, effort, and money to what may keep you healthy and mobile in the long run. Because (true confession here) I don’t want to rehab your total knee – I want to help you prevent it! What a novel construct. I would suggest it’s not only possible, but ought to be the norm as opposed to accepting that “Uncle Arthur” (some people’s synonym for arthritis) dictates that knee replacements are an inevitable part of life. I base my advice here on four pretty good sources of information:
- 59.5 years (at this writing) of managing my own body and issues, sometimes more successfully than others.
- 37+ years (and still going strong) in practice working with people in pain.
- Seeing what works and what doesn’t in both realms.
- My education.
Please don’t wait until things are broken to think about fixing them. It’s so true that an ounce of prevention is worth a pound of cure, and often those cures aren’t really cures at all: they’re band-aids. A stitch in time saves nine, and may also save the staples, glue, rods, screws, etc. that accompany surgery.
Are you one of those who is addicted to exercising and working out? Or in the other camp of those who prefer the recliner and remote? Regardless of your feelings about exercise, studies support that EVERYONE needs it in some form. Those whose lifestyle entails sedentary tendencies require it even more. Research also demonstrates that exercise can be as addicting as sugar, and help rewire the brain to feel as rewarded with exercise as it is with sugar – a much healthier trade off.
My intent with this post is not to outline the parameters of appropriate frequency, duration, and intensity of exercise. That can be found in multiple other sources such as Physiopedia, and this article on exercise. It spells it out far better than I can or want to. They open with this statement that is so true: “Physical activity prescription is an under-utilized tool for improving community health.” Bingo.
I would much rather do an activity that I enjoy – like hiking, biking, swimming, volleyball – than to get on a stationary bike or do exercise. I get bored with working out. I used to love running, but ankle surgery years ago kiboshed that one for me. So now I bike, outside, where I don’t get bored. But that’s tough to do in the cold and snow.
When it comes to doing exercises, like the kind you may get in physical therapy or rehab, the camp of those who love doing them gets even smaller. In this classic 1991 study researchers Sluije and Knibbe found that 64% of patients complied with their physical therapy prescribed exercise program while in treatment. But this number dwindled to 23% after discharge from a formal therapy program. While the numbers may vary, rest assured that this construct has not changed over the years. Maybe it’s because often these exercises are BORING! Compound that with the fact that patients are often given a LONG LIST of BORING exercises and it’s no wonder they go AWOL! Then PT’s blame a patient’s lack of progress or a return of the problem on the fact that the patient did not adhere to their exercise program. Furthermore, there remains much controversy over the ideal frequency, or how many sets, reps, and even which exercises really work best. It’s no wonder most people aren’t motivated about doing them.
These are some of the reasons I don’t like doing exercises and I don’t like prescribing them. Having said that, I do believe if we are going to MAINTAIN mobility and health, and have the best chance of PREVENTING problems, a few exercises may help us accomplish this goal. Over the years I have compiled a very short list of my favorites – the ones I use the most and with most people. One role they can serve is to highlight a problem, especially if you can’t do them. They aren’t for everyone, and they don’t solve everything. (If you have trouble with them or feel they aggravate something then maybe they are not for you. Consider seeking help to find something more suitable for you.) Here they are, in no particular order.
- Target: Stretch the front of the hip (of the leg behind), the back of the calf (of the leg behind), and the front of the chest/shoulders. This is where you should feel it stretching. Be sure to keep the back heel down.
- Purpose: Counteract the effects of sitting, wearing heels, and arm use in front of us (computer, phone, reading, driving).
- Frequency: for someone who sits a lot at least once daily or more if possible. Others once a week.
- Duration/reps: Hold for 4 slow breaths in through the nose, out the mouth, pause for 4 seconds between each breath. Do as many as you like, but each leg gets a turn in back as that’s where the stretching occurs.
- Who needs this? Everyone who can do it safely, especially those who sit, work at a computer.
- Target: Stretch the back of the neck by gliding the head back.
- Purpose: Counteract the effects of a forward head posture, which often occurs with reading and computer work.
- Frequency: for someone with a very forward head or who reads/is on the computer a lot at least once daily or more if possible. Others once a week.
- Duration/reps: Hold for 4 slow breaths in through the nose, out the mouth, pause for 4 seconds between each breath. Do as many as you like.
- Who needs this? Everyone who can do it safely, especially those who have a forward head posture.
- Target: Stretch the side of the arm, trunk, and leg.
- Purpose: We rarely if ever in the normal course of a day elongate in this manner. If you don’t use it you lose it.
- Frequency: once daily to at least weekly as needed/desired.
- Duration/reps: Hold for 4 slow breaths in through the nose, out the mouth, pause for 4 seconds between each breath. Do as many as you like. Do on both sides.
- Who needs this? Everyone who can do it safely.
- Target: Pelvic and lumbar segments.
- Purpose: Increase/maintain mobility and neuromuscular control in the core.
- Frequency: daily/weekly as needed/desired.
- Duration/reps: As desired, all directions. The sagittal (front to back) and frontal (side to side) planes of motion are shown below. The horizontal plane (not shown) involves moving the pelvis in a circular motion, clockwise and counterclockwise. With all movements try to keep the upper body still while the lower body does all the movement.
- Who needs this? Everyone who can do it safely.
This one needs no explanation! This is one of the best, safest, and funnest core exercises there is! Many people can’t do this, and often say they never could even as a child. I’m not sure what to make of that, as I always have been able to and still can. Not all hula hoops are the same – cheap, small, light ones can be hard to use (but you don’t have to pay a lot for a decent one). It’s a great torso exercise, but if you can’t do it then the Pelvic Ball is an option. The main thing is to get active and have fun!
“Sit up straight!” “Pull your shoulders back!” “Stop slouching!” I can still hear the nuns barking at us in elementary school. For others it might be a well-meaning Mom. We’ve all seen slouchers, maybe in photos, maybe at a meeting, maybe we are/were the sloucher. It does communicate an aura – perhaps of depression, lack of confidence, possibly fatigue, maybe even trying to look cool versus nerdy. Bottom line is we do look better when we exhibit “good” posture. Yet this construct of good posture seems to be more of a lofty ideal we grasp for than an achievable goal. Exactly what is good posture, when do we “arrive” at it, how do we sustain it, and does it really matter?
Let’s start with defining posture. Wikipedia states the following: The word posture comes from the Latin verb ponere, which means “to put or place.” The general concept of human posture refers to the “carriage of the body as a whole, the attitude of the body, or the position of the limbs (the arms and legs). They go on further to define poor posture as the posture that results from certain muscles tightening up or shortening while others lengthen and become weak, which often occurs as a result of one’s daily activities. It may lead to pain, injury, or other health problems. I’ll interject here that muscles are not that smart. They are the boots on the ground, the infantry following orders – muscles are not the generals. So I have issue with saying a muscle tightens up/shortens or lengthens/weakens all on its own, even as a result of daily activity (more on this in a bit). It’s responding to a stimulus (or lack thereof), namely from the nervous system.
Conversely, Webster’s New World Medical Dictionary defines good posture (also termed neutral posture) as the stance that is attained “when the joints are not bent and the spine is aligned and not twisted. Neutral posture has given rise to the idea of achieving ideal posture – proper alignment of the body’s segments such that the least amount of energy is required to maintain a desired position. The benefit of achieving this ideal position would be that the least amount of stress is placed on the body’s tissues. In this position, a person is able to completely and optimally attain balance and proportion of their body mass and framework, based on their physical limitations. Good posture optimizes breathing and affects the circulation of bodily fluids. Now this is a definition I can embrace! They even edged into answering the does-it-matter question with a resounding yes! Perhaps a better definition of poor posture would be any deviation from this ideal. Think of it like a pile of books that’s not stacked straight: makes it kind of precarious. Or holding a 20# weight in your hand. It requires more energy and places more stress on the arm to hold the weight out away from the trunk than required when hold it closer in. Think of your head and neck in the same manner: it requires less energy and places less stress on tissues to hold the head stacked over the neck stacked over the shoulders stacked over the hips, knees, and ankles instead of leaning out or forward.
So how can you know if you have good posture?” It’s actually pretty easy: by doing a POSTURE CHECK:
- Stand with your back to an empty wall.
- Position yourself so that your buttocks and your mid-back touch the wall. Depending on the size of your derriere, your heels and calf muscles may or may not touch the wall.
- The back of your head should easily contact the wall. For me this feels very natural and easy. But for many people this feels unnatural, and some may not be able to contact the wall with the head even with effort to force it back. This would implicate the presence of what’s termed a forward head posture.
- Another way to check posture is to stand with a plumb line to your side. If you don’t happen to have one hanging from the ceiling you can use a picture of yourself from the side and draw a line on it. Good posture would show the line bisecting the ear, shoulder, hip, knee, and ankle.
- This also applies in the seated position: the plumb line should bisect the ears, shoulders, and hips, while the knee and ankle are not a factor in sitting. Keeping the back against the back of the chair helps align everything as well.
- For a different perspective, stand facing a full length mirror. Ideally your eyes, ears, and shoulders should be level. Your hands perched on the highest point of your pelvis should also look relatively level.
Now’s a good time to clarify that I am NOT saying we should always look like this. We are humans, not robots or toy soldiers. We are meant to move and change positions. But if the majority of our time is spent in sub-optimal positions whether sitting or standing then, as noted above, more energy is expended just to function against gravity AND the tissues are subjected to greater stress. As mentioned above, if we assume these postures frequently and long enough then the tissues will begin to adapt in ways we may not like. Even frequent and/or prolonged sitting can gradually promote changes in the front of the hip that can lead to trouble, which is why I advocate breaking up periods of sitting.
So what can you do if you find yourself habitually assuming less-than-ideal postures? As with changing any other habit, awareness is the first step and hopefully being accomplished as you read this. There are products on the market to address faulty posture, such as braces to theoretically help pull the shoulders back or at least remind the offender to do so. Special tape can be applied to the skin on the upper back to serve the same purpose. In preparing this I even stumbled across a little device you wear on your back which vibrates to alert you that you’re slouching and need to sit up straight. Kind of like a perpetual nun, Mom, or even little angel on your shoulder prompting you to do right.
While there may be some individuals who might benefit from these measures, I don’t recall ever recommending any of them (well, maybe the angel). For the most part I find that making people aware of their posture and teaching them posture checks goes a long way. In the case of a forward head posture, the Chin Tuck exercise (see above) can be very helpful. The Doorway Lunge (above) can also help to stretch out the front of the shoulders, which can shorten with bad posture. Changing a habit takes time, effort, and consistency especially if it’s been practiced for an extended period of time. And ultimately if a brace or other such cue helps to solve the problem then go for it! But I see it as a temporary measure, to be utilized in conjunction with these other elements.
If a posture check or the exercises suggested are difficult it’s possibly because you have not moved this way in a long time. Restriction(s) that are very chronic (present a long time) may prevent you from being able to get into these positions. You may be battling something that stretching and effort alone are not going to change, and require more help. If the tissues, let’s say the front of your neck and shoulders, have been overloaded for an extended period of time, then they may have developed densifications in the fascia that simply will not stretch out (you can read more about this here). Identifying the most problematic sites in the tissues and addressing them with Fascial Manipulation, percussion/vibration, cupping, and dry needling may be very helpful for promoting a more ideal, upright, and efficient posture. Then you may find yourself able to do these and other exercises, and make some positive and sustainable changes.
I remember sitting on the couch with my husband watching the 2018 Olympics. An ad came on as often is the case during a major broadcast, and I got up to do something else as is often the case during ads. But my attention was riveted back to the TV as I heard these words in a Toyota ad: “When we’re free to move, anything’s possible.” Ironically, I couldn’t move from the TV. It struck me as incredibly profound and brilliantly simple. While I wasn’t compelled to rush out and buy a Toyota, that phrase has stayed with me over the years. I even toyed with using it in our practice tag line, but decided Toyota might not like that. Evens so it epitomizes all we do in our physical therapy practice as we persistently work to maximize pain-free mobility and function. Our professional association acknowledges the importance of movement and cites it as the cornerstone of our vision statement and, beyond that, our profession.
So what does movement look like, and what defines normal versus abnormal? That’s a million dollar question that has been the topic of research and debate for years. Normal movement can be defined as the most efficient and economical movement or performance of a given task and is specific to the individual. This can be very difficult to describe, especially when it varies from one person to another. Perhaps this is why this post has taken me so long to complete: movement is complicated!
There’s a Brazilian study published in 2014 in the European Journal of Preventive Cardiology that I find pretty interesting. The researchers tested the mobility of 2002 men and women ages 51-80 by using a simple test they call the Sitting-Rising or Longevity test and specifically noted which subjects needed to use their hands and knees (kneeling, pushing on legs with hands) as props to get up and down. They then tracked these subjects for an average of 6.3 years and made some startling discoveries. Those who needed to use both hands and knees to get up and down were were almost seven times more likely to die within 6 years, regardless of their age at the time of the test, than those who could spring up and down without support. Now before you rush to select your tombstone, please appreciate that these are likelihood statistics and not absolutes. If it was a 100% guarantee then I would have been a widow years ago, as my husband Bill has not been able to do this for ages (probably because he doesn’t take supplements – see above).
For those unable to perform the Sitting-Rising Test, a less challenging global test of movement is the Timed Up and Go test, known as the TUG. It basically assesses the ability of the subject to stand up from a chair, walk 10 feet, turn around, and return to the chair. Longer time needed to accomplish the task signals an individual who is not only struggling with movement but also more likely to fall.
The ability to perform daily activities can also tell a lot about a movement system that is struggling. Consider these activities of daily living and how easy or difficult they may be for you:
- Walking – cadence (speed) tells a lot in that with walking (or any activity for that matter) the speed with which it is performed can be indicative of the level of difficulty associated with it (such is the basis for the above noted TUG test). Step length is another parameter to assess. A shortened step length may be a reflection of loss of mobility, as well as fear of falling. Feet placed far apart from side to side, as well as feet that are turned out, signal a system that is challenged to stay upright and trying to stabilize.
- Stairs – ascending or descending, doing them reciprocally (stepping past and not to the same step like a child), keeping the toes pointed ahead and not turned out, not using the arms to help pull yourself up the steps.
- Transfers – can you get up from sitting without much difficulty or having to use your arms to push up? Ideally you should also be able to lower yourself to sitting without using your arms or sitting down hard. Difficulty getting in and out of the car on either side can also signal a movement system that is losing ground.
- Reaching – up into a cabinet, behind your back to wash, into the back seat of the car from the front (NOT while driving!) are all examples of daily activities that test the movement system.
- Squatting – I love using squatting (when appropriate) as a global movement test for the lower half of the body. It gives me a lot of information about the hips, knees, and ankles and the connective tissue network that moves these joints. I also like to check any difference between squatting with the heels up versus down. Many people can go further with the heels off the ground, which typically signals a movement problem in the calf and /or foot. In the US we don’t squat much, and seem to accept that it’s one of those activities that disappears with age. Yet other countries and cultures belie this as their elders squat fully.
MOVEMENT ASSESSMENT VIDEO
This has been a long time coming, and I’m excited to finally be able to share this Movement Assessment Video with you. I tried writing out all of these movements and explaining how to do them, how far you should be able to move, etc., etc. It went on and on and I almost lost my mind! I finally decided to just make a video and walk you through it all, so HERE IT IS! Allow yourself a little over 16 minutes to complete it.
So how do you stack up? Do you have any items on your “check engine” list? (I have to acknowledge my good friend and colleague, Larry Steinbeck, for that one.) Most of us do. That’s to be expected. But the fewer the better and the sooner you deal with them the better. What should you do to address shortcomings? You have lots of options:
- Get Moving. Join a live or online class, purchase a membership to a fitness center, buy a DVD, get some home equipment, start a walking program, get a bike – just do something to get moving! Especially if your work or lifestyle is sedentary – you need activity more than someone who is active all day. Begin by breaking up periods of sitting. A little bit of movement goes a long way.
- Exercise. The internet is loaded with options, and above is my effort to give you some of my pearls with exercise. Just don’t force something to happen with stretching. If there’s an obstacle to movement then it’s far more intelligent to identify and resolve it than to bulldoze your way through it. If you have to keep stretching just to maintain mobility then logic dictates that something else may be driving the problem. Please also appreciate that stretching is not the answer to every problem, especially for hypermobile people like me.
- Footwear. Shoes are the most important piece of clothing on your body. Name brands don’t always tell the whole story, as some companies make both good and lousy shoes. Cost is also not the sole (ha ha) determinant, as you can pay a lot for junk and sometimes get a great shoe on sale. This applies to athletic shoes, dress shoes, sandals – anything you put on your feet. Knowing how to judge a shoe is your best bet, and we have two videos on this topic that will walk you through how to know what’s best: PT Tips and Tricks Choosing Shoes Part I, and PT Tips and Tricks Choosing Shoes Part II. We also have a nice brochure on footwear available on our Appalachian PT website.
- Use percussion, vibration, and/or cupping which I cover thoroughly in these sections. They are wonderful aids at addressing pain, stiffness, movement deficits, and other symptoms arising from the connective tissues. Just keep in mind that they are only as good as the operator, and where you apply them can be the determinant of how helpful they are. When in doubt or if results aren’t lasting then seek help!
- Wait and see what happens. Seriously, if you check your mobility later and it’s better then no worries. But if you keep checking and the problem isn’t improving or is worsening then you can expect to continue on that path unless you do something to make a change.
- Get help when necessary. This is too important to do nothing and hope for the best. Whether that means consulting us in physical therapy, a trainer, massage therapist, body worker, physician, acupuncturist, chiropractor, yoga teacher, coach – whatever and whoever – go for it! Letters after someone’s name are not the whole story of what they know. From my perspective, the best clinicians are the ones who never stop learning and have a heart for people. There are lots of ways to approach problems – one intervention isn’t the whole story and isn’t the complete answer for everyone. You need to feel confident in and comfortable with whomever you consult. And please don’t wait years to act. This isn’t a contradiction to what I’ve said above. Ecclesiastes says there’s a proper time for everything, and there’s an art (actually it’s called wisdom) to discerning what the next step should be and when.
We’ve covered a lot of material in this series on Maintenance and Prevention. Even so this series is not comprehensive and does not cover all aspects of what we need to monitor to take care of ourselves. I would be neglecting important aspects of self care if I did not at least mention other vital and perhaps less tangible aspects of a maintenance and prevention program. I know my areas of expertise as well as my limits, so all I’ll do is mention these here and encourage you to seek wiser sources for further information:
- Nutrition: while I’m not vegetarian or vegan, I do believe in the value of having plant-based foods as a staple in the diet. Things that don’t need labels or ingredients listed are ideal, and when we do eat foods with a list of ingredients the shorter the better. Kind of like fascia, it’s rather remarkable how many health issues could be averted with more attention to food and drink choices. Moderation is key, and even a little bit of chocolate occasionally is ok!
- Prayer/Meditation: whatever that looks like for you, we all need to feed our souls.
- Sleep: A lot happens to regenerate our mind, body, and soul when resting. Certainly some folks just seem to need less than others, but for the most part our highly productive, rushing everywhere society seems to promote sleep deprivation. Not good. Do all you can to optimize your sleep time including attention to lighting, noise, temperature, pillow, mattress, etc.
- Rest and recreation: I’m one of those highly productive people who drives the more laid-back folks nuts. It’s just how I’m wired. Regardless, I have to make time to relax, rest, and do things that are simply for my enjoyment. We are not machines that can produce 24/7. Give yourself freedom to stop producing every now and then.
I hope this series has given you some insight, direction, and awareness of how crucial it is to tune into what your body is telling you. Pick up on these signs, act on them, and I truly believe that many of the aches and pains considered to be an inevitable part of aging can be minimized or even eliminated. A little bit of maintenance really does go a long way!