Finding Your Breath, Finding Your Voice

Written by Lisa Grimmer, Elements Physical Therapist

With working and being at home more, many of us find ourselves sitting more, exercising less, and slouching toward screens or books. All of these changes in habits affect our posture, affect our voice, and affect our breath.

Posture, voice, and breath are intimately connected. To get a more practical sense, let’s try an experiment. 

Voice and Posture:

• Sit down with your neck tipped forward, your shoulders slumped, and your feet tucked under your chair. Try to call out your favorite book title or sing your favorite song. Not so easy, is it? 

Let’s try again.

• Sit down and find even weight on both sit bones. Make sure your knees are lower than your hips. A wedge pillow or small blanket can help with this. Ground both feet flat into the floor, and find one hand on each leg, not crossed. Feel your shoulders stack over your hips, and the back of your neck lengthen. 

Now try.

Did it feel easier to speak? By changing our alignment, we can find an effortless way to improve speaking volume. Further work can be done by improving our core strength and improving the quality of our breath.

Breath:

Changing our breath can also change our internal chemistry. If you breathe too much, or hyperventilate, you increase your blood pH. You may become lightheaded or even have tingling in your fingers. If you breathe too little, or hypo-ventilate, your blood pH decreases. Effects of hypo-ventilation include fatigue and increased anxiety.

One way to improve our breath is through a diaphragmatic breathing practice. Diaphragmatic breathing has been shown to decrease cortisol levels (stress hormones), improve attention, and improve mood in both children and adults. 

While a steady practice is most helpful for long term effects, including improved sleep, a single session of breathing for 15 minutes reduces blood pressure, increases oxygenation, enhances lung function, and improves cardio-respiratory fitness and respiratory muscle strength.

The muscles:

When we breathe in, we use our diaphragm and external intercostals (muscles between our ribs). Normal, relaxed expiration is passive, meaning we don’t have to forcefully exhale. When you inhale, your diaphragm contracts (tightens) and moves downward. This creates more space in your chest cavity, allowing the lungs to expand. When you exhale, the opposite happens — your diaphragm relaxes and moves upward in the chest cavity. However, if we choose to forcefully exhale, we use the internal intercostals, intercostalis intimi, subcostals, and the abdominal muscles. You may have noticed it’s an easy way to increase your abdominal contraction with a “pursed lip” breath- that helps recruit the abs for your exhale.

While we have our main muscles of inspiration, we also have accessory muscles, including the sternocleidomastoid, the scalenes, pectoralis major and minor, as well the inferior fibers of serratus anterior and your latissimus dorsi. Typically, we use these when we are breathing hard – think at the end of a race, when you’re recruiting everything you can. For some of us, whether due to posture or habit, we begin to rely on these muscles for much more. You may notice your shoulders shrugging up and down with your breath when you’re stressed. You may also notice this group of muscles kicking in with abdominal work – when we try to stabilize the core, we’ll try anything to help us out! Luckily, both in regard to breathing and abdominal work, we can train ourselves to decrease compensation with our neck muscles. 

The Technique:

Lie on your back on a comfortable surface with a pillow under your knees. Place one hand by your heart, and the other just below your ribs. Breathe in slowly so your belly expands, while your chest stays still. If you notice a lift in your chest, that is recruitment of the secondary respiratory muscles. Initially, this exercise can be quite tiring – both on the brain and the body! As you practice 5-10 minutes, up to 3-4 times a day, you’ll notice it becomes easier. You can also work up to a 15 minute session for extra stress-relieving benefits. Once you’ve mastered breathing on your back, you can either add a book on top of your belly for extra resistance, or try the same technique seated in a chair. 

Now you’re set! Take a look at your computer setup, your reading chair, and make sure to sit tall. With these tweaks in posture and techniques in breath, you’re ready to tackle your Zoom and FaceTime calls with ease. 

Refernces:

Ma X, Yue ZQ, Gong ZQ, et al. The Effect of Diaphragmatic Breathing on Attention, Negative Affect and Stress in Healthy Adults. Front Psychol. 2017;8:874. Published 2017 Jun 6. doi:10.3389/fpsyg.2017.00874

Russo MA, Santarelli DM, O’Rourke D. The physiological effects of slow breathing in the healthy human. Breathe (Sheff). 2017;13(4):298-309. doi:10.1183/20734735.009817

Diaphragmatic Breathing. https://my.clevelandclinic.org/health/articles/9445-diaphragmatic-breathing Last modified 2018 Jun 14. Accessed 6/28/20.

Johns, Catherine. Can You Really Speak Well Sitting Down. https://catherinejohns.com/can-you-really-speak-well-sitting-down/ Accessed 7/2/20

Muscles of respiration. https://www.physio-pedia.com/Muscles_of_Respiration#cite_note-:0-2 Accessed 6/25/20.

 

Prevent Osteoporotic Hip Fractures with Exercise

There are two main ways to prevent a hip fracture by using exercise: Decrease your chances of falling and Strengthen your bones.

Additional ways to prevent fractures are through diet and medication (which we will discuss in future posts)

Decrease your fall risks

90% of hip fractures are due to falls so improve your strength, balance, posture and environment to prevent a fall!

Below are three “modifiable risk factors” for falling which we can eliminate with exercise…

1) Weak quadriceps, also known as thigh muscles. Decrease this risk of falling by strengthening your legs…

One of the best exercises for your legs is going from sitting to standing, also known as a “squats”. If you may lose your balance/fall back, place a chair behind you, and squat to near the chair seat level.  The lower the chair the harder the exercise!

Photo by Andrea Piacquadio on Pexels.com

After you perform this 8-10 times your legs should be tired. If they are not tired it is too easy and you may need to find a lower chair or add some weights. You could wear a fanny pack and put a few cans in it or hold some weights.

 

2) Poor balance. How do gymnasts get better and better on the balance beam? PRACTICE PRACTICE PRACTICE! Balance improves with practice.

Try practicing your balance by standing on one leg.

If this is easy try standing on a wobbly surface such as a pillow. Make sure your pillow is not slippery or on a slippery surface. A wobble will challenge your balance and help you improve however we do not want you to fall. Have a counter or chair in front of you or next to you to hold on to if needed.

Once you have perfected standing on one leg, try closing one eye, the other eye and then both eyes. Then add the pillow again.

3) Poor posture

Be mindful of how you sit and stand through out your day. Try to sit upright as you read or use the computer and take breaks to move around every 20-30 min. Place what you are reading or typing at eye level so you do not have to look down or slouch.

Sit and stand with head over shoulders and shoulders over hips (picture 2) . Avoid rounding your back and having your head forward of your shoulders (picture 1).

Modify your home and environment for safety. Here are some ideas:

• Clear clutter through out the house. Including cords and objects hanging low to the floor which you may trip over.
• Have good lighting especially on porches, stairs and halls. Also if you have to use the bathroom in the middle of the night, make sure you have a light you can easily turn on by your bed.
• Tack down loose carpets and/or get rid of throw rugs.
• Place a sticky mat or stickers for bottom of bath tub. Install grab bars in bathrooms.
• Hold on to hand rails on stairs, keep hands free by using a fanny pack or a bag around your shoulder.
• Avoid or prepare for Slippery conditions – For example if its snowing or icy, carry a bag of salt, sand or cat litter in a plastic bag so you can sprinkle it on stairs or slippery patches.
• Clothing, avoid long pants you may trip over. Avoid slippery or loose foot wear such as flip flops or slippers.

Strengthen your bones! Prevent bone loss. 

To strengthen the bone that tends to break in the hip (the neck of the femur) impact is required. Walking is great way to get some impact into your bones, fast walking is even better. Wear comfortable and sturdy walking shoes. Gradually progress to avoid injury and challenge yourself. To improve bone strength you must challenge the bone more then it is used to, so walk faster, longer or add some hills. It is recommended to walk at least 30 min 5 times a week to strengthen bones.

Although swimming and biking are great exercises, since there is no impact these exercises will not be very effective for preventing fractures.

Try the National Osteoporosis 10,000 step challenge! NOF.org

In addition to impact, strengthening all the muscles of the hip is helpful to decrease bone loss in the total hip (such as the greater and lesser tubercle of the femur).

Try some side leg kicks and back leg kicks. Hold on to the back of a chair or onto a counter. Stand very tall pull your tummy in and keep breathing.

• Kick your right leg out to the side 10 times
• Kick your left leg out to the side 10 times
• Kick your right leg back 10 times
• Kick your left leg back 10 times

If this is easy, add an ankle weight to your ankle. Remember keep breathing and be mindful of your posture. Stay safe and have something sturdy to hold on to.

Have a healthy and bone safe May! Keep moving.

Check out all our bone building activities Facebook and instagram:@elementscenter or on our website http://www.elementscenter.com

Justine

 

Leading with the pelvis part 2

Leading with the pelvis:

part 2

In my last blog I discussed the pelvis and strengthening and mobilizing the hips to get the pelvis over the feet. In this blog, part 2, its time to transition the floor exercises to standing with the pelvis underneath the trunk and over the feet. As usual it has taken me a little longer then promised, the body is so incredible and I started getting inspired by other aspects of the hip and how it relates to gait and the feet (bunions and fallen arches etc) and my “keep it simple” resolution went out the window. So months later here is part 2, I’ll save the other stuff for future blogs. Enjoy…

 

My favorite standing hip exercises… Keep in mind the intension is to elongate the spine and walk with ease, keep this idea in your mind when performing the exercises. Stay mindful and curious, these should be fun.

 

Standing

 

~ Side step ups: start with straight knee

Don’t do too many of these, they can irritate the glute med tendon which is often misdiagnosed as “hip bursitis.” Use this exercise as a “ah-ha moment” notice if one side is easier or harder to prepare for stabilizing in the next step up exercise. Try 4-5 reps on each side, once you “have it” move on.

1) Allow your left foot to drop along side the step, sink into the right hip.

2) Now use the muscles in the right hip to make your feet even. Don’t put weight on the left foot. Just even out the pelvis. Notice if you feel your hips are even, are your feet even? Often there is one side where even may not feel even. 

 

 

 

 

 

 

 

~Step up with bent knee: Now step up and keep hips even (photo 2 above), bend and straighten the standing leg without sinking into your hip. Try 10 reps on each side, repeat

This action (right hip abduction) is required to prevent excessive hip drop during while walking. (“Trendelenburg gait”)

Here is a picture with hips even and leg out to the side

Variation: step up with leg abduction – add hip abduction with out compressing the spine. Bend right knee, keep pelvis even, then when you straighten the right leg lift the left to the side. This series helps prevent too much lateral shift (the model walk from leading with the pelvis part 1) and allows the pelvis to move forward when walking. You can either add abduction for your second set, or just try two sets of these.

 

wrong: Notice in this incorrect picture the left hip is hiked up and she is starting to bend and twist the spine. 

 

 

 

 

 

~Lunges – hip flexor stretch with glute strength

Get into a lunge position, bend and straighten the front leg. Keep the back knee soft and draw abdominals in towards the spine to avoid stress and compression in the low back. Keep your hips square forward like headlights, avoid twisting, feel a stretch in the front of the back thigh. People with tight hip flexors are prone to low back pain.

variation, stretch only: ~Hip flexors stretch – seated lunge. If it is too difficult to stand this can be performed sitting on the side of a chair. Or hold on to a chair for balance.

 

 

 

~Squats

Standing squats are helpful for every day activities, great leg exercise, and you can do them anywhere. As you sit back release the gluteal muscles allow the femur to slide and roll. As you stand the glutes will kick in when needed, avoid over using the glutes and tucking the tail, this will put extra pressure into the knees. At the end stand up and elongate the spine. 10 reps, 2 sets

Notice Zelda, our skeleton, approves of this alignment

 

 

How does leading with the pelvis transfer to walking?

Thinking of propelling yourself forward from your sacrum, the triangle bone between the two sides of the gluteal muscles, this will help activate hip extensors when walking. Note this is NOT a tuck of the pelvis nor is it a leaning back of the shoulders. It should almost feel as if you are falling forward like a rocket ship taking off. Often we see people leading with their chin or shoulders and, even more now with the texting posture, leading with the top of the head. This puts tremendous pressure on the neck and upper back. If you need to text while you walk lift your device to eye level.

Play with walking postures. Try walking with your chin forward (“forward head posture” or “sway back posture” D) take a moment to feel where stress starts gathering. Now try leading with your belly button (“increased lumbar lordosis”also “forward head posture” B.) Feel your low back starting to gather tension? Now try looking down with rounded shoulders and walking forward (“texting posture.” C) Lastly, stand and feel your weight drop into the center of your foot, feel your pelvis neutral a sense of the pubic bone leading with out tucking, feel your head floating up, allow natural rotation and swinging of the arms; now walk as if someone is gently pressing your sacrum forward (“good posture” A). Feel lighter?

Enjoy exploring walking from the pelvis. Next time we will visit the feet…

 

 

 

Next blog… More on the foot, avoid bunions and lift those arches.

Leading with the pelvis

Lately I’ve been fascinated by the gluteal muscles, possibly due to a Gyrotonic® principal, “wrapping of the sacrum”, which clinically I have seen help multiple people with SI joint and low back pain or possible due to my gradual decline in the posterior perkiness of my behind as I sit more and more in the massive Washington DC traffic. However, I would like to believe my fascination is due to a rare gradual anterior hip subluxation in one of my patients and a unique weakness in internal rotation and abduction without external hip weakness in another patient, her compensations were quite remarkable prior to treatment. Whatever the inspiration here are some thoughts on the behind and how it should lead us through life.

While we explore the amazing orchestra of the human body, we cant ignore the components of the deep fascial structures, the neural tissue and the vascular supply that are interwoven through out the muscles and bones however as I’ve been told many times “keep it simple stupid.” Thus, I will do my best to focus on the major muscles of the hips and leave out some of the structures around the hip. Please note, I do realize this is like having an orchestra of drums and violins and leaving out the flutes and harps.

Altered mechanics and firing of the gluteal muscles around the hip have been shown in people with chronic low back, hip pain, knee pain (altered patella tracking, increased risk of ACL tears) and even ankle sprains. Much like the rotator cuff of the shoulder/ humeral head, the gluteus muscles help to stabilize the femur in the hip socket. Gluteal stretching, tissue mobility and strengthening is an important part of any spine and lower extremity rehab program. In order to fix these mechanics lets start with a short review of the anatomy and function of the muscles:

The major superficial muscles of the hip are:

1) Gluteus Maximus –primarily a powerful hip extension, attaches from iliac crest down to top 1/3 of femur (not just to the gluteal fold, down the leg!), antagonist to psoas

2) Gluteus Medius – hip abduction (pelvic stabilization in gait) and internal rotator

3) Gluteus Minimus – hip abduction and internal rotation (similar to medius)

4) Tensor Fascia Late – hip abduction and internal rotation and knee stabilization and pelvic stabilization in gait

When the leg is up in the air (not attached to the ground) abduction will look like this…

Note the waist will be off the floor with proper abduction, if the waist is on the floor then this is spine bending not leg lifting. Keep in mind average hip abduction range is 30-50 degrees, you will not be able to kick very high

 

When standing on the leg abduction will keep the pelvis neutral. In the photo below the left hip abductors are working to keep the pelvis level….

not like this (aka “model walk” or “Trendelenberg gait”), with the right hip dropped and the left leg in relative adduction…

 

The 6 deep muscles of the hip are:

1) Piriformis (acts as an internal rotator in flexion/sitting, external rotator in extension/standing)

2) Gemellus superior and 3) Gemellus inferior

4) Obturator Internus and 5) Obturator externus

6) Quadratus Femoris

The above 6 muscles turn the thigh bone, femur, out in the hip socket, acetabulum, (lateral or external rotation) and with the tendons, labrum and ligaments help stabilize the femur. They have been referred to as “the rotator cuff of the hip” (you may have heard of rotator cuff injuries in the shoulder). Our feet naturally strike the ground at about 15 degrees of external rotation or “toe out” (norms range from 7 to 25 degrees) thus these deep lateral rotators are extremely important in supporting the thigh bone in gait and may even prevent osteoarthritis in the knee (4).

So that’s 10 muscles on each cheek!

 

Now that the anatomy lesson is done…

Here are Favorite floor hip Exercises:

Supine/ lying on back

1a) Bridges double (with two feet on floor)

or

1b) Single leg variation (with one foot on floor and one in air)  for hip extension

a glute max pick me up.

Keep knees in line with feet. Start by pressing feet into floor, roll shoulders back, lift hips. Feel the knees reaching away so there is no compression in low back. Make sure to activate the gluteals! If 10 reps feels easy, try lifting one leg and do 10 bridges on each side.

Single leg bridge, the more advance version, keep abs in and hips level

2) Figure 4 stretch lateral rotators, repeat this exercise again at the end of your gluteal routine. The goal is a strong butt not a tight one.

This photo shows a seated version. If you just finished your bridges then try it lying down on your back. Note keep spine long and feel the stretch in the outer hip of crossed leg. Hold 20-30 seconds to allow tissues time to stretch.

3) Turned out bridge, Hip abduction and ER – “wrapping the sacrum” in Gyrotonic® method or “grand plié” on back in floor barre, feel the sacral/medial fibers of deep rotators activate.

lie on back, open knees and activate glutes, while stretching inner thighs

 

Prone/ lying on belly

4a) Opposite arm and leg in supine or quadruped – thoracolumbar fascia into glute max and hamstrings for hip extension and lumbar/pelvic stability, multi tasking the superficial back line in one exercise.

Lift one arm and opposite leg on an exhale, draw abdominals in tight. Note this model is a ballet dancer, your legs and arms may not go as high, dont force it. The goal is to feel the muscles along your spine and gluteals contract in a joyous way. You should not feel pain or compression in the back. alternate sides and repeat 10-15 times until fatigued while maintaining good alignment.

4b) hip extension in quadruped, aka leg lifts on all 4s

here is another version on hands and knees. Keep hips square with pelvis level to floor, no twisting of the spine

Side lying/ lying on side

5) Hip abduction in flexion neutral pelvis, the standard “clam shell”. Lie on side with knees bent open and close top knee, keeping feet together.

6) Hip abduction with hip extension neutral pelvis ( Prefer this exercise over clam shell since we often need the abductors in standing when the hip is neutral or in extension)

Lift top leg up and down, keep waist long and lifted, feel glute med contract 10 reps 2 sets. If this is too easy try going into a side plank and then do side leg lifts in the plank position.

6b) Leg swing: hip flexion and ext while maintaining abduction, same as position above however swing leg forward and backward. keep abs tight.

(Repeat fig 4 exercise #2 stretch from above)

The next post will look at translating these floor exercises into standing and walking! Try the above exercises to prepare for the next post. I recommend you choose 4 of the above exercises to do 2 times per week and alternate them in order to work the muscles at different angles and to challenge your balance and strength.

Enjoy your fabulous body, until next time.

Warmly,

Dr. Justine

References…

_____________________________________________

1) Br J Sports Med. 2013 Mar;47(4):193-206. doi: 10.1136/bjsports-2011-090369. Epub 2012 Jul 19.

Factors associated with patellofemoral pain syndrome: a systematic review.

Lankhorst NE¹, Bierma-Zeinstra SM, van Middelkoop M.

“Less hip abduction strength, lower knee extension peak torque and less hip external rotation strength”

2) Int J Sports Phys Ther. 2014 Aug;9(4):468-75.

Patellofemoral pain subjects exhibit decreased passive hip range of motion compared to controls.

Roach SM¹, San Juan JG², Suprak DN², Lyda M¹, Boydston C¹.

Hip extension range: “Control group was 6.8° bilaterally. For the PFP group, the mean hip extension was -4.0° on the left and -4.3° on the right.”

3) Arch Phys Med Rehabil. 1998 Apr;79(4):412-7.

Back and hip extensor fatigability in chronic low back pain patients and controls.

Kankaanpää M¹, Taimela S, Laaksonen D, Hänninen O, Airaksinen O.

“The chronic low back pain patients were weaker and fatigued faster than the healthy controls. The EMG fatigue analysis results suggest that the gluteus maximus muscles are more fatigable in chronic low back pain patients than in healthy control subjects during a sustained back extension endurance test.”

4) Ann Rheum Dis. 2007 Oct; 66(10): 1271–1275.

Published online 2007 Jan 31. doi:  10.1136/ard.2006.062927

PMCID: PMC1994298

The relationship between toe-out angle during gait and progression of medial tibiofemoral osteoarthritis. 

Alison Chang, Debra Hurwitz, Dorothy Dunlop, Jing Song, September Cahue, Karen Hayes, and Leena Sharma

My 5 favorite post workout snacks, and easy too!

• 1) Water, water, water

Many people don’t drink enough water. If you loose weight during a workout it is from loosing water not fat. Humans consist of 60-70% water. It is essential for many functions of the body including lubricating joints (prevent arthritis), breathing and sweating, excreting waste, and carrying nutrients. Drinking water has been shown to help loose weight, decrease constipation, increase energy, and prevent and reduce headaches. Drink water before, during and after exercise.

• 2) Almond Butter & Apple Delight:

Slice 1 organic apple and spread organic almond butter on the surface. Keep the apple skin on for increased fiber. Almond butter is higher in protein then peanut butter and less risk of inflammation from a sensitivity or allergy reaction. That being said, peanut butter is a less expensive and healthy option if preferred.

• 3) Amazon Trail Mix

Take 2-3 Brazil nuts, dried coconut slices, dark chocolate chips and blueberries and mix it in a bowl. Fiber, protein (Leucine*), good fat, and a little caffeine kick from the chocolate. Yum

• 4) Almond butter and Jelly Sandwich (remix)

Take one tablespoon of organic almond butter and one tablespoon of your favorite fruit-only jelly (without added sugar) and spread them in between two slices of low GI whole grain bread. Easy to pack and brings back nice childhood comfort-food memories.

• 5) Nutty Yogurt Parfait

Take ¼ cup of Greek yogurt, add walnuts, and your favorite sliced fruit. Get one of your 3 servings of dairy requirements per day plus Leucine* from nuts and fiber from fruit (reminder daily recommended amount of fiber for a woman is 25 grams!)

*Leucine, an amino acid, has been shown in several studies to stimulate protein synthesis, help turn on the body’s switch to build muscle and spare muscle when dieting and post workout. Leucine is an essential amino acid, which simply means our bodies cannot produce it and we must get it from dietary sources such as mean, nuts, and dairy. Research suggests to eat 0.2g/kg body weight of protein after a heavy training session.

For more healthy snack ideas visit Nuts.com . Check out their “NUTritious” facts and the ways to restore your energy with high protein picks!

Here’s a picture of me working out.

A quickie before my next hip post…. Avoiding injury is the key to building bone

Sorry I have not posted in a while! Ive been deeply focused on the hip and pelvis at work. I still have to enter some pictures into my next hip blog before I post it. Until then here is a short statement to chew on…

When building bone through exercises one important thing to consider is avoiding injury. There is a fine balance between gradually increasing the difficulty (good stress) of an exercise on bone and too much stress causing “bad pain” and injury.

Listen to your body and focus on the following three components…

1) Alignment – the resistance you use should be at an amount where you maintain proper alignment. In general the spine should be elongated, the shoulders rolled back and the knees should point in the same direction as the toes. You want to try to lift a weight that is challenging enough where you can maintain good alignment yet fatigue after 8-12 repetitions.

2) Feel the burn in the muscles NOT pain in joints – The “burn” when lifting weights is the normal lactic acid by product in the muscles from an anaerobic energy state. The muscle burn is not necessary for building bone but a good sign you are working hard. The burn should occur after around 8 repetitions. If you feel the burn sooner try warming up more with a light weight or some cardio, then try lifting an appropriate weight where the burn occurs between 8-12 reps. A burn after 3-4 reps puts you at a higher chance of injury such as a muscle strain causing searing pain in the muscle (it could take 12 weeks to recover!) You should not feel sharp pain or pain in a joint. For example in the knee, a sharp pain could be from the patella (knee cap) rubbing on the femur (thigh bone.) this is not a pain to “work through,” stop, check your alignment, stretch and/or lighten the weight. Burning pain when not working out is a sign of an injury and could be due to a nerve impingement, this too is not a pain to work through.

3) Enjoy the workout – when you enjoy what you are doing, you will return for more! Consistency is key.

Spend time with your feet, fix and prevent ankle sprains…

It was the end of a full day and I was carrying many things when I stepped on the edge of the sidewalk, my foot twisted sideways over the edge and boom, down I went. So with a scraped bloody knee and throbbing pain in my ankle, I sat for a moment and was inspired to blog. Once the nausea eased up, I cleaned up and bandaged my knee and iced my ankle. After icing, I diagnosed myself with a lateral grade 1 ankle sprain. Phew, nothing major.

An ankle sprain happens when you quickly over stretch the ligaments and tendons around your ankle. The most common ankle sprain is a lateral or inversion ankle sprain when one lands on the outside of the foot as I did. The classic ankle sprain involves the anterior talofibular ligament (ATFL) and sometimes the Calcaneaofibular ligament.

Ankle sprains are divided into three levels of injury:
Grade 1- Over stretched ligaments but not torn. People may be able to walk with out pain but it hurts to stretch or touch the area associated with minor swelling.
Grade 2 – Ligaments partially torn, swelling and pain to touch or stretch. People return to normal activity in 10-18 days depending on the activity.
And
Grade 3 –A fully torn ligament which could be combined with a fracture as well. Often people experience extreme pain and cannot walk. Often requires crutches and sometimes a boot. Medical intervention is recommended to rule out a dislocation, syndesmosis (injury to a ligament that connects the tibia and fibula) or a fracture.

If you have pain in the midfoot or bone tenderness at the fifth metatarsal (outside midfoot) or at the navicular bone (inside midfoot), or inability to bear weight for four steps, an x-ray is indicated.

Most people heal without medical intervention. The standard of care is to get rid of swelling with P.R.I.C.E. Protection, Rest, Ice, Compression and Elevation. This will greatly decrease the pain. Protection avoid hitting it or re injury to the ankle by using protective tape, bandage or brace. Rest the ankle and don’t perform anything that causes pain or puts the ankle at risk for re-injury. For example, If jogging doesn’t hurt start jogging short distances, use an ankle support and run on even surfaces or predictable routes you know well. Of course, if jogging does hurt, continue to rest and stick to walking or a non-painful activity. Ice with frozen veggies or a plastic bag with ice cubes and some water 15-20min. There are fancy ice packs out there but often not necessary. For Compression have a trainer or physical therapist tape your ankle or the local pharmacy probably has an ankle compression stocking. An old pair of tight hose or dress sock may do the trick if tight enough. Elevate by putting your foot up on a comfortable surface.

After PRICE if still painful and once the swelling is down, a medical practitioner will do ligament testing to make sure the ligaments are intact. There is much evidence to suggest that for lateral ankle sprains a short period of protection and early weight bearing should be followed by range of motion and neuromuscular training ASAP. Early functional treatment leads to the fastest recovery and least rate of reinjury.(2)
The risks for an ankle sprain are: a previous ankle sprain, weak ankles, shoes that are too small or worn down on one side, uneven sidewalks, sports that require side to side shifting (tennis, foot ball, basket ball…) and fatigue.
In order to prevent ankle sprains wear shoes that fit and aren’t worn out. The general rule of thumb is to replace sneakers every 6 months or alternate two different pairs over a years time. If you are very athletic you will need to replace your shoes more often or have more pairs, if you are less athletic or exercise bare foot (yoga, Pilates, GYROTONIC® exercise) then your shoes will last longer.
Keep in mind a previous ankle sprain puts you at risk for future sprains in the same ankle and in the other ankle. (1) It is important to re-train and strengthen your ankles.

Here is a program to prevent initial injury or to prevent re-injury. Many of these exercises will also be given in physical therapy to rehab an ankle sprain.

Ankle mobility:

Circles – For range and mobility put your foot up on a stool and circle the ankles in both directions. 5 slow large circles in each direction. Progress to circling your foot in a bucket of sand or rice.

Alphabet – For more of a challenge and to increase endurance draw the alphabet with your foot. Make big letters and perform exercise on both sides.

Retraining Balance – Stand on one foot, eyes open. Repeat with eyes closed make sure there is something to grab and prevent falling.

Repeat on pillow – To challenge your balance more, stand on pillow (uneven surface) first with your eyes open. Progress to closed eyes (make sure you are in a safe environment to prevent falls). Your ankle should fatigue with this above exercise. Your body is re-learning how to correct and weight shift to right your self and maintain balance.

Dynamic Balance-

Stand on the floor, on one foot and bend knee and hips to pick up an object from the floor.

To increase the challenge repeat on pillow. Make sure pillow is on a surface where it wont slide.

Repeat on thicker/higher pillow

Keep in mind a loss of balance is good for retraining the ankle and motor control centers to improve balance, falls are not. Choose an appropriate exercise to challenge your current level of coordination and balance.

Calf and ankle stretch and strength:

Eccentric Calf raises – On a step rise up to toes and slowly lower down, hold stretch, repeat rise up slowly lower down.

Theraband inversion and eversion – this is exercise is to strengthen the muscles and tendons around the ankle.

Wrap band around outside of working foot and under non working foot, hold band. Press working foot (in this picture the right foot) into band until muscle is felt on outside of ankle and shin. Start with 5 reps 2 sets and build to 10 reps until strength is restored.

This is a closer photo of the eversion exercise to strengthen peroneal muscles around were the ligaments were over stretched during the injury.

Directions wrap band around outside of working foot and under non working foot, Press top working foot into band until muscle is felt along inside of ankle and shin. start with 5 reps 2 sets and build to 10 reps until strength is restored.

Myofasical release/massage:

Take care of your feet massage them with lotion or oil and wiggle your toes.

Take good care of your feet. They are important for many daily activities including balance! Your ankles have a direct link to areas of your central nervous system responsible for knowing where you are in space so keep them happy.

Warmly,

Dr. Justine
1) Int J Sports Phys Ther. 2014 Oct; 9(5): 583-95.

Injury risk is altered by previous injury a systematic review of the literature presentation of causative neuromusclar factors.

Fulton J, Wright K, Kelly M, Zebrosky B, Zanis M, Drvol C, Butler R

2) Ortho Rev (Pavia). Jan 2, 2012; 4(1):e5.

Diagnosis and Treatment of acute ankle injuries: development of an evidence-based algorithm

Polzer H, Kanz K, Prall W, Haasters F, Ockert B, Mutschler W, Grote S.

Reviewed

Exercise and improve your posture during your commute

I recently moved and now have a long commute to work. I’m not a person who likes sitting still for very long, so I thought I would share some exercises to keep you busy and improve your posture while sitting in the car.

These are isometric exercises, which are often used in posture training because postural muscles must work for extended periods of time. Thus, isometric endurance training is helpful to train your muscles to work while sitting at the computer, driving a car, washing dishes, etc.

For all the exercises, sit forward in your seat; do not lean back. (see last photo in this blog)

Start by exhaling and engaging core muscles then contract for the isometric exercise. Continue to breath normally. 

Note: Isometric exercises can raise blood pressure. For this reason I prefer to stick with short duration multiple repetitions: 3 sec hold and 15-20 reps.

Always listen to your body. Stop if you feel light headed or dizzy and of course pay attention to the road. The exercises should make you more alert and energized.

 

Trunk:

1) Sit forward in your seat. Inhale and lengthen your spine. Drop the chin and lengthen the back of your neck.

Exhale deeply and contract the core muscles (pelvic floor, transverse abdominals, obliques, diaphragm, back extensors – see previous blogs for details) by drawing in the tummy while continuing to lengthen the spine upright. 

Repeat, allow the belly to expand as you passively let the air rush in (inhale), exhale and contract the core muscles while maintaining a wonderful elongated spine.

Repeat 15-20 times

 

Upper body:

1) For pectorals, open elbows at a comfortable height press into the wheel. Inhale to prepare, exhale to engage core lengthen spine and press hands in.  Feel your long upright spine and a contraction of the front of your chest and shoulders.  Keep breathing normally and hold 3 sec. Relax and repeat 15-20 times.

 

 

2) For rear deltoid and peri-scapular muscles – hold wheel and pull elbows wide. Feel the muscles in your upper back and shoulders contract. Continue to maintain upright posture sitting forward in your seat.

 

3) Repeat 1^st exercise with arms at a lower angle and push in and up into the wheel. Continue to exhale engage abdominals, inhale lengthen spine. Keep shoulders wide as you contract the chest muscles. 

 

4) Repeat 2^nd exercise with arms at a lower angle like on a rowing machine. Feel muscles between the shoulder blades contract but do not pinch shoulders together feel upright and wide through the back and chest.

 

 

Repeat entire sequence from the top. This is a nice 10 min series that will help you improve your posture and feel accomplished when you arrive at your destination. 

Enjoy, and continue to lengthen, strengthen and move.

Warmly,

Justine

elementscenter.com

 

Diastasis Recti – the separation of “six pack abs”

Recently, Elements has seen an influx of women and men with diastasis recti, a separation of tissues in the abdomen, resulting in a protrusion or bulge running vertically down the center of the tummy. The two options for treatment are a conservative approach, exercise, and non-conservative approach, surgery. I highly recommend finding a trained physical therapist or personal trainer before considering the surgical option.

Diastasis (a separation of normally joined parts) recti (the “six pack” abs, see picture below) is a condition in which the recti separate by a pathological amount, usually as a result of thinning and stretching of the linea alba, the narrow band of tissue that runs down the midline between recti. This condition happens most frequently with pregnant women. However, it also occurs in men with over-training of the rectus abdominis without the underlying support of the internal obilques, external oblique, transverse abdominis, pelvic floor and diaphragm. People with a history of abdominal or inguinal hernia may develop diastasis recti; also, asthma can cause altered breathing patterns, thus altering the unique stability of “the core.” The core muscles are the transverse abdominis (TrA), internal oblique (IO) and external oblique (EO) muscles, and the diaphragm and pelvic floor muscles; see image below and previous blog [https://elementsjustine.wordpress.com/2014/01/19/stability-with-gyrotonicr-exercise/]

In the picture above the linea alba is the vertical line of connective tissue where the belly button is.

 

Do you have diastasis recti? If you do a “crunch” (sit up) and see a bump or ridge running up the center of your abdomen, you probably do. This bump is a result of the separation of the rectus abdominis at the linea alba with a protrusion of underlying tissues. When you are relaxed and lying down, the bump recedes and leaves a gap.

Physical therapists measure the gap by the number of fingers we can fit into the separation. The goal is to have no more than a 1-2 finger separation. We also look at the recruitment and timing of the muscle firing and where there is expansion in the body with an inhale. When you inhale, the lungs fill and there is a natural rise of the belly. When you exhale, the belly falls, and that is the optimal time to contract the core muscles to avoid the separation of the linea alba.

When you contract the core muscles on an exhale, the deep core stabilizers help support the abdominal wall. In addition to preventing or resolving diastase recti, this also stabilizes the spine. The action of the rectus abdominis muscle is to flex or bend the spine forward, it is not designed to stabilize the spine. Thus when training the rectus abdominis it is important to engage the, TrA, IO, EO, diaphragm and pelvic floor to protect the spine and avoid excessive sheer on the disks. Keep this in mind when training the six-pack for beautification, it is pretty but not very functional. In people with diastasis recti, the rectus is often overworked without the support of the core muscles underneath.

A wonderful exercise for diastasis recti is to sit upright, either on the floor or on a short stool, with your back against a wall. If you are sitting on the floor, you may cross your legs or put them out in front. Pregnant women usually find it more comfortable to cross their legs. Breathe in and feel the belly expand, then breathe out and feel the belly flatten. As you exhale again, gently draw in the abdomen. If your shoulders rise or you feel tension or your pelvis tucks under you, then you are working too hard. Try again with a little less effort. If it is too difficult to start against a wall, try lying down (see blog on true core [https://elementsjustine.wordpress.com/2013/07/01/the-deep-transverse-abdominal-muscle-just-breath/ ] ). In the supine position, lying flat, gravity is working with you thus it is an easier position. In sitting you have to hold your body upright against gravity so it can be a bit more challenging. Whether you are sitting or lying down for the exercise, it is important to remember that drawing in the abdomen during the exhale is just part of the picture. The exhale also helps recruit the diaphragm and gently draws up the pelvic floor, as if stopping the flow of urine. This exercise can safely be done during pregnancy and after (once cleared by MD). Remember exercise pre and postpartum has been proven to prevent diastasis recti (see reference number 2 below.)

 

To challenge the pelvic floor, it sometimes helps to feel the contraction by doing the draw-in exercise while in a deep squat position. Stand with your feet wide and squat all the way down, then exhale and draw abdomen in while contracting the pelvic floor. This position stretches the pelvic floor and makes contracting a little more difficult and challenging.

The goal is to be able to recruit the “core” muscles in everyday life. Try doing the draw-in exercise while standing, while reaching for a glass and then try drawing-in walking. Again, as you exhale, draw in the abdomen by contracting the muscles in the front (TrA), the sides (IO and EO), the back (multifidus), the top (diaphragm) and the bottom (pelvic floor picture below). Keep in mind the draw-in should not create tension, just a feeling of support.

Enjoy moving your beautiful body and remember the body does heal!

For more information, contact Elements Fitness and Wellness Center at 202-333-5252 or email frontdesk@elementscenter.com

Warmly,

Dr. Justine Bernard

 

1) Sharma G, Lobo T, Keller L. Postnatal exercise can reverse diastasis recti. Obstet Gynecol. 2014 May; 123 Suppl 1:171S. doi: 10.1097/01.AOG.0000447180.36758.7a.

“Conclusion: Women who started after delivery an exercise program aimed at reducing diastasis recti achieved the same reduction in diastasis recti as those who started the program during pregnancy. (N=63)”

2) Benjamin DR, van de Water AT, Peiris CL. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014 Mar;100(1):1-8. doi: 10.1016/j.physio.2013.08.005. Epub 2013 Oct 5.

“Results: Eight studies totaling 336 women during the ante- and/or postnatal period were included. The study design ranged from case study to randomized controlled trial. All interventions included some form of exercise, mainly targeted abdominal/core strengthening. The available evidence showed that exercise during the antenatal period reduced the presence of DRAM by 35% (RR 0.65, 95% CI 0.46 to 0.92), and suggested that DRAM width may be reduced by exercising during the ante- and postnatal periods.”

3) pictures from wikipedia commons.

Stability with GYROTONIC(R) exercise

At Elements we have a monthly two hour “continuing education” teacher meeting. This last meeting was particularly inspiring. We discussed how Gyrotonic exercise addresses Lumbar and Pelvic stability.

Recently more and more people have walked through Elements Center’s door with a diagnosis of “hypermobility syndrome.” Some symptoms included back pain, torn capsules in hips and/or shoulders, achiness and fatigue similar to fibromyalgia. Hypermobile joints can be due to three primary reasons 1) a disease such as Ehlers-Danlos syndrome 2) Ligament laxity with certain body types often seen in dancers and gymnasts, you may be familiar with the “Gumby” type person 3) or compensatory hypermobility due to hypomobility elsewhere in the musculoskeletal system, for example if someone has a fused joint in the spine due to arthritis or surgery often the joints above and below the fusion are hypermobile to make up for the loss of range in the fused joints. In general hypermobile people present with excessive or extreme range of movement.

Of course we discussed the Gyrotonic principle of “Narrowing the Pelvis.” “Narrowing” consists of and isometric contraction of the core stabilizers such as the transversus abdominis, pelvic floor and multifidi to elongate the spine while supporting the pelvis. However, this very important and effective maneuver can take quite a long time to perfect before introducing movement safely to the hypermobile crowd. In a non-injured healthy body narrowing occurs naturally before movement. After an injury or altered mechanics narrowing needs to be re-learned. For more information on narrowing, please read my previous blog on the Transversus abdominis.

Above is a baby standing with a nice round belly and then below he naturally narrows, drawing in his abdominal stabilizers flat, as he prepares to go up on his toes.

Discussed next was the Gyrotonic concept of “stability through contrast.” Another wonderful principle in which one reaches through the spine or limbs in opposite directions to create stability just like a tightrope is stable in the middle because the two ends are pulled tight. This too is an effective way of creating stability so that movement can still occur. However, creating the sensation of internal traction for hypermobile people without hyperextending the knee or overstretching a capsule can be difficult for the beginner student to differentiate. In the beginning Gyrotonic students learn “leg pumps” by sliding the heel into the resistance of the weight while sitting on the floor. When done well the force goes right through the center of the bones through the heel, no pressure goes into the ligaments in the back of the knee.

Lastly and what we spent the most time on was “wrapping the sacrum” which goes along with “burying the sacrum.”  In physical therapy we teach creating stability in the sacroiliac joints through form closure and force closer of the sacrum. In form closure the bones of the sacrum fit into the bones of the ilium to create stability and in force closure the muscles, fascia and ligaments that connect to and over the ilium and sacrum create force on the sacrum into the pelvis. We all agreed many of the Gyrotonic exercises that involve wrapping the sacrum could be introduced to a beginner student or safely taught in a group class with a hypermobile student as long as the anterior labrum or psoas is not compromised/injured.  The “wrapping muscles”, deep external rotator muscles, also help stabilize the lumbar spine in closed chain movements such as standing phase of walking. Several people with instability of the lumbar spine present with weak gluteal muscles as well as weak deep abdominal muscles, if the ligaments are physiologically over stretched and the muscles are weak there is very little support for the pelvis, SI joints and lumbar spine.

Combining the narrowing with the wrapping of the sacrum allows for the anterior sheath connecting to the pubic bone (via external oblique, internal oblique and Transverse abdominus), the posterior diagonal sheath (gluteus maximus and biceps femoris), and the longitudinal sheath (multifidus, deep layer of thoracolumbar fascia and long head of biceps femoris in to the sacrotuberous ligament) to all support the low back and pelvis.

Some of the final ideas we drew from our meeting were:

-Limit the range until the concepts of narrowing, stability through contrast and wrapping the sacrum are practiced.

-Teach arch and curl series on the handle unit much later for the hypermobile clients. It was debatable if the benefits of moving the fascia, viscera and muscles through the arch and curl series seated on the handle unit out weight the risk of increasing range in the spine is even warranted in this population.  Begin with spinal motions on the stool maintaining a narrowed pelvis or even cat back series from Gyrokinesis until the student understands the range they can tolerate without loosing the strength to narrow and maintain an elongated spine through out the movement. Perhaps introduce arch and curl series facing the tower with resistance to help activate tone in the muscles or standing so the ligaments can stay elongated and the legs active to help maintain stability with movement, which is the ultimate goal.

– Use resistance to help create traction thorough hypermobile joints and strength through the muscles such as in traction series which consists of using heavier weights in a smaller range.

– Teach Psoas abdominals over simple curl ups to allow for less mobility and work to stabilize the spine against the pull of the psoas again if the hip labrum is not injured.

-Often at Elements we return to the homework series created by Paul Horvath for the scoliosis workshop. It requires stabilizing the pelvis with all of the above Gyrotonic stabilizing principles with emphasis on a slow three second exhale allowing the stabilizers including the diaphragm to coordinate and initiate prior to movement.

These ideas have worked in our practice but we only have antidotal evidence. I have heard many times that Gyrotonic exercise is too “stretchy” for my body, or Gyrotonic exercise doesn’t work for me I need more strength not more range. We at elements disagree, people with hypermobility are drawn to the Gyrotonic method because it feels good and works through out ones range. Hypermobile people can learn to stabilize with movement from an experienced instructor using the Gyrotonic method.

The staff’s conversation and practice went well beyond the 2 hours and continued via email. What we all agree on is that the body is an amazing creation with biodynamic, energetic and anatomical interrelationships that science has only begin to discover not to mention that 2 hours and a few emails just touch the surface of the benefits of the Gyrotonic method for people with hypermobility.

Lengthen, Strengthen, Move,

Justine