Category: Exercises

Don’t Forget Your Back

Most of us spend a large portion of the day hunched forward.  Think about when you are working on the computer, cooking, driving or even relaxing.  Your typical posture during these activities is head and neck forward, shoulders rounded forward, back curved and hips flexed.    When you remain in this position for an extended period of time, the muscles in the front of the body tend to shorten or contract, while the muscles in the back of the body tend to weaken.    This can be a set up for back, neck and shoulder problems and in addition, tends to make you look shorter, heavier and less confident.

Stretching before and after exercise as well as during the day is often overlooked in the rush to “get your workout in”.   Stretching however, has numerous benefits.   According to a study published in the Annals of Physical Medicine and Rehabilitation Medicine in September 2016, by I Fekhfekh, et al, dynamic muscle stretching of the knee musculature actually resulted in an increase strength gain in those muscles.  Interestingly, this study also found a decrease in the postural stability of the knee after stretching.    In English, it appears that stretching helps your to build strength, but may decrease the stability of the muscles you stretch at least temporarily.

In general, stretching helps to improve flexibility, joint range of motion, and usually is helpful for injury prevention.    Stretching helps by increasing blood flow to the muscles stretched.  This increased blood flow carries important nutrients to your muscles to allow for muscle growth and repair.  In addition, the increased blood flow helps to wash away muscle “waste” which leads to decreased soreness and inflammation of the muscle.

If allowed to remain in a contracted position for a prolonged period of time, our muscles will shorten.  For example if you spend a large portion of your day sitting in a chair or driving, the muscles in the front of the hips, your hip flexors will shorten.  These muscles have a direct effect on both your posture and your back health.

 

So what should you do?

It is important to stretch the muscles in the front of the body at least daily.

Exercises that focus on the hip flexors:

-Kneeling hip flexor stretch  – in the position of a lunge, allow your back knee to touch the floor and drive the hip of your front leg forward.  This will stretch the hip flexor of the knee on the floor

–Pigeon stretch – extend your right leg straight back and bring the heel of your left leg underneath your right hip.  Then drive your hips forward towards the ground.  Stretch and repeat on the other side.

– Yoga poses such as: low lunge, crescent lunge, upward facing dog, and revolving side angle pose

 

Stretches that focus on the chest muscles and prevent rounded shoulders:

– Door Frame stretch- stand in a doorway or at the corner of a room with your arms up like you were going to stop traffic.  Line your arms up from the elbow to the hand with the doorframe or in the corners of the wall.   Step towards the door and you should feel a stretch in your chest (pectoralis “pec” muscles) and hold for 20-30 seconds.

– Wall slides – stand with your back to the wall and keep your shoulders against the wall.  Walk forward 1-2 steps and slide your arms up and down the wall and squeeze your shoulder blades together.  You should feel a stretch in your upper chest muscles.

–Shoulder squeeze stretch –  clasp your hands together behind your back and slowly try to lift your hands.  Squeeze your shoulder blades together to stretch out the chest wall.

– Yoga poses include : bridge pose, camel pose, cobra pose and cow face pose

 

Stretches for your neck:

– Chin Tucks (Neck Retraction) – keep your shoulders back and your head in a neutral position (eyes facing forwards, chin level) slowly move your head backwards until you feel a slight stretch in the back of your neck.  Hold for 10-20 seconds and repeat.  If needed you can apply a gentle pressure on your chin with your fingertips to press your chin backwards and deepen the stretch.

Incorporating these exercises into your daily routine will help to prevent shortening of the muscles in the front of the body which leads to poor posture and often pain of the neck and back.  As always, if you are having pain which persists you should be evaluated by a certified health care professional to ensure that these exercises are safe for you.

This week we primarily discussed stretching exercises to prevent muscle contraction, and next week we will discuss the importance of strengthening the back muscles to further combat the issues of a hunched posture.

Common Causes of Knee Pain

The primary function of the knee is to bend and straighten the leg, to allow for a smooth gait during walking and running and to allow for jumping.    It is very common to develop knee pain in both new and seasoned exercisers.  Often the type of pain which develops is related to the type of exercise being done.

To understand knee pain, it is helpful to have a basic understanding of knee anatomy.

The knee joint can be divided into intra-articular and extra-articular compartments.

Intra-articular – structure inside the knee  joint

Extra-articular – everything else

The knee joint is where the surfaces of the leg bones meet and interact.  In order for the bones to move smoothly against each other and to provide additional stability, there is articular cartilage or cushioning shock absorber called the meniscus on both sides of the knee joint.  There are also many important ligaments which connect one bone to another and provide stability.  In addition, there are fluid filled sacs called bursae which allow for separation between solid tissues so that smooth movement can occur.

To help visualize the components of the knee, let’s break it down into 3 parts.

  • The anterior (front) of the knee
    •  Knee cap or patella
    •  Quadriceps tendon
  •  The medial aspect (side) of the knee  closest to the other knee
    • Medial meniscus (cushion)
    • Medial part of the joint capsule (the whole joint capsule encloses the entire knee)
    • Medial Ligaments  (provide stability for the knee and connect bone to bone)
  •  The Lateral aspect (outer) part of the knee
    • Lateral part of joint capsule
    • Lateral meniscus
    • Lateral ligaments

The knee is actually more complex then described above and does have the ability for rotation in addition to bending and straightening and other components not described above.  For the purpose of this article, we will focus on basic knee motions and components.

Now that we have a basic understand of the knee, let’s focus on what can go wrong with the knee.

In general, knee pain can be caused by:

  • Injuries due to trauma
  • Overuse injuries due to
    • Body misalignment
    • Muscle imbalances
  • Degenerative conditions
  • Injuries in the hips or feet

Patellofemoral syndrome (Anterior knee pain – front of the knee)

Common in new exerciser, especially runners and jumpers.  This is usually due to irritation between the patella (knee cap) and femur (thigh bone).  This pain can occur with increased jumping, squatting, running and climbing stairs.  Usually pain occurs if there is repeated stress on the knee or if there is a sudden significant increase in physical activity.   It is often treated with rest, ice, elevation and compression (RICE) and specific exercises to strengthen muscles surrounding the knee, and core.

Structural Injuries 

Knee injury can also result from structural changes or damage such as a dislocation, slippage or tears of the menisci or ligaments surrounding the knee.

Meniscal Injuries – The meniscus serves as a shock absorber for the joint.  Injuries of the meniscus can be the result of a twisting injury and can cause considerable pain, joint swelling, difficulty with stairs and the sensation of locking of the knee.  Occasionally the pain in the joint due to meniscal injuries will cause the brain to “shut off” the quadriceps at the knee causing the knee to “give way”.

Ligament Injuries – Ligament tears, such as a tear of the ACL (anterior cruciate ligament) can occur with a twisting injury and results in knee instability and may require surgical intervention depending on the degree of the tear.  It is common to sense a “pop” and immediate leg instability with this injury.    If surgery is used to repair the ACL, recovery is long and only low impact exercises are recommended initially to strengthen the muscles around the joint.  In contrast, PCL (posterior cruciate ligament) tears often can be treated non surgically with physical therapy and if indicated bracing.   When ligaments are torn or lax (loosened) it is common to have the sensation of poor balance or joint instability.

Tendon Injuries – Tendons are tissues that connect muscle to bone.  Typically, complete tendon ruptures are abrupt and result in the inability to move the joint.  The quadriceps tendon is quite large and a significant amount of degeneration must be present for it to rupture.  More often this injury is the result of a high force injury.   A completely torn tendon requires surgical intervention, but a partially torn one, will likely heal with immobilization followed by physical therapy.

Overuse injuries

Overuse injuries such as bursitis (inflammation of bursae), tendonitis (inflammation of the tendons), muscle strains, and Iliotibial band syndrome are usually the result of repetitive stress on a muscle, tendon or bursa.  Usually there is a component of body malalignment, muscle strength imbalance, improper shoe wear, or poor form which leads to the development of these conditions.  Treatment may include RICE (rest, ice, elevation, and compression) along with a detailed musculoskeletal exam to determine the etiology of the injury.  This will allow for a proper treatment plan to prevent recurrence.

Arthritis

Arthritis can be divided into Osteoarthritis (wear and tear), Rheumatoid (immune mediated), Gout (due to gout crystal build up) and Septic (due to infections).   Arthritis may be the result of poor diet or gluten sensitivity in some individuals.   While some forms of arthritis are genetic, diet modifications, weight loss, proper shoe wear and exercise may help to offset the severity of these conditions.

Exercise Through The Pain Versus Get It Checked?

As an individual either new or returning to exercise it is very common to sustain injuries.  Most often injuries occur in the joints such as knees, hips, feet, low back, neck and shoulders.   Although there are numerous reasons for injuries, the most frequent injuries are a result of poor body alignment, overuse injuries, increasing exercise duration or intensity too quickly, unequal strength that develops in opposing muscle groups, and improper shoe wear.

The warm up before exercising is very important because it allow for an increase in blood flow to the muscles.  Red blood cells carry oxygen, a requirement for muscle function.  As you become more “fit” your muscles get better at extracting oxygen from the blood.   In addition to carrying oxygen, the increased blood flow to the muscles helps to “wash away” hormones and neurotransmitters that can build up in the muscles and cause irritation and pain.

Pain is an adaptive mechanism that the body uses to prevent injury.  For example, if you put your hand near a fire you will sense instant pain and reflexively pull your hand away to prevent a burn and limit further damage.   In this case the sensation of pain in beneficial.

The pain pathways are very complex and the body has a remarkable way of increasing and decreasing pain sensation.  When you bang your leg and develop a bruise, the bruise and the surrounding areas become exquisitely sensitive.   Due to the release of certain substances, the body is able to up-regulate the sensation of pain.  Over time, as the bruise heals and the swelling decreases, the sensitivity in that area returns to baseline. However, sometimes the pain system can go awry.

In some cases, there is an acute injury that causes increased pain sensitivity, but instead of the pain receptor sensitivity returning to normal over time, they remain ultra-sensitive.  Even though there is no longer a reason for the sensation of pain to be generated, the body gets “confused” and can interpret sensations of light touch, heat, cold, or pressure as pain.   In this instance, the pain is no longer adaptive nor beneficial.   This malfunction is often seen in individual with chronic pain.

In my mind, there are two types of pain, “safe pain” and “dangerous pain”.   Safe pain to me, is pain that does not indicate worsening damage, cancer pain, or harmful injuries.  Safe pain is pain that often gets better during exercise and mobility.   In contrast, dangerous pain is pain that indicates a significant issue that needs prompt attention.   Some examples of dangerous pain include but are not limited to:

A fall or high-speed injury resulting in immediate severe pain and the inability to bear weight.  This pain can indicate conditions such as fractures, ligament injuries, or instability.

Chest pain or heaviness which occurs during exercise should never be ignored.  Typically, cardiac pain is described as chest tightening or pressure which often radiates down the right arm or into the jaw.  However, in individuals with diabetes, chest pain can be atypical and present like indigestion.  Chest pain is a medical emergency and should be evaluated immediately.

Neck or low back pain with associated numbness, tingling, or weakness should also be evaluated promptly.  In addition, any neck or back pain associated with bowel and bladder symptoms such as difficulty controlling urine, loss of sensation or funny sensation around the buttocks, and/or constipation and loss of bowel control needs to be addressed by a doctor.

The general rule of thumb is that pain which worsens incrementally with activity, persists despite rest, or is associated with numbness, tingling, radiating pain down arms or legs should be evaluated by a trained medical professional.   Pain that improves after a few minutes of exercise and is not associated with the above mention symptoms will often improve in its own.  Again, it is most important to listen to your body.  If you feel that “something isn’t right” or your symptoms are not improving you should  go with your gut and have your symptoms evaluated.

Eating Time With Regard To Exercising

To answer this question, I have been reviewing the literature on this topic and it appears that there is not a general consensus on this subject.  The answers, which are still up for debate seem to depend on the goals you are trying to achieve.   It appears that not only the timing of meals, but the type of meals, and the timing of exercise plays a role on the metabolic effects.

In an animal study by Sasaki published in Nov 2014, his findings suggest that eating in the morning and exercising later in the afternoon or evening has a more beneficial effect with regard to body fat and weight gain.  In the group that ate early and exercised later, the was less body and fat weight gained.  In addition, there was an increase in skeletal muscle weight gain.    So according to his findings, eat earlier in the day and exercise later for increased fat loss and increased skeletal muscle weight gain.

Bo published a study in Dec 2015 in the International Journal of Obesity that found that the same meal consumed in the evening resulted in a decreased resting metabolic rate and increased insulin response. In English, this means that you will essentially burn more Calories by eating a meal in the morning then you would by eating the same meal in the afternoon or later evening. Furthermore, multiple studies have observed that skipping breakfast is correlated with obesity, elevated BMI (body mass index) and increased waist circumference.

According to KJ Hackney in a study published in the journal of Medicine and Science in Sports and Exercise, consuming protein before heavy resistance training (weight training) results in an increase in resting energy expenditure (increased metabolism) as compared to consuming carbohydrates prior to heavy resistance training.   Other research suggest that whey protein is beneficial because it is fast absorbing and contains branched chain amino acids, specifically leucine, which has anti-catabolic (muscle breakdown) and increased anabolic (muscle building) signaling.

For trained athletes who are competing in endurance (long time or long distance) exercises, the recommendation at this time is to consume low glycemic carbohydrates or complex carbohydrates such as oatmeal, heavy mixed grain breads, or most vegetables.  Exercising in a fasted state compromises fuel stores and results in less than optimal performance.    There is also some research to suggest that high fat or even protein intake before exercise can be beneficial as well.  Therefore, again there is no definitive consensus on the type of food to consume prior to exercise.

In another study, published by Sasaki in 2014 in the Journal of Nutritional Science and Vitaminology, eating between 1 and 4 hours before exercise resulted in no difference in the metabolism of trained subjects.    The metabolism of both carbohydrates and fat oxidation remained the same despite the timing of intake.  Thus, as long as you eat between 1 and 4 hours before exercise there is no difference in the body’s ability to metabolism fat and carbohydrates afterwards.

Obviously, eating a very heavy meal immediately before exercise is not recommended because your body will shunt blood to your stomach and GI tract to help with digestion and this blood flow will be at the expense of your muscles.    Small meals with moderate complex carbohydrates and protein, such as an almond milk smoothie, with protein powder and a little fruit, eaten at least 30 before exercise may be ideal.  This allows for some digestion to occur prior to exercise and allows for fuel stores to replenish.

With regard to eating after exercising, the British Journal of Nutrition published a study in 2013 by NM Farah, that contradicts the above studies, and demonstrated that there may be an advantage for body fat regulation exercising before breakfast instead of after breakfast.

Further research suggests that eating a meal right after resistance exercise (weigh training) may increase muscle mass and decrease adipose (fat) tissues as opposed to eating a meal several hours after weight training.  After your workout, your body needs to repair itself and restore the energy you just burned.    For the first 2 hours after your workout, your body uses your food intake to refill your muscle energy stores.  Two-hours post exercise, this ability to store energy decreases by about 50%, and then those Calories are more likely to be stored as fat.

As was discussed in prior articles, insulin sensitivity is very important.  The more resistant you are to insulin, the more likely you will have issues such as abdominal obesity, heart disease, high blood pressure, diabetes, etc.   By eating within 2 hours after exercise, there is a beneficial effect on your body’s insulin sensitivity for the next 24 hours.

A small meal at least 30 minutes to 1 hour prior to exercise appears to refuel your energy stores and enable more optimal performances during exercise.   Eating within 2 hours of completing exercise helps to refuel your muscle glycogen stores and appears to enhance metabolism and increase insulin sensitivity for the following 24 hours.    Our bodies are remarkably complex and depending on genetics, environment, and baseline level of fitness, our needs are different.   As always, it is important to listen to your body and eat accordingly.

Exercising With Arthritis

 

We have all different levels of fitness. Some individuals have been exercising for years, while other individuals have never exercised a day in their lives.  We are all at different levels in terms of our cardiovascular fitness, our muscle strength and flexibility and our overall health.   It is quite important to remain active in spite of arthritis.  In fact, movement in people with arthritis is crucial to health and well-being.

Despite what we once thought, it is my experience that it is possible to modify the severity of certain types of arthritis.   In my mind, arthritis, chronic pain and other autoimmune diseases are the result of multiple factors.  All these factors such as genetics, environmental exposures, nutritional deficiencies, dietary influences, and gut health to name a few factors, all line up as if you were to “win” in the slots.  When this potent combination occurs in your body, havoc ensues.   The result is inflammation and chronic disease.   While you can’t change your genes per se, it is now thought that you can change or modify your gene expression.  In addition, you can certainly modify some of the other risk factors just mentioned to offset the severity of your debility.

In most cases, moderate exercise is essential to health and well being.  Proper, varied forms of exercise raises heart rate, raises endorphins, improves muscle strength, improves balance, improves flexibility and increases blood flow throughout the body including the muscles and joints.  In the case of arthritis, there is inflammation in the joint capsule and the bones themselves which leads to severe pain and often deterioration.     The nerve endings in the joint become super sensitive and pain can be unbearable.

Believe it or not, your choice of diet can directly impact your ability to exercise. When you consume an Anti-Inflammatory Diet, often you will notice you will able able to exercise with less pain is because this diet eliminates many known triggers for arthritis.

 

Some examples of arthritis triggers include:

  • Fried and processed foods
  • Thought to be due to compounds called AGE – (advanced glycation end products) These products are the result of heating, grilling, and frying foods.  The body utilizes pro-inflammatory molecules called cytokines in an effort to break them down and the result is excess inflammation in general as well as in the vascular system (blood vessels).
  • Sugary foods
  • Dairy
  • Alcohol
  • Foods/Oils with Omega-6 fatty acids – such as vegetable oil (safflower), corn oil, fried foods, certain nuts and seeds, mayonnaise

 

Some examples of beneficial foods include:

  • Foods containing high levels of Omega-3 Fatty acids – (ex. salmon, herring)
  • Avocados
  • Flax seed
  • Cherries and other berries (contain anthocyanins that are thought to be anti-inflammatory)
  • Leafy vegetables, broccoli – contain vitamin D
  • Green tea – has EGCG (epigallocatechin-3-gallate) a powerful antioxidant
  • Vitamin C containing foods (ex. papaya, brussel spouts, broccoli, citrus fruits)
  • Garlic, onions and leeks

 

It is very important to listen to your body.  Pay attention to the foods you are eating and the way you feel.  Often times, foods that are considered healthy may cause issues for you.  If you suffer from arthritis, try rotating your foods (i.e. do not eat the same food everyday).   If there are certain foods you think might bother you, wait 3 days in between eating them.  Then pay attention to the way you feel when you re-introduce those foods.  If you notice you have more difficulty with pain or decreased ability to exercise try eliminating the offending foods for a week or two.

Typically, it will take several weeks of following the diet closely before you see results with regard to decreased pain from inflammation.

When exercising with arthritis, it is important to modify your exercises as per trainer recommendations.  If exercises hurt, if possible, discuss with your trainers to find another way to exercise that muscle group.  In the beginning, there may be some exercises you simply cannot do.  What is important is that you are attempting to exercise.  With each passing week you will find that you can do a little more than the previous week.  Progress may be slow, with ups and downs.  As always, if despite closely following the diet, you are still having issues, it might be time to seek the advice of a health care professional.

Aerobic Versus Anaerobic Exercise

There are various types of exercises that affect our bodies differently.  Done in combination, this affords you the most “bang for your buck”.    By changing up the type, frequency, intensity and cardiovascular demand in your exercise regimen on a daily basis, you will have a synergist effect and derive numerous benefits from your exercise.

There are to major classes of exercises with regard to oxygen utilization. Aerobic exercise, exercises that utilize oxygen for energy, and anaerobic exercise, exercises that utilize fuel already present in the muscle for energy.

 

Aerobic exercises:

In this type of exercise, our muscles require the oxygen carried in the blood to be used for energy production.  Our muscles use this oxygen to burn both fat and carbohydrates as fuel.  Fuel can be constantly produced in the presence of oxygen, therefore, aerobic exercise can be sustained for a prolonged period of time. The body reacts accordingly by increasing the heart rate and breathing rate to keep up with the muscle oxygen demand.   Over time with training, our muscles become more efficient at extracting oxygen from the blood stream and thus we become “fitter”.  When this happens, you will notice that you will be able to exercise at a higher intensity without feeling winded or noticing a significant increase in your heart rate.   During aerobic exercise, you should feel slightly out of breath, but be able to carry out a conversation.

Some benefits of aerobic exercise includes: 

  • Improved overall level of fitness
  • Improved mood
  • Possible reduction of
    • Cancer risk
    • Cardiovascular disease
    • Osteoporosis
    • Diabetes
  • Higher level of fat burning (as opposed to anaerobic exercises)
  • Improved bone density (less beneficial then anaerobic exercises)
  • Moderate reduction in blood pressure
  • Decreased insulin resistance
  • Increases likelihood of surviving a heart attack

Anaerobic exercise:

In contrast to aerobic exercise, anaerobic exercise is exercise performed without oxygen.  This type of exercise is performed at a higher level of intensity and can only be sustained for a few moments.  Sprinting and heavy weight lifting are two examples of anaerobic exercise.   Anaerobic exercises utilize the energy that is already present in the muscle tissue.  However, because no oxygen is present to produce more energy, these exercises cannot be sustained once the fuel present in the muscle runs out after about 10-15 seconds.

Some benefits of Anaerobic exercise:

  • Strengthen bones and improves bone density
  • Builds and maintains lean muscle mass
  • Burns fat (though less so then an aerobic exercise)
  • Increases performance in sports by increasing strength, speed and power

A specific type of anaerobic exercise is Plyometric exercise.

Plyometric Exercises:

These types of explosive exercises are known as plyometric exercises (jump training).    This type of exercise uses your own weight and the force of gravity to provide resistance during the exercise.    The reason to incorporate these exercises into our exercise regimen is that plyometric exercise helps to develop explosive power and increase agility.

Without getting too technical, plyometric exercises are based on the muscle stretch reflex.

Whenever a muscle is stretched, a signal is sent to the nervous system that indicates that the muscle has been stretched.  The nervous system processes this signal and stimulates the muscle to contract in response to this stretch.    This is a reflex because the response is instantaneous.  Over time and with training, the fibers in the muscle (fast twitch fibers) become more sensitive to the stretch and maximize the speed and number of motor units that respond to the stretch.  By increases the fiber number and sensitivity, the muscle response becomes more explosive and generates more power.

Numerous studies have demonstrated that plyometric training should start slowly and work up gradually in intensity.  Plyometric training can be general such as jumping, jump squats, jump lunges but can also be more sports specific depending on the activities you would like to improve.    Typically plyometric exercises tend to focus on the lower body and utilize muscles around the knee and hip.    However, the use of medicine balls allow for plyometric activities of the shoulders and arms.

It is very important to warm up properly to increase the flexibility of the muscle and connective tissues around the joints to prevent injury.  It imperative that you slowly add in and increase your plyometric exercises when you feel your body can handle the impact.   For example, start off doing stepping jumping jacks and then gradually add in 1 jumping jack for every 5 stepping jacks.  Over a period of days to weeks, continue to add more jumping jacks and decrease the amount of stepping jacks.  Once you are able to comfortably complete a minute of jumping jacks without any pain or significant shortness of breath, you can start adding in superman jacks.   Again add 1 superman jack for every 5-10 jumping jacks and gradually increase the amount of superman jacks.   Since this is an anaerobic, plyometric exercise, if you are doing them correctly, you will only be able to do about 10-15 seconds of this until you become winded and need to take a break.

Shortness of Breath During Exercise

 

According to the American College of Sports Medicine, to attain the cardiac benefits from exercise, the exercise should be

  • At least 3 times per week for at least a 12 week duration
  • At least 30 minutes per session (can be broken up into 3 ten minute sessions)
  • Performed at an individual’s perceived intensity of 13-15 on a scale of 6-20 (the Borg Exertion scale) or at a level of “somewhat hard to hard”.

Some of the most common benefits of exercise include:

  • Improved exercise tolerance
  • When Exercise and Diet is combined:
    • Improved Lipid (fat) and Lipoprotein (fat/protein) levels
    • Decreased blood pressure
  • Stress Reduction
  • Improved Psychological well-being

One important question, especially among beginning exercisers and those returning to exercise after a long hiatus, is “Is this safe for me?”

Certain risk factors increase the likelihood of heart attacks and strokes and it is important to be aware of these factors when deciding on your exercise regimen.   Some risk factors are modifiable and can improve with exercise and diet, while others are fixed risks. Some common risk factors are:

  • High Blood pressure (hypertension)
  • Diabetes
  • Elevated Cholesterol or abnormal lipid (fat) profile
  • Family history of heart disease or strokes
  • Smoking
  • Sleep Apnea
  • Abdominal Obesity

According to Dr. Baggish, the Associate Director of the Cardiovascular Performance Program at the Massachusetts General Hospital, “ Everyone can do a form of exercise, if it is done carefully, with the supervision of a doctor”.  If you are starting and exercise regimen with a significant number of risk factors, it is important to first be evaluated by your Primary Care Physician or Cardiologist for clearance to begin an exercise regimen.   In general, it is important to “start low and go slow”.   Even just doing brisk walking does provide substantial improvement in overall health.

 

When beginning with an exercise regimen it is perfectly okay to try modifications first and increase your intensity as tolerated. Sudden start and stop exercises can put extra stress on the heart, especially if you are normally sedentary so it is important to all yourself a cool down period after exercising.

SYMPTOMS occurring during exercise that can require immediate attention are:

  • Left sided chest pain
  • Pain radiating into the jaw or down the left arm
  • Significant shortness of breath that does not quickly improve with rest
  • Dizziness
  • Sensation of an irregular heartbeat or pounding in the chest
  • Nausea or indigestion (usually Gastrointestinal related but can be a sign of heart issues)

In addition, if you suffer from chronic shortness of breath with minimal to no exertion, or from swelling in both legs, this can indicate issues with the hearts ability to pump.   It is important to note that individuals with diabetes, especially females, may not always have the “classic” symptoms for heart issues.   Vague complaints, flu-like symptoms and/or indigestion may be the only symptoms. Or you may have none at all.

If you suffer from any of the above listed symptoms, it is crucial to be evaluated to make certain that you are not putting your self at risk during exercise.

Belly Fat

 

Body image and self-confidence can be greatly improved with physical activity and dietary changes, but arguably more important, are the numerous health benefits of exercise and proper nutrition.

One misconception about belly fat or abdominal fat is that you need to target only the abs to reduce belly fat. This is not exactly the case because the body is not very efficient at targeted fat burning.   Instead, fat burning exercises, such as aerobic exercises, burn fat fairly evenly throughout the body. Losing belly (abdominal) fat can best be attained by combining several techniques, rather then focusing on just abdominal exercises such as crunches and sit-ups.

It is important to take note of your body habitus or shape. By now, you have probably heard about the “apple” and the “pear” body shapes.

  • Pear–shaped body: people carry fat around under the skin or “subcutaneously” in the hips, thighs and buttocks
  • Apple–shaped body type carries a type of fat known as “visceral” fat, or fat stored in the abdominal cavity

The danger of this visceral fat in the abdomen is that it surrounds internal organs such as the liver, pancreas, kidneys, intestines, etc. Visceral fat cannot be pinched. You can be skinny and still have visceral fat.   Fat cells are not passive, but in fact, active cells. Visceral fat cells produce fatty acids and inflammatory cytokines (chemicals) that can drive or worsen existing inflammation (such as arthritis or cardiovascular disease).   In contrast, subcutaneous fat (fat you can pinch under your skin) produces beneficial hormones such as leptins that drive your sense of fullness.

There are many factors that determine the placement of fat on our bodies. Some are modifiable while others are not. Genetics definitely play a role on visceral fat, as does various hormone levels, but so to does your total calorie intake. In addition, the composition of your diet, including the amount of dietary protein, level of dietary sugar intake, and type of fat consumed in your diet, all have implications on fat storage and overall health.

Elevated visceral fat (belly fat) has been linked to:

  • Metabolic disturbances
  • Cardiovascular disease (strokes and heart attacks)
  • Diabetes
  • Cancers (such as breast)
  • Arthritis
  • Demenita, Anxiety, Depression
  • Sexual dysfunction

According to the American College of Sports Medicine, you are at significantly increased risk of cardiovascular events if you have a waist circumference of > 40 inches in males and > 35 inches in females.   There is a test you can do to determine if you are at an increased risk called the Waist-to-Hip circumference ratio. Using a tape measure, check the circumference of your waist at your narrowest point and measure the circumference at the widest point of your hips.   If your ratio of Waist/Hips is > 0.95 as a male or > 0.86 as a female you are at significantly increased risk for cardiovascular events, hypertension, and type 2 diabetes.

So what should you do?

Diet: this is the most important component of your strategy to reduce your abdominal fat and bloating.

  • Avoid foods which bloat you (different for different individuals)
  • Avoid chewing gum
  • Avoid simple sugars and processed carbs
  • Avoid alcohol – the liver will burn this instead of fat for energy
  • Avoid dehydration – Drink water
  • Avoid bubbly drinks as this can worsen abdominal gas and bloating
  • Avoid wheat/gluten
  • Chew your food until it is liquefied for better digestion
  • Consider adding a probiotic if o.k. with your Physician or Health Professional
  • Add 10 grams of soluble fiber to your diet –(1 cup of peas or 2 apples)
  • Avoid trans-fats which are stored as visceral fats

Exercise:

  • At least 30 minutes of moderate intensity exercise 5 days per week
    • High intensity interval training – helps burn visceral fat
  • Strength train 2-3 times per week to build muscle mass
  • Target all major muscle groups when strength training
  • Core exercises build abdominal muscle which will in turn burn fat all over body (but not locally around the abdomen)

Other:

  • 5-8 hours of sleep per night is optimal per study done by Wake Forest
  • Try to reduce stress – cortisol (a stress hormone) promotes visceral fat storage
  • Have your doctor check your hormone levels if you are worried – low testosterone in males and low estrogen in females can be associated with visceral fat storage

One caveat to this is that after a significant weight loss, you are sometimes left with excess skin. Excess skin is very different from abdominal fat. Unfortunately, at this time, I am unaware of any medically sound practices that reduce large quantities of excess skin aside from plastic surgery at this time.   That being said, the reduction of visceral fat and increase of muscle mass, due to proper diet and exercise, have profound, lasting effects on your health and well-being.

Hamstring Injuries

 

The hamstring muscles are actually a group of 3 muscles located in the back part of your upper leg. The hamstrings muscles originate from the pelvis (buttocks) and the femur (leg bone) on the backside of the leg and cross the knee joint to insert on the medial (inside) and lateral (outside) part of the leg just below the knee. The main jobs of the hamstrings are to extend (straighten) the hip and to flex (bend) the knee.   In addition, some of the hamstring muscles play a role in rotating the lower leg.

The most common thigh injury is a hamstring strain.   These injuries can often occur when the hip is flexed and the leg is extended, as in a single leg front kick. This is because 2 of the 3 muscles that make up the hamstring group cross over two joints (the hip and the knee).   These muscles are maximally stretched when the hip is bent and the knee is straight, and if movements are quick, the muscle can get strained or even tear.

Certain physical findings can increase your chances of getting a hamstring injury, such as:

  • Tight hamstring muscles – (inability to completely straighten your knee on standing)
  • An imbalance between the muscle strength in the upper leg (hamstrings and quadriceps)
  • Tightness of the quadriceps or hip flexor muscles (inability to completely stand up straight while the legs are straight — you will notice that you bend forward at the hips slightly if your legs are otherwise straight)
  • Insufficient warm up before exercising
  • Poor muscle coordination
  • Muscle fatigue
  • Muscle strength or flexibility imbalances

Usually a hamstring injury will present with pain on the backside of the upper leg, possibly with swelling, bruising, and an associated popping sensation at the time of injury.   If the hamstring muscle is fully torn, there may be an obvious mass which is actually the muscle contracting into a “ball”.

Treatment of hamstring injuries can be broken down into the acute phase that occurs immediately after injury and for the first 2-3 days. The sub-acute phase that occurs for several days to a few weeks after injury and the chronic phase that begins several weeks after injury.

Acute treatment of a hamstring injury generally follows the acronym PRICE.

Protection – In a severe hamstring strain or tear, an individual may require a crutch or a cane to protect the injured leg while walking.

Rest – for the first few days, remain off the injured leg as is possible, as this will enable the hamstring to begin healing.   The caveat is that stretching muscle begin shortly after injury because the muscle will scar down as it heals leading to further muscle tightness and predisposing you for another injury.

Ice– using a plastic bag filled with ice and water for 20 minutes 3 times a day is helpful to further reduce swelling. Heat is initially not recommended because heat increases the blood flow and is thought to worsen swelling. However, a few days after an acute injury heat can be helpful as heat increases blood flow to the injured area and helps with healing.

Compression – An ace wrap or compression dressing should be applied to the upper part of the thigh to prevent further swelling.

Elevation – Elevating the injured leg helps to further prevent swelling.

As mentioned above, hamstring injuries require both stretching and strengthening in order to recover. The main issue is that after a tear or strain, the muscles heal by scarring down. This scarring results in decreased flexibility of the muscle.

One big mistake athletes and weekend warriors make after sustaining a hamstring injury is to return too quickly to their prior level of activity. It is very important to only return to exercise after the pain has subsided. This is because if you return to exercise too early, you will change your biomechanics (i.e. alter your posture or positioning) to compensate for the pain. This altered position or step length while exercising can allow the muscle to shorten. When the muscle heals and contracts (shortens and scars down) you are then at increased risk for a repeat strain or tear.   Typically it takes at least 4-6 weeks for the muscle to properly heal.

It is helpful to begin stretching and strengthening exercises under the supervision of a qualified physical therapist so that you do not re-injure yourself and you can recover optimally. It is possible to regain or even surpass your pre-injury strength and flexibility with a proper treatment regimen.

PRP or Platelet Rich Plasma injections are sometimes recommended for assistance with tissue repair and quicker recovery time. However, an article published in 2015 from the Department of Sports Medicine at St Lucas Andreas Hospital in Amsterdam, reviewed the data for the treatment of hamstring injuries and found that lengthening exercises (stretching the hamstrings) provided the quickest return to play time, but did not affect re-injury rate. PRP injections did not improve outcome or re-injury rate when compared to controls. Therefore, at this time, it appears that a physical therapy regimen focusing on first stretching the hamstring muscles, then strengthening them (while maintaining improved flexibility) provides the best chance for recovery and return to exercise.   It was also suggested in this study that progressive agility training and trunk (core) strengthening and stability might reduce re- injury rates.

As always, if you suspect you might have a hamstring injury or other leg injury it is important to be evaluated by a trained health care professional. It is quite possible that you will be referred to a physical therapist for optimal treatment that includes a both a stretching and strengthening regimen. While initially your treatment will focus on the injured muscles, it will be important to analyze and treat your body mechanics to prevent repeated injury.

Exercise as a Pick-Me-Up: Can You Combat Depression

Depression is a very complex emotion that is influenced by many factors.
Sometimes depression can be brought on by a serious illness in yourself or a family member. Other times, depression may be due to significant life altering events. In many cases, genetics and gene expression can play a crucial role.   While it is not thought to be possible to change your genes, it is possible to change your gene expression (they way your genes work). In addition, there are many lifestyle modifications you can make to improve your emotional state.  Today we will focus on the beneficial role of exercise in treating depression.

The number of research articles written on the causes and treatments for depression is staggering. It has been repeatedly demonstrated that people suffering from depression have altered brain chemistry and function. The ENIGMA consortium, a large multi-center collaboration of 70 institutions, has analyzed both genetic data and neuroimaging studies with regard to depression. They have established that the size of the hippocampus, the area of the brain responsible for memory and emotion, actually decreases in response to chronic depression.

So what can you do to prevent this?

Exercise!!!

An excellent article written by Lynette Craft and Frank Perna, in The Primary Care Companion – Journal of Clinical Psychiatry, published in 2004, address various theories as to why exercise helps depression.   It is highly possible that the combination of all of the theories presented below lead to the beneficial effects of exercise with regard to depression.

The first hypothesis as to why exercise benefits those with depression is termed the Thermogenic Hypothesis. The idea behind this hypothesis is that exercise raises your core body temperature and the temperature in your brain. When the temperature rises this increases the activity of certain areas of the brain thereby altering brain chemistry and improving depression.

Another theory is termed the Endorphin Hypothesis. This hypothesis asserts that exercise increases endorphin levels. Endorphins are substances what are released by the brain during exercise, and help to relieve pain and increase feelings of pleasure.   Endorphins essentially are morphine or opioid compounds produced by our bodies.   There is some criticism to this hypothesis because it is not known if these elevated levels of endorphins detected in the blood after exercise actually induce a change in brain chemistry.

Currently the Monoamine Hypothesis seems to have the most support. The basis for this hypothesis is that exercise causes an increase in the availability of neurotransmitters such as dopamine, norepinephrine and serotonin in the brain. The concentrations of these neurotransmitters are often lower in depressed people. In fact, most anti-depressant medications work by preventing breakdown of these important neurotransmitters.   Studies done in the 1970’s by RM Post and others have demonstrated an increase in these neurotransmitters both in the blood and in the urine after exercise.   Theoretically, this rise in neurotransmitters may lead to a decrease in depressive symptoms.

The Distraction Hypothesis states that intense exercise leads to distraction from worry and depressing thoughts.   In this hypothesis, exercise is likened to a meditative state and serves to provide solace and relief from feelings of despair.   These distraction activities serve as a type of coping mechanism.

Finally, there is the Self-Efficacy Hypothesis. This hypothesis asserts that by consistently participating in an exercise program, you develop a sense of confidence. This cycle becomes a self-fulfilling prophecy. Initially when you begin an exercise program, you are filled with feelings of doubt and insecurity, however as you begin to stick to the program and see benefits, you become more confident and determined to persist.   This confidence is thought to offset depressive thoughts.

Most likely all of these hypotheses are at least partially correct. So what’s the take home message?

Stick to it and continue exercising!!!  

The most common benefits of exercise include:

  • Improved endurance
  • Improved cardiovascular fitness
  • Improved balance
  • Improved strength and flexibility
  • Improved body composition (increased muscle mass, decreased fat stores)
  • Improved sleep
  • Improved self-esteem
  • Stress reduction
  • Decreased depression and anxiety

The most important times to exercise are the times you don’t want to exercise. It is rare that you will leave an exercise session feeling worse then when you entered. Not every day will be the best day, but you just need to show up and give it your all. If you are on the fence about coming in, just focus all the benefits you obtain from routine exercise!