Everything in Moderation

Can the world be divided between those who love to exercise and those who loathe exercise? A recent study would seem to indicate that is true. A research report in this month’s PT Journal states that 38% of adults in this country “never engage in physical activity during leisure time”. The American Heart Association among others has recommended that adults get a minimum of 5 moderate aerobic workouts per week, lasting 30 minutes or 3 intense aerobic workouts, lasting 20 minutes each. They also recommend strengthening exercise at least two days per week. The authors of the article referred to data collected from the 2005 National Health Interview Survey. 24% of the Americans surveyed meet the guidelines exclusively by doing intense exercise. Only 16% of Americans meet recommendations by doing moderate exercise alone and a meager 3.4% meet guidelines by combining both intense and moderate exercise. Only 20% do twice weekly strength training. This trend was consistent with physical therapists and health care professionals. 52% of PTs meet the guidelines by doing intense exercise, 15% with moderate exercise and 9% with a combination of both. 60% of PTs do regular strength training. So while PTs are much better at doing regular exercise, we still favor intensity over moderation.

Why is there a such a low number of those who engage in moderate exercise? Are people overestimating the intensity level of their workouts? Are people opting for intense exercise rather than moderate in the interest of time management? Do people need to experience the exercise high and become addicted to it in order to be consistent with an exercise program?

Personally, I do like to work up a good sweat and I don’t feel good either physically or mentally if I don’t get my heart pumping at least a few times per week but as a PT and as a yoga teacher, it concerns me that moderate exercise is not more popular. There are good reasons to include at least some moderate workouts in your exercise routine whether or not you exercise regularly. Here’s why:
It is better (MUCH better) than doing nothing. Going for a 30 minute walk (better yet, two 15 minute walks to the store and back) or 30 minutes of vinyasa yoga in your living room is a great way to get some activity into your day even if you don’t have time or money to make it to the gym.
You are less likely to be injured compared to intense exercises. Intense exercise can result in acute injuries such as a sprained ankle while playing basketball or over-use injuries like patella tendonitis from running.
With intense exercise you learn to push your body to it’s limits (and often past it’s limits) but with moderate exercise you learn to respect your body’s more subtle messages such as a tendency to favor one side or another, early signs of fatigue and compensatory patterns of breath and movement.
Some forms of moderate exercise, especially yoga, incorporate strengthening, stretching and/or balancing so that your workouts can more more time efficient.

I know that I am guilty of an all-or-nothing approach to exercise. I like to really ‘work out,’ to sweat profusely and feel weak in the knees when I’m done. I tend be sedentary when I don’t go to the gym or the yoga studio. But studying yoga has helped me to embrace moderation. I walk more often (using a pedometer helps me to feel ‘rewarded’ from those walks) and I enjoy gentle hatha yoga sessions, especially when I’m feeling tired or run-down.

What do you think? Are you an all-out or nothing exerciser? Do you avoid exercise all together out of distaste for sweaty, heart-pumping exercise? Do you consider yoga a moderate exercise? How do you think we can make moderate exercise more appealing to more people on both ends of the exercise spectrum?

Asana Analysis: Bridge/Setu Bhandasana

Bridge/Setu Bhandasana: This seemingly simple pose is actually full of complexity. It is a backbend and an inversion that can be done for even the most gentle practice but it can also be challenging for an advanced practitioner as there are many subtle aspects of alignment to master and there are an endless number of variations to try.

Muscles Strengthened: Gluteus maximus, hamstrings, adductors (especially adductor magnus), spinal extensors, rhomboids, middle trapezius,

Muscles Stretched: Rectus femoris, tensor facia lata/IT band, iliacus, psoas, pectoralis major and minor

Points of Body Awareness:
*Do your knees splay outward, are they wider than the hips? If so, this may be due to weakness of the inner thighs, tightness of the IT Band or over-dominance of the gluteals.
*Is there any pain or pinching in the lower back? Although this pose is a backbend, it should be balanced by a sense of lengthening through the legs and spine. There should not be any pain in your back.
*Try drawing the pubic bone up toward the navel. This will roll the pelvis so the tailbone moves towards the knees, engaging the abdominal muscles and lengthening the lower back.
*Do you feel your shoulder blades squeezing in toward the center? The muscles between your shoulder blades should be active while you press the backs of your shoulders into the ground.
*If you are interlacing the hands behind you, make sure that the elbows are not hyperextending. Keep them in contact with the ground.
*Is your neck and jaw relaxed? Make sure to maintain a neutral curve in the neck so that there is some space between the back of the neck and the floor.

To Modify: If your chest or shoulders are tight, use ‘robot arms’ instead of clasping the hands behind your back. If your neck is uncomfortable, try lying on a folded blanket with the folded edge under the top of your shoulders. This will create more space beneath the base of your neck. If your lower back is uncomfortable, back off the height of your lift and instead focus on engaging the abdominals and lengthening the lumbar spine.

To Challenge: Squeeze a block between your thighs to increase the action of the adductor muscle and to encourage an inner spiral of the thighs. Try a dynamic version of bridge pose by marching the legs. Lift one foot a couple of inches away from the ground then alternate with the other. Keep the pelvis stable, moving only at the ball-and-socket joints of the hips. One other advanced variation is to raise one leg strait up toward the ceiling and hold for several breaths.

A Restorative Variation: Place a block under the sacrum and allow your weight to be supported by the block. Try using the tallest side of the block (the short, skinny edge of the block will be under your sacrum) . If this hurts your back then go to the middle height (long, skinny edge). Keep the legs somewhat active, lengthening through the thigh bones and grounding through the heels. Use a belly breath and enjoy this supported posture for 2-5 minutes.

PT Notes: Bridging is another posture that I knew as a rehab exercise before I ever knew that it was a part of yoga. Anyone familiar with PT, knows that we can use some form of bridging for patients in a hospital bed to outpatients with sports-related injuries. I have always thought of bridging primarily as a gluteal strengthening exercise but in the yoga world, teachers will often instruct students to minimize contraction of gluteals during setu bhandasana. So the questions arises, to glute squeeze or not to glute squeeze? The answer depends entirely on who you’re treating and why. For the 75 year old lady who has trouble going up stairs or standing up from a chair... glute squeeze. If you’re working on independence with bed mobility... glute squeeze. For the injured runner who’s got great hamstring strength but has inhibited gluteals... you know the answer! But for your ACL patients, you probably want to emphasize the hamstrings more than gluteals so try the ‘yoga-style’ bridge with them. A patient with an irritated SIJ is another one who may prefer less gluteal contraction and more focus on the hamstrings.

Another therapeutic consideration while doing setu bhandasana is whether to start with a neutral spine position (maintaining lumbar lordosis) or to start with a posterior pelvic tilt (PPT). Of course, this too depends on the patient and the diagnosis. I usually always start with a neutral position but switch to PPT if the patient has back pain. This often seems to work better for older patients with lumbar stenosis or spondylolysis. It can also be beneficial for those patients who have difficulty learning to incorporate abdominal activity with bridging.

There's so much more to this pose than simply lifting the hips up off the ground. Don’t underestimate this simple posture!

See Yoga Journal for more details.

Food, Glorious Food!

Food is the foundation of all societies. Families, neighbors and friends have always found common ground by sharing a table. Cultures can be defined in part, by their unique spices, flavors and methods of preparing foods. Food has also been the basis of conflict and wars. Just in the past two years, there have been riots in Africa and violence in Haiti related to the scarcity of food. When I read Jared Diamond's Guns, Germs, and Steel: The Fates of Human Societies
">Guns, Germs and Steel a few years ago, I was amazed how often history was changed over matters related to food; it's cultivation, storage, and transportation. On one level it makes sense because food is necessary for survival but it is so much more than that. Food can also represent status. It gives us sensory and emotional pleasure. It's used ceremoniously for religious rituals and secular celebrations. Sadly though, I think our culture, 21st century America undervalues food. Some of us look at food as nothing more than fuel and strive to get it as quickly and cheaply as possible. Some look at it as something to have control over in order maintain a perfect outward appearance. There are those who abuse it as a way to provide temporary pleasure without regard to how or if it nourishes our bodies and souls. Even when we do try to make healthy choices, many times we are overwhelmed by conflicting stories of what is healthy. The pesticides in our strawberries and e. coli in our lettuce can be enough to make us stick our heads in the sand and go grab a burger!

But food gives us endless opportunities to practice yoga off the mat. What we eat and how we eat indicates where we stand in our spiritual lives. When we eat, we are not just putting food into our own bodies. That food came from somewhere. And the chain of events that led to that food being on your plate are reflective of the society we live in. Everyday we have choices to make that will contribute to the values of our society. Do we want to protect the environment? If so, we can buy more organic foods or local foods or foods that have minimal packaging. Do we believe in social justice? Then we can support local farmers and food artisans. We can stop buying cheap meat that is produced by massive slaughterhouses where the workers are underpaid to do dirty and dangerous work. (Watch the movie, Food, Inc for compelling evidence about the social and environmental impact of food.)

Even if we do make ethical and healthy choices, food can still offer a challenge for spiritual growth. I had a yoga teacher who gave an assignment of pausing before you put anything in your mouth to eat. The point being, to have a moment of stillness to appreciate what you were about to consume. I had a lot of trouble with this assignment. It seemed that I could never remember to pause until I was about ten bites in. It made me realize how powerful food and physical cravings can be.

The next time you find yourself at the grocery store or about to take a bite of your next meal, ask yourself what this food means to you? Have you made a socially or environmentally conscious choice? Are you about to nourish yourself or are you looking to satisfy a craving? Are you grateful for what you are about to eat? Will you enjoy it? Hopefully you will. As they say in Korean, "Jal-mok-gae sum-ni-da!" (Eat well)

Asana Analysis: Reclined Hand-Foot Pose/Supta Padangusthasana

Reclined Hand-Foot/Supta Padangusthasana: I often refer to this as 3-Part Strap Stretch as it is rare that I don’t do (or instruct) all three variations in succession.
Variation A: Abduct the leg supported by the strap out to the side.
Variation B: Cross midline with the leg that is supported by the strap

Muscles Stretched: Hamstrings, gastrocnemius, all adductors (for variation A), gluteals, tenor fascia lata/ITB, piriformis, small external rotators (for variation B)

Points of Body Awareness:
*Are you holding the strap with as little effort as possible?
*The arms should be relaxed with the shoulders resting on the ground.
*Are you ‘grounding’ through the leg that remains on the floor? Press the back of that leg down into the earth and keep the ankle flexed (toes toward the nose).
*Lengthen the lifted leg. Feel yourself reaching through the bottom of the heel toward the ceiling.
*Is your lower back flat on the ground? Try to maintain a neutral spine in this pose, so there will be a small space between the lower back and the ground. If this is difficult to maintain, try lying on a small blanket to passively support the lumbar curve.
*When doing variation A, continue to ground the opposite leg. Do not allow the pelvis to roll toward the abducted leg.
*For variation B you can either let the pelvis roll away from the ground for a spinal twist or you can keep the pelvis more grounded, which will create more of a stretch in the muscles and soft tissues of the hip.
*Are you breathing slowly, fully and without restriction? Try to direct the breath to wherever you feel the greatest resistance to the stretch.

To Modify: Lie in a doorway and support the leg on the frame of the door instead of using strap. This is a good way to make this a ‘yin’ pose and to be able to hold the posture for 2-5 minutes. You can also use props such as bolsters, blocks or a wall to support the leg for a prolonged stretch in variations A and B.

PT Notes: I knew this as a supine hamstring stretch before I ever knew that it had a sanskrit name. But learning the subtle aspects that yoga brings to the pose make it more safe and effective. I have found that stretches work better if the patient learns to breath and relax more while holding the stretch. This may not be the most practical way to stretch the hamstrings but I do think it is the most effective way.

I recently discovered that variation B can be a great stretch for mobilizing the sacral plexus. By anchoring the the pelvis downward while simultaneously lengthening the leg upward, I personally feel an intensity in the sacral area that feels like a nerve glide (I suppose it’s possible that I’m actually just feeling a stretch of the piriformis origin but either way it’s an area I had not ever accessed before). Breathing deeply provides some degree of oscillation but it may be useful to add distal oscillations as well. I have not used this pose in this way with patients but I do teach it in my class and there is a wide variation on whether students ‘feel it’ and whether it is intense or mild.

See Yoga Journal for more details.
See previous Asana Analysis posts.

Shifting the Center

A few months ago I was in a yoga class working on headstand when my teacher can over and adjusted my center of gravity by moving my hips back ever so slightly. Then she had me come out of the pose by lowering both of my legs to the ground. I could not believe how effortless it felt. As a physical therapist, I am fully aware of the mechanical power of our center of gravities but the intellectual awareness is a far cry from experiencing such a profound change on a physical level. I never thought that coming out of headstand was very difficult but I also never knew that it could be so easy. This experience got me thinking about how this lesson applies to life outside the yoga studio. I came across an alternative definition of center of gravity online that defines it as, "the source of power that provides moral or physical strength, freedom of action, or will to act." (Interestingly enough, this definition comes from a military theorist.) I believe that our centers of gravity define how we relate to the world around us. Can a small change in our center or our perspective on the world, help us to tap undiscovered reservoirs of personal strength?

I can think of a few examples in my own life when this was the case. Dealing with physical injuries, grieving for the loss of a friend, living in a diverse neighborhood alongside immigrants and homeless people, and traveling and volunteering in developing countries are all examples of times when my world view was changed to some degree and when I discovered strengths that I didn’t know that I had and when my opinions and passions were solidified by experience.

But I’m more interested in hearing your stories. Is there a time when your center was shifted, when you discovered hidden strengths or talents or passions? Where does your 'source of power' come from and what does power mean to you? And if you have a story of a literal shift in center of mass and how it helped you or a client or patient, I'd love to hear that story too!

Asana Analysis: Triangle Pose/Trikonasana

Triangle/Trikonasana: A standing pose that is wonderfully balanced. It’s a great posture for both stretching and strengthening of the legs, shoulders and torso.

Muscles Strengthened in Triangle Pose: quadriceps, hamstrings, external rotators of front leg, adductors of the back leg, transverse abdominus, obliques, rhomboids, middle trapezius, scalenes, sternocleidomastoid,

Muscles Stretched in Triangle Pose: hamstrings, adductors of front leg, gluteals and tensor facia lata of the back leg, pectoralis major and minor, anterior deltoid,

Points of Body Awareness:
*Are your legs strong and rooted?
*The front hip is rolling out, the back hip is rolling in slightly.
*Press the ball of the front leg down to avoid hyperextending the knee.
*Feel the spine lengthening.
*Can you feel the ribcage (on the side of the forward leg) move toward the ground to allow for greater lengthening of the spine?
*Can you feel a sense of freedom and mobility in the ribcage (on the side of the forward leg) as you breath while holding the posture?
*Open the heart by rolling the top shoulder blade back, in line with the bottom shoulder blade. Feel the arms reaching in opposite directions.
*Can you feel the lines of energy in the pose? Ground down through the legs, lengthen through the spine and open from the breastbone through the arms.

To Modify: If you can’t reach the ground without curving the spine, place the bottom hand on a block, or the seat of a chair. If there is any discomfort in the neck, keep the gaze forward or down but be sure to continue lengthening through the neck.

To Challenge: Use a wall to ensure full rotation and chest opening. Feel three points of contact: the buttocks of the forward leg and both shoulder blades. If you can’t reach the wall with your top shoulder blade, use a block or chair as described above. Try unweighting the bottom hand for a greater core strengthening challenge (but only if you can maintain a strait spine).

PT Notes: This is a good pose for patients who are working on thoracic rotation and scapular coordination. One common mistake people make with this pose is that they reach too far back with the top hand (horizontal abduction) rather than increasing scapular retraction or thoracic rotation (intervertebral and/or costovertebral). This can place stress on the anterior capsule of the shoulder and can perpetuate dysfunction of the humeral-scapulo-thoracic complex. Using a wall as described above is helpful for cueing the patients for the correct alignment but they should be able to progress to pain-free, proper alignment without cues in order to demonstrate normal proprioception and scapular awareness. This is a good posture to try after doing joint mobilizations on the thoracic spine and/or after manual PNF for increased scapular recruitment and ROM.

Tightness of any of the pelvic girdle muscles will cause a compensation of spinal side bending. If a patient is unable to perform this posture without side bending then use a block or chair as described in modifications. Then assess which pelvic girdle muscles are tight and give the patient separate stretches to isolate those muscles. For example if gluteals are tight, gomukhasana or cow’s face stretch is a good pose to work on. If the adductors and hamstrings are tight, reclined strap stretches are a safe and effective way to increase flexibility.

For more details see Yoga Journal

I’ve recently discovered the book, Yoga Anatomy
">Yoga Anatomy by Leslie Kaminoff. It’s a good resource and has wonderful drawings of muscles in many different poses. I highly recommend it for anatomy geeks like myself!

Strong Girls are Powerful Girls!

My brother coaches high school track, sprinters specifically. He was recently telling me about one of his frustrations, that the girls won’t lift weights. He told me that they are concerned about ‘bulking up too much’. This was appalling to me. As someone who ran track and lifted weights throughout high school and college, I can not believe that in this decade, in this century, in this age of information that these girls can have such an attitude. If this were a group of girls who were not athletes I guess I would not have been as surprised but I expect more from girls who are willing to commit their afternoons and weekends to sporting events. It makes me sad and angry that we, as a society, can’t seem to get past this concept that the ideal female body image is one of slenderness. It seems as though we are clinging more and more tightly to these false images of health and beauty even as we become a nation plagued by obesity. The girls on my brother’s team surely are not obese, but the fact that they cling to a physical ideal of slenderness and avoid the possibility of building a muscular body in spite of the fact that it will help them to run faster and avoid injury, says to me that we have a lot of work to do in educating our young people about health and well-being.

Strength training should be an essential part of anyone’s fitness routine. The ACSM has published guidelines for strength training for adults and has emphasized the importance of maintaining strength and muscle mass in older adults but another group that would benefit greatly from strength training is teenage girls. Strength training can be done by lifting weights, doing calisthenics such as push-ups, taking pilates classes or certain forms of yoga such as ashtanga or ‘power yoga’ classes. Any form of strengthening for teenagers would be good but weight training can offer additional benefits important for young women.

Reasons Teenage Girls Should Lift Weights:
Improve Bone Density - All young women should know that bone density peaks at about age 26. So teenage girls who lift weights can maximize their ‘bone bank’ and slow the progression on bone loss and perhaps prevent osteoporosis. It can be difficult to convince a girl to do something that might be helpful 50 years in the future but if they know anyone, especially someone in their family who’s body has been wrecked by osteoporosis, they should know that there is something they can do now to avoid the same fate.

Increase Metabolism - Lifting weights helps to shift body mass to a higher amount of lean mass (muscle and bone) and a lower body fat percentage. This allows a person to burn more calories throughout the day, making it less likely that they will gain unwanted pounds and more likely that they will maintain a lean figure.

Improved Posture - By strengthening ‘core’ muscles and muscles of the back and shoulders, it is easier to stand upright. Improved posture is associated with more efficient alignment of the skeleton, better function of the vital organs and fewer problems with chronic pain and repetitive stress injuries. But perhaps even more compelling for young ladies... good posture looks makes you look good!

Learn Anatomy - If a teen has any interest in going into the health care field, they’ll need to learn anatomy. Whether she wants to be a doctor, nurse or xray technician, she’ll have a head start if she knows her pec press from her deltoid flies. And if she aspires to be a physical therapist (an excellent choice!), she should not even think about applying to PT school unless she has spent at least some time learning how to lift weights!

Improve Athletic Performance and Decrease Injuries - This is especially relevent for female athletes. A sensible, specific weight lifting program helps to improve running speed, jumping and throwing ability, agility and power. It will also prevent injuries such as muscle strains and tendonitis. One study of high school soccer players showed that 26% of students who did strength training had an injury, compared to 74% of students who did not do any strength training.

It will NOT bulk you up! - Some body types are more naturally muscular than others so some people are more likely to show muscle tone. But even a guy who is genetically predisposed to a muscular type of body still has to do a LOT of training to put on significant muscle bulk.

The bottom line is that all teenage girls should be doing some kind of strength training. Female athletes will benefit most from a well-designed free weight program. Non-athletes may get more out of pilates or yoga but all young women should understand regardless of the size or shape of one’s body, strengthening will make you healthy. It can make you strong not only physically, but mentally as well. Love your bodies for their own unique shapes and appreciate all that it can do for you!