Walking - The Best Exercise?

I came across an interesting piece today in the online newsletter, The Onion, that I thought is well worth sharing with you all:

NEWS IN BRIEF

Study Finds Placing One Foot Forward, Then The Other, Remains Best Method Of Walking

ITHACA, NY—Confirming long-held suspicions surrounding bipedal commuting, researchers at Cornell University published a study Monday that found stepping forward with one foot, followed by taking the subsequent step with the other foot and then repeating the sequence as necessary, remains the best method of walking by a large margin. “Our findings show that 99.9 percent of respondents strongly preferred putting one foot forward, usually but not necessarily while moving an opposing arm in conjunction, compared to other methods such as moving both feet forward at once, moving only a single foot forward indefinitely while the other is dragged behind, or taking a series of three quick hops before jumping in the air and spinning completely around while clicking their heels together,” said lead researcher Dr. Hirokazu Miyazaki of the department of biomedical engineering, who used motion-tracking sensors to monitor the gait structures and motive rhythms of more than 1,400 participants during the course of the 18-year, $26.5 million study. “While techniques such as dragging your knuckles on the ground and effecting a sort of mild gallop will certainly take a person from point A to point B, our research proves all such alternative methods are far less efficient than the conventional approach of placing one foot in front of the other.” In a related report, researchers at Marquette University have found that closing one’s eyes and then quickly reopening them remains the most effective method of blinking.

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Okay - for those of you who may not be aware, The Onion is a satirical news website, but reading this piece made me think about how so many people view walking as simply a natural activity of daily living and not so much as a viable and effective form of exercise.

When I began my professional physical therapy education program 37 years ago, I quickly decided I wanted to concentrate on the evaluation and treatment of running injuries. Being a runner myself, I had a natural interest in the topic, but I also found the study of gait in general to be fascinating.

Gait is defined as a manner of walking or moving on foot, and understanding all the components of this requires a substantial amount of knowledge of anatomy, kinesiology, biomechanics, and much, much more.

Running differs from walking in some obvious ways, but the basic concepts are essentially the same. Much research has been published on the topics of running efficiency, energy expenditure, faulty movement patterns that lead to injury, and more.

And since the “running boom” of the late 1970s, there has been much debate about which form of exercise — running, biking, swimming, cross-country skiing, weight-lifting — is considered the “best” form of exercise. Most of the time, the criteria used when trying to answer this question is the effect of the activity on cardiovascular (heart/lung) health, with perhaps some consideration of bone health (i.e., prevention of osteoporosis) and general muscle strength.

All of the activities listed above share at least on thing in common: they require a certain amount of extra effort as compared to normal daily functional activities. That extra effort (what we in the field call “overloading”) is what leads to improvements in heart/lung function, and muscle and bone strength. So the natural conclusion that many people come to is that, since walking is considered a “normal daily activity,” it would not be considered to fall within that definition of exercise.

The fact is, this couldn’t be farther from the truth. Numerous studies have shown that sustained, brisk walking confers just about all of the same benefits as running, biking, x-c skiing, and swimming. (The one exception might be weight-lifting; walking will not improve muscle strength to the same degree.)

Now, to be sure, there are some differences. For instance, you would have to walk the same distance as a runner to derive the similar improvements in C-V function, calorie expenditure, weight loss/control, lowered blood pressure, reduced risk for almost all types of cancer, mental health, and more, so you would naturally be out there 2-3 times as long, but even just a 30 minute walk, 5 days/week would make a significant difference in your general fitness and health.

In fact, almost 10 years ago, when the country was in the midst of the healthcare debate that eventually led to the Affordable Care Act (Obamacare), a study was published by a physician who used computer modelling to show that if every American walked that amount, we most likely wouldn’t have had to have that debate because the decreased costs for our nation’s health care that would result from this (less obesity, heart disease, cancer, diabetes) would have negated the soaring insurance premiums that set off the crisis!

Walking may require more time than running (or biking, swimming, etc.), but on the plus side, there is generally less risk of injury associated with those more strenuous activities, so that’s something to take into consideration. And let’s face it — just about everyone can walk 30 minutes day, 5 days/week. Running or those other activities are not for everyone (I hate swimming!), and if you really dislike something, you won’t sustain it for long. But I don’t know many people who would say they genuinely dislike walking.

Walking may not be the “best” exercise, but that’s a subjective measure that has to take into account your goals and likes. But it certainly is the best “minimum” exercise that everyone should be able to do. There really is no excuse…

 

Is This All In My Head?

IS THIS ALL IN MY HEAD?

If there is one question that all physical therapists will tell you they hear over and over again from patients, this is the one.

The “this”  in this question is pain.  

More specifically, it usually is asked in reference to chronic pain, the kind of hurting that seems to be persisting for much longer than expected and was originally caused by some kind of injury, such as to the low back or neck, to name two of the most common areas affected in this way.  People suffering from this long-term pain seem to have an innate sense that this is not normal, that the discomfort “should be gone by now,” and when it isn’t, they begin to question whether it is something they are imagining – that it’s “all in my head.” 

It’s a legitimate question, and one I will try to answer to the best degree possible given the current state of scientific knowledge on the topic.  The first thing we need to understand is what we mean exactly when we talk about “chronic” pain.

Experts in the field of pain differ in what they consider the necessary period of time that must pass before they apply the “chronic” label, but 12 weeks generally seems to be the average.

Why does 3 months seem to be the standard time for changing the description of pain from acute (or sub-acute) to chronic? Understanding what happens in our bodies when we are injured is crucial to appreciating why we change our terminology as time passes.

As an example, let’s look at low back pain, generally thought to be the result of some injury to the lumbar spine.  This can involve the ligaments, tendons, muscles, discs, or nerves in that region, and quite often we really do not know which of those structures has been injured specifically, causing us to feel pain.  (See blog entry #1)  Nonetheless, if you feel significant pain after you’ve lifted something heavy, fallen, or twisted unexpectedly or excessively, almost certainly you’ve caused some disruption to some part of your spinal column.

When that happens, the nerves in the area – even if they themselves are not the main structure injured – send a signal to your brain that something’s wrong, and that signal is perceived as pain.  In some sense, it’s an alarm going off telling you to stop whatever it is you’re doing that’s causing injury.  (If it hurts when you do that – don’t do that!) Our body will then start the process of limiting the damage and then repairing it.  We usually refer to this as the inflammatory response, which is, for the most part, a natural occurrence.  The swelling and pain that often accompanies this response is designed to tell us to take it easy for a while until the injured part has healed, a process that usually takes anywhere from 2 to 8 weeks, depending on the severity of the injury.

The important thing to realize is that, without our brain, there would be no pain, sort of like there being no sound from a tree falling if no one is in the forest to hear it. So, in a real sense, pain is in your head, at least as far as perceiving it even if the problem starts elsewhere.

But what about chronic pain?  Is it the same thing?  The answer is – yes and no.

Chronic pain is still related to what our brain perceives, but the difference is what causes it.  While acute pain is clearly generated by nerves in the area of the injury, recent research appears to indicate that chronic pain may not be.  Exactly where it comes from had been a complete mystery for a long time, since we know that chronic pain persists long after the injured tissue had healed.  If it wasn’t coming from the injured area, where was it coming from? This didn’t just mystify physicians and therapists; patients intuitively knew this didn’t make sense, which is why so many would ask “Is this all just in my head (i.e., imagination)?”

The answer appears to be, it is in your head, but in a very real, and not imagined, sense.  Experts in the field now believe that patients who suffer from chronic pain are experiencing a malfunction of sorts in the nervous system, whereby the pain-sensing centers of the brain have created a looping playback of the original signals received from the nerves in the injured structures.  While those nerves are no longer sending a message to the brain, your brain is sending the message to you that says “Ouch!”

Many people have a hard time accepting that this can be the case since, in the instance of musculoskeletal injuries such as the ones we see in the spine, movements or positioning that seemed to increase the pain in the acute stage still do likewise in the chronic condition, so it seems logical to assume there is still a problem at the original site.  There is evidence, though, that this is due to a learned response in the brain that is exclusively responsible for the felt pain or at least exaggerating it.  In the latter case, it is thought that the whole nervous system has become over-sensitized, so that even a little stimulation to a structure – which under normal circumstances would not even be felt – is perceived as painful.

An excellent example of this phenomenon that may help illuminate this mystery is the condition known as “phantom-limb pain,” which is a very common condition experienced by patients who have undergone a limb amputation.  A large proportion of such patients will describe feeling pain in a foot or hand that no longer exists, and this has been documented for centuries.  Physicians thought for years that it was generated by the nerve endings in the remaining limb stump, but have come to understand that it actually is due to the changes in the brain that occurred as a result of the pain felt in that area prior to the amputation.

Why do most people recover within a few weeks from an injury while others go on to develop this chronic pain?  Well, that is still not well-understood.  There is speculation that stress and anxiety play a role and there is even recent research that implicates a genetic factor.  Much work in this area remains to be done before we can claim to really know the best ways to address this problem.

So why is what we do know, this new knowledge on chronic pain important?  It turns out that simply understanding the mechanisms of chronic pain helps patients overcome it to some degree, if not completely.

We have known for years that exercise is probably the most effective intervention for chronic pain, but getting patients to buy into this was difficult since that exercise often increased pain and, understandably, fear that it was causing further “damage.”  Understanding the true nature of this pain and accepting the premise that “hurt does not always equal harm” helps reduce that fear, which reduces anxiety, which reduces pain, which allows more exercise, which further helps reduce pain, etc.  In other words, it dials back the haywire loop in the brain. 

Is this approach to treating chronic pain always successful?  No – and that may be due to other factors that are beyond the scope of this explanation of the causes and nature of chronic pain.  But it has been shown to be effective enough of the time to warrant serious consideration by anyone suffering from this all-too-common problem. Certainly, it is a viable and preferable alternative to the over-prescription of opioid medications that are wreaking havoc throughout our country.

 

 

A Heavy Lift

I recently received a request for information on how to avoid injuring one’s back when lifting heavy items.  So, I thought that might be a good topic to include in this blog since almost no one forever escapes hurting themselves while trying to get large grocery bags out of the car trunk, moving a garbage pail, or even hoisting a baby out of a crib.

Unfortunately, this is even more true as we age, as the muscles of the back get weaker and the supportive ligaments and discs of the spine become less resilient, leading to instability of the spinal joints.  While the muscles can be strengthened through exercise, the other structures may not be as responsive to active training, not that it shouldn’t be attempted.

Perhaps another way to protect yourself is to have a good understanding of the proper mechanics involved in safely lifting something large and/or heavy. There are good and bad ways to lift things, and many times people have false information on what those are.

First and foremost is the advice often given that one should maintain the inward arch in the lower back while lifting, forcing a sort of Chuck Berry, duck-walk position that might look something like this:

Squat-lift-arched.jpg

 

Turns out this actually de-stabilizes the ligaments and discs of the back, making it more likely you would suffer a sprain or strain.  It is actually safer to maintain a neutral, or even slightly flexed low back that would look like this:

flexed lift.PNG

In both images, though, you’ll notice that the lifter is squatting and has the object close in to the body, and this is actually the most important thing to keep in mind whenever you lift.  The riskiest position for lifting is one where you are leaning forward with straight legs…

lifting.gif

…or with outstretched arms, such as when lifting a box or grocery bags from the trunk of a car, or perhaps trying to lift a child from a crib or stroller…

 

In these cases – in all cases – you want to try to bring the object as close in to your body as possible and use your arms and legs to do the bulk of the work:

correct baby lift.jpg

Another technique to use when reaching into the car trunk or even for lifting a light object from the floor is known as the Golfer's Lift.  If you can, use one hand to steady yourself by holding onto something, then lift one leg behind you as you lean forward:

golfers lift.jpg

The most important thing to remember is that often, discretion is the better part of valor. Know your limitations!  When I have to lift something really heavy, I often just use my index finger – to point to a young, strapping lad to help!

young lifter.jpg

 

 

 

 

Benefits and Pitfalls of MRI tests For Back Pain

MRI (Magnetic Resonance Imaging) exams have been around now for more than a quarter century.  When they first arrived, they were greeted by the medical community and public as nothing less than the discovery of the Holy Grail.

The common perception of the lay public is that viewing an MRI is like looking through a window into the inner workings of the body.  Unlike X-rays, which can only visualize bone tissue for the most part, the advantage of the MRI is that it can provide an image of soft tissue structures, such as spinal disks, muscles, tendons, ligaments, and cartilage.  An expectation quickly grew among both healthcare professionals and patients that, without an MRI, an accurate diagnosis of the cause of neck or back pain was not possible.

Research studies over the past 20 years, however, raise serious questions about this assumption.  The link below will take you to an online article from PainScience.com that gives a nice overview of this topic.  After looking at it, I hope you will think twice before asking your doctor (or accepting their recommendation) for an MRI at the first sign of back (or shoulder or knee or ...) pain.

https://www.painscience.com/articles/mri-and-x-ray-almost-useless-for-back-pain.php