“Somedays it takes me about 45 minutes to get on a pair of briefs”, said one of my patients with Parkinson’s Disease (PD).
As a physical therapist, I knew that we had to solve this problem. Spending 45 minutes of life donning clothing is no way to live.
If you are reading this and have PD, you may know what I am talking about. For those of you who are not as familiar with PD, this is a small window into the world of living with PD.
And when the problem of donning clothes reaches this level, it significantly reduces quality of life. It is not only the frustration that the patient with PD experiences, but the further drain on his or her already limited energy.
Without exception, the number one complaint I get from all of my patients with Parkinson’s Disease is fatigue. To those of us living outside of the PD world, we might think that the tremors and mobility impairments are the number one complaint—and they are a big deal. But the fatigue component trumps them all. Why? Because fatigue means that one can spend less time in life enjoying the company of others and engaging in activities that bring him or her joy and purpose.
Why can it be so hard to get briefs on when one has PD?
Stiffness and rigidity: PD causes stiffness and rigidity throughout the body, particularly in the spine and hips. This can make it difficult and/or painful to bend forward towards the feet or bring a knee up to lift a foot through the leg hole of a pair of briefs.
Motor initiation, planning, and sequencing: With PD, some of the tasks that one used to take for granted and didn’t even think about (i.e., putting on clothes, getting out of a chair) become very difficult. Sometimes getting the tasks started is the hardest part. And when a task involves a series of steps, such as putting on briefs (i.e., orienting the briefs properly, getting legs into the right holes), becomes very difficult.
Reduced amplitude of movement: Typically, once we learn how to do a motor tasks in our lives, we have an automatic program in our brain as to how much effort or force is needed to accomplish the task. For instance, getting into and out of a chair is easy because the brain “knows’ how much force should be put through the legs to rise from the chair. If the chair is exceptionally low, the brain knows that more force is needed through the legs vs. if the chair is a higher. With PD, people lose that sense of calibration and not enough effort/force is put into the movement and the task is not accomplished. Most of my patients come to physical therapy with complaints of falling back into a chair when they try to come to standing. Their brains have recalibrated the motor program for getting out of a chair. This recalibration occurs across all movements including fine motor skills, that are needed to handle a pair of briefs and orient them properly for donning.
Tremors: Tremors that are characteristic of PD obviously hinder motor tasks—especially fine motor tasks that take precise grip to open up and orient a pair of briefs for donning. And when a task becomes more difficult, people with PD often experience worsened tremors.
So what can a physical therapist do for a patient with PD who cannot get his briefs on? It depends on the individual’s characteristics, but what follows is an outline of the approach that I take:
Determine the patient’s primary limitations in putting on briefs. Some people exhibit stiffness and rigidity as their primary issue. If this is the case, we spend time working on mobility and stretching to regain range of motion in the spine, hips and other lower extremity joints. We make sure the motions of putting on briefs are possible. For other people, they have the available range of motion needed to put on briefs, but they are not putting enough effort or force in to make the task possible. For example, they cannot lift their foot high enough to get it into the leg hole on the briefs. For other people, it’s the fine motor skills that are the biggest limiting factor. Sometimes getting the briefs opened up and properly positioned to facilitate donning is the biggest problem. And sometimes, it’s a combination of all of these issues.
Design a rehab program that targets the biggest limitations and practices the skill of putting on briefs. More than likely, there is combination of limitations described above that need to be addressed. A comprehensive program might work on fine motor skills with one’s hands, mobility and flexibility and recalibration of force needed to accomplish the task of putting on briefs. For the latter, LSVT-BIG exercise is a well- researched exercise program that works very well for retraining the brain to initiate movements with greater force to make everyday tasks possible. LSVT-BIG is backed by over 25 years of U.S. National Institutes of Health research as being effective and can have long-lasting effects post physical therapy treatment. Weber Physical Therapy and Wellness is one of the only physical therapists in Southeast Idaho to offer LSVT-BIG treatment.
Take comorbidities into consideration that complicate one’s life with PD. In the life of someone with PD, PD often takes center stage. However, other health issues layered on top, may make things even more difficult. To maximize the benefit from physical therapy, these other problems need to be taken into consideration. For instance, it is common for people with PD to struggle with dementia, visual deficits, other orthopedic injuries/pain that exacerbate the issues that they already stem from having PD.
The patient quoted at the top of this article had a unique presentation in that it was actually his comorbidities that were limiting his ability to don his briefs. He saw double up close and had dementia that caused him to hallucinate at times. He had some motor planning deficits that would get him “trapped” in a position, bent over with the brief only around the tips of his toes. And that is where he would stay for 35 minutes. And that was after the 10 minutes it would take him to fiddle with the briefs to open them up and find the leg holes—seeing double makes this very difficult. As a physical therapist, I cannot fix someone’s vision, but I can adapt a task so that it might get around some of the problem.
I built this patient a dressing aid that holds his briefs open for him so he can easily see the leg holes. And since the device holds the briefs open, he doesn’t have to hold onto them and can focus on just getting his legs into the leg holes. Once his feet are in place, he just has to grab the waist band and pull up. That’s it.
This device allows him to get his briefs on in 3 minutes or less. Saving him 42 minutes to do things that he loves and make his life full.
If this story sounds similar to your situation or that of someone you love, consider physical therapy. As a physical therapist I provide tailored, one-on-one services for patient driven success. You can ‘wear the pants’ again.
Carolyn F Weber, DPT, PhD is one of the only physical therapists in Southeast Idaho who is certified in LSVT-BIG treatment for Parkinson’s Disease. She provides one-on-one physical therapy and fitness programming for clients with Parkinson’s Disease in the comfort of their homes. Medicare of Idaho and Railroad Medicare insurances are accepted. You do not need a doctor’s referral to get started—just call or email Carolyn to set up your first appointment.
Carolyn also leads an exercise group on Wednesday’s at 5 PM at the River of Life Church located at 1211 S 5th Ave, Pocatello, Idaho 83201. This class is FREE, but space is limited. Email Carolyn for more information or to her know that you want to reserve your space in the class.
“Fall” is a four-letter word, in more ways than one, especially as people enter their later years. Most of my older patients know full well that falls can be associated with broken bones and quick decline. Most of my patients over 70 have some kind of loss of what is commonly referred to as “balance” and this is exacerbated by Parkinson’s Disease. Balance is one of those things we take for granted until we realize that it is becoming compromised. The lyrics by Tom Keifer (performed by Cinderella) sum it up pretty well in that regarding balance you “don’t know what you got ‘till it’s gone”.
Balance is often talked about as one thing, but it’s actually pretty complicated. To simplify things a bit, your overall ability to maintain your balance (i.e., stay standing upright) is dependent on how well three major things in your body are functioning:
vestibular system. The vestibular system is located in your inner ear and sends signals to your brain about motion, head position and spatial orientation. The brain integrates all of this information and then sends signals to the rest of the body to stabilize our head while we move and maintain posture so we don’t fall down.
somatosensory system. There are specialized structures located throughout your body that tell the brain where your joints (e.g., knees, hips, ankles) are in space and allow you to feel textures, pressure and temperature on the surface of your skin. As we will discuss, the working ability of sensory receptors in the soles of your feet play an especially important role in balance because they literally allow your brain to feel what you are walking on and where they are in space.
visual system. Your eye sight is important for seeing where you are in space and for telling your brain what may exist in your environment that could challenge your ability to stay upright (e.g., slick surfaces, rocks to step over, stairs).
For more information on the vestibular system:
Your brain is able to integrate signals from the three major systems listed above and then send signals to your muscles (also known as motor output) to adjust your posture, take a step, tilt your head—whatever you need to do to prevent yourself from falling. This obviously happens very quickly—in a tiny fraction of a second—when working optimally. For most of our lives this happens without us even thinking about it.
However, as we age, so does our vestibular, visual and somatosensory systems, and they don’t work quite as well as they used to. When the systems that control our balance begin to decline, our ability to navigate environments we once used to, such as curbs and bumpy sidewalks, becomes compromised. Balance is also affected by a person’s mindset, fatigue/attentional capacity, muscle coordination and integrity of the skeletal system. If you are distracted by someone shouting hello to you or you have lasting effects of injury (limited joint mobility), these are going to further challenge you balance. Furthermore, when you superimpose disease, such as Parkinson’s Disease, on top of an aging visual, vestibular, and somatosensory system, one’s ability to maintain upright posture—or prevent falls—-becomes even more compromised.
Although commonly known for its association with advancing type 2 diabetes, peripheral neuropathy has also been noted to be common in people with Parkinson’s Disease (Viseux et al. 2020). Peripheral neuropathy is characterized by poorly functioning nerve fibers in the soles of the feet that transmit information to the brain, allowing one to experience touch, position in space (proprioception), vibration, pain and temperature. The transmission of this information to the brain is critical to maintaining your balance and avoiding stepping in places that may cause injury. Romagnolo et al. (2018) estimates that 55-75% of patients with Parkinson’s Disease who are treated with levodopa (by oral or intestinal infusion) could develop peripheral neuropathy. The reason for developing peripheral neuropathy is unclear and it may also be linked with vitamin B12 deficiency and/or degradation of nerve fibers in feet and other parts of the body.
So the question is, how can we best prevent falls for people with Parkinson’s Disease?
Improving balance requires a multi-faceted approach. Central to this approach is working with a physical therapist to improve strength and ability to use the visual, somatosensory and vestibular systems together to the best of your abilities. A physical therapist can provide a safe environment in which one’s balance can be challenged, but injury can be avoided. Optimizing balance also includes a checkup on the three major systems that contribute to balance. This includes making sure that one is doing everything he or she can to preserve the health of one’s eyes and improve eyesight to the greatest extent possible. Has a person been putting off dealing with cataracts? Now may be the time. How is the health of the vestibular system and ears? Believe it or not, a buildup of wax in your ears can interfere with balance. Other more serious problems such as vertigo, Meniere’s Disease, acoustic neuroma, and vestibular neuritis can also interfere with your vestibular system. If you suspect or know that these are problems, then you need to see an ENT (Ears Nose and Throat specialist), neurologist and may even be referred to a physical therapist depending on the root of the problem. Another piece of the approach is making sure that one is maximizing the sensory information coming up to the brain from their feet to better inform the brain about where the feet are in space and what kind of surface they are standing on. And this is the best news: recent research has shown that increasing the sensory stimulus to the feet can enhance motor control for improved balance (Viseux et al. 2020).
Sensory stimulus to the feet can be enhanced through the use of textured insoles.
Research recently reviewed by Viseux et al. (2020) indicates that textured insoles can help not only people with Parkinson’s Disease improve their walking and balance, but also people with multiple sclerosis and healthy people too. Wearing textured insoles has been found in studies to decrease body sway from right to left (Qui et al. 2013; Robb and Kelley, 2000), improve postural stability even with eyes closed or standing on foam surfaces (Qui et al. 2013), increase step length (Qui et al. 2013), decrease the number of steps needed to complete a 180 degree turn (Robb and Kelley, 2000), improve functional reach tests (Volpe et al. 2017), improve single leg stance time and muscle activation in the lower leg (Jenkins et al. 2009) and improve ability to feel the bottom of the foot (Lirani-Silva et al. 2017).
How quickly are results achieved after wearing the insoles? Studies used different time frames for testing, but improvements in two studies were noted immediately (Jenkins et al. 2009; Qui et al. 2013).
What’s more is that data indicates that long-term use of insoles may promote increased representation of the bottom of the foot in the primary somatosensory cortex of the brain which improves ability to feel the bottom of the foot (Qui et al. 2013).
Where can you get such insoles? Below is a listing of some examples. As a disclaimer, I have no financial connection with any of these companies and I am not necessarily promoting their products—I am merely providing examples:
If you are wondering about the specific details of the research studies examining the effects of wearing textured insoles on balance and walking, please see brief summaries below:
Qui et al. 2013:
Participants: 20 healthy people and 20 people with Parkinson’s Disease
What was done in the study: Participants stood on firm and foam surfaces while barefoot, wearing smooth insoles, and while wearing textured insoles. While doing this, standing balance was measured using a force plate. Specifically, the data included measures of anterior -posterior and medial lateral sway.
Results: Only the textured insoles decreased medial-lateral sway in the Parkinson’s group on firm and foam surfaces.
Robb and Kelley 2020:
Participants: 7 people
What was done in the study: The dynamic stability of participants was examined wearing footwear only, footwear with a textured insoles or footwear with a nontextured insoles. Measurements were collected at the beginning of the study, 4 weeks later and 5 weeks later.
Results: Improved dynamic stability was noted in the frontal plane and the number of steps required to make a 180-degree turn was reduced in those wearing the textured insoles.
Volpe et al. 2017:
Participants: 20 people with Parkinson’s Disease
What was done in the study: All participants performed balance training for two weeks (5 days per week). Half of the participants wore textured insoles. Measurements on functional reach testing was completed at the beginning of the study, immediately following the 2-week balance training program and 4 weeks after the balance training ended.
Results: People who wore the textured insoles had improved functional reach tests even after the balance training program had ended.
Jenkins et al. 2009:
Participants: 40 people with Parkinson’s Disease and 40 age-matched healthy controls
What was done in the study: Study participants wore ribbed insoles (these are insoles with a ridge around the border of the insole) and regular insoles during separate walking trials. Single leg stance time was measured while walking as well as electromyography measurements of lower leg muscles.
Results: wearing ribbed insoles improved single leg stance time during walking and anterior tibialis activation was improved according to EMG measurements.
Lirani -Silva et al. 2017:
Participants: 19 participants with Parkinson’s Disease
What was done in the study: At the start of the study, sensation in the bottom of the participants’ feet was tested using Semmes-Weinstein monofilaments. At the start of the study, all participants had their walking filmed for stride length measurements. All participants wore textured insoles for 1 week and the same measurements were taken again. Participants were instructed to wear regular insoles for the week following the study. After the week following the study, a third set of measurements was collected.
Results: After one week of wearing textured insoles, stride length and sensation in the soles of feet were improved. After one week of wearing regular insoles (following the one week with textured insoles), plantar sensation improvements were still present, but walking improvements were not. Study authors concluded that continuous use of insoles may be needed to improve gait.
Jenkins et al. 2009. Plantar cutaneous sensory stimulation improves single limb support time, and EMG activation patterns among individuals with Parkinson’s Disease. Parkinsonism and Related Disorders. 15:697-702.
Lirani- Silva et al. 2017. Continuous use of textured insole improved plantar sensation and stride length of people with Parkinson’s Disease: A pilot study. Gait and Posture. 58: 495-497.
Qui et al. 2013. Effects of textured insoles on balance in people with Parkinson’s Disease. PLoS. ONE: 8(12). e83309.
Robb and Perry. 2020. Textured foot orthotics on dynamic stability and turning performance in Parkinson’s Disease. Journal of Motor Behavior. 52: 396-403.
Romagnolo et al. 2018. Levodopa-induced neuropathy: a systematic review. Movement Disorders Clinical Practice. 6:96-103.
Viseux et al. 2020. Postural instability in Parkinson’s Disease: Review and bottom-up rehabilitative approaches. Clinical Neurophysiology. 50: 479-487.
Volpe et al. 2017. Effects of a sensory-motor orthotic on postural instability rehabilitation in Parkinson’s Disease: a pilot study. Journal of Clinical Movement Disorders. 4:11.
Masks, fear, illness, death, economic shutdown, hoarding and empty grocery store shelves. These things are forever etched in the history books of 2020 in association with the COVID19 pandemic. Pre-pandemic, most Americans were fortunate enough to have never experienced any problem with food supply and took fully stocked grocery stores for granted. However, for years, food production and distribution processes have been vulnerable to breakdown in the face of environmental, economic and sociopolitical crisis. The COVID19 pandemic has merely illuminated this. But the problem runs deeper than simply not having the grocery store shelves fully stocked. Even when contemporary food production and distribution processes are running smoothly, they produce foods that have diminished nutritional value by the time they get to the grocery store shelves. And it gets worse every year. To put it simply, the broccoli in today’s produce section has less nutritional value than the broccoli of 5 years ago. The declining nutritional value of our food has been a key driver of the rise of illness resulting from metabolic disorders in the United States. And those with metabolic disorders have weakened immune systems and are more prone to illness such as COVID19. All of the processes associated with production, distribution and waste management, otherwise known as our “food system” is intimately intertwined with human health.
And the intimate relationship between our food system and human health is exactly why I care about this as a physical therapist. Lack of access to healthy foods lowers the potential for all of us to lead active and healthy lives. Poor nutrition is even the root cause of why people end up in physical therapy in the first place. I spend part of my time as a physical therapist working at a skilled nursing facility. We frequently receive patients from hospitals that have been diagnosed with metabolic encephalopathy, which alters ones mental state. The cause of metabolic encephalopathy is often liver disease, uncontrolled diabetes and kidney disease, which for many people is preventable with good nutrition. Poor nutrition also increases the risk of infection and often our metabolic encephalopathy patients come in after they’ve suffered a urinary tract infection. While these types of metabolic encephalopathy are reversible with overcoming infection and getting metabolism back in check, these people spend weeks in recovery and develop severe weakness and difficulty with daily activities (i.e., walking, getting out of a chair). This health decline often results in significant loss of quality of life and for some causes them to lose their ability to live independently. Furthermore, lack of access to good nutrition is especially problematic for people overcoming injury or coping with chronic illness. The outcomes that I can help my patients achieve through physical therapy interventions (i.e., increased strength, endurance, mobility, decreased pain) are diminished when they don’t have access to healthy foods that complement their physical rehabilitation. The role of nutrition in our physical well-being is not to be underestimated.
COVID19 has monopolized the news in terms of illness and death rates, for obvious reasons, but it is interesting to put some facts and figures into perspective. About 50% of Americans have diabetes or are pre-diabetic and 530,000 people die annually in the U.S. due to poor nutrition, which is almost 1500 deaths per day (Dr. Mark Hyman podcast: What does food have to do with COVID19?). By comparison, about 265,000 people have died from COVID19 in the US so far this year, with only about 1 month left in the year. This is absolutely not to diminish the gravity of the COVID19 situation or diminish the value of the lives that have been lost due to it. However, it is important to point out the magnitude of the nutrition problem in the U.S. Most perceive that malnutrition is a problem that is restricted to 3rd world countries. Not so. What’s more is that poor nutrition and COVID19 have an important linkage. People who are more vulnerable to COVID19 infection and subsequent death are those that are “metabolically compromised”. Good nutrition is necessary to have a strong immune system to fight of infection of any kind—including COVID19. Specifically, one might consider zinc, vitamin A and vitamin C which are critical, among other nutrients/vitamins, for a strong immune system and nearly 40% of Americans are not getting adequate daily intake of these. The short story is that our resilience against death from COVID19 or any infection could be drastically improved through good nutrition that supports our immune system. Should I mention at this point that 60% of your immune system resides in your gut? Hyman podcast: What does food have to do with COVID19?) Yep. That means the quality of the food you eat is of utmost importance.
OUR VULNERBLE FOOD SYSTEM AND HOW IT IS COMPROMISING OUR HEALTH
To illustrate why food insecurity exists as well as the relationship between the food system and human health, let’s examine the three major parts of our food system and their vulnerabilities to environmental, economic and sociopolitical crises:
Food Production/Processing: In the United States, food production utilizes 50% of land and 80% of the total freshwater that is consumed (Gunders, 2012). This rate of water usage is faster than aquifer recharge in some regions (Sachs 2015). Food production also depends heavily on fertilizer and pesticide application, which is adversely impacting ecosystem biodiversity (Sachs, 2015). Additionally, farming is increasingly focused on the mass production of fewer staple crops (i.e., wheat, corn and soy). Reduced crop diversity reduces the nutritional value of the average diet and makes food production less resilient to environmental change (Khoury et al.,2014; Hunter et al.,2016). For instance, should an insect that damages wheat dramatically increase in abundance during a particular growing season, a region that is focused solely on mass production of wheat will have its entire product decimated. On the contrary, a region that is producing greater crop diversity, might still, on the whole, be successful that season. The amount of processing a particular crop requires has been especially highlighted by the pandemic. During COVID19, meat producers got hit especially hard as workers became infected with the virus and were unable to work. Slow production increased prices and slowed supply of meats across the country. In contrast produce that is processed in more automated ways using machinery (e.g., nuts) was less affected by the Pandemic.
Food Distribution: Much of America’s produce is transported over long distances from farms to urban centers. This transport consumes 10 % of the total energy budget in the U.S. (Gunders, 2012) and contributes to food waste as it spoils or is contaminated enroute (Sachs, 2015). The average meal in the U.S. has traveled 1500 miles from farm to table (CUESA). By the time produce has traveled 1000 miles or more to its destination, it has likely lost substantial nutritional value (Rickman et al.,2007). Reliance on these long food distribution routes threatens food security in urban areas, where over 54% of the World’s population is concentrated (UN, 2018); Reliance on food supply from distant regions puts sustenance of Urban centers at the mercy of natural disasters in distant locations. For instance, when people of the intermountain West rely heavily on produce from California’s Central Valley, their food supply may suffer in the event of large wildfires in California. Furthermore, urban reliance on food produced in distant locations limits accessibility to produce that has short shelf-lives and, therefore, poor transportability. This in turn, increases urban dependence on heavily processed and packaged foods that travel well but do not contain well-rounded nutrition. Many urban areas are turning into “food deserts” in which people do not have ready access to a complete compliment of required nutrients (Walker et al.,2010). Many pre-packaged foods contain excessive amounts of calories, but lack the well-rounded nutrition (i.e., sufficient amounts of vitamins and minerals) that humans need. As a result, urban areas experience a dichotomous problem of nutritional excess, yet insufficiency. This is exemplified by one-third of the world’s people being overweight and/or undernourished (Sachs, 2015; Garnett, 2013; Remans et al.,2014). This problem impacts countries of every economic status (Garnett, 2013). It is now estimated that 19 million Americans now live in food deserts and the Pandemic could double the number of people across the globe that are experiencing food insecurity (Silva, NPR, 27 Sep 2020). Food insecurity may have hit as many as 23% of American households in early 2020, up from 10.5% (13.7 million households) last year (Silva, NPR, 27 Sep 2020). These numbers include people who were not able to obtain enough food to meet their needs or had uncertainty in how to obtain their next meal (Silva, NPR, 27 Sep 2020).During the COVID19 pandemic in early 2020, issues surrounding distribution were observed in the dairy industry. For instance, dairy producers that package and sell to restaurants and schools could no longer do so as restaurants and schools closed during the pandemic. Because of the specificity of their production and distribution lines to restaurants and schools, dairy companies were not able to quickly pivot and redirect milk to other end users. This resulted in a lot of dairy products in both the US and the UK being dumped.
Food Waste Management: 40% of the food produced is never consumed, comprises the largest component of municipal waste and is responsible for a large fraction of annual methane emissions in the United States (Gunders, 2012). Food waste occurs at several different points during its life cycle: 1) food spoil and are thrown away during transport from farms to urban centers, 2) Food spoils or expires on store shelves or in consumer’s homes before it can be eaten, 3) food is wasted during meal preparation in the home (i.e., broccoli stems are trimmed and thrown away instead of eaten), 4) people don’t eat 100% of each meal that they prep and the unwanted food is thrown into the trash. Uneaten food contains vitamins and minerals, that, if composted and returned to the soil, could be used to fuel the production of more nutritious food. But instead, food that is thrown into the trash makes its way to the landfill where nutrition is lost forever rather than being used to recondition our soils and thus allowing us to continue producing food with high nutritional value. In throwing food into the landfill, we are defeating the natural process of composting that replenishes soils of their nutrients. This in combination with farming processes increase erosion and result in nutrients being leached out of soils and washed into rivers and waterways has greatly diminished the quality of our soil and our ability to produce nutritious food. Food waste increased during the COVID19 pandemic as producers were unable to redirect their product to alternative consumers. Potato farmers in Idaho were left with piles of potatoes in the fields that went to waste because restaurants were closed. Some of these potatoes were redistributed to the average consumer and some were trucked off to New York (what did we say above about the problems of long transport lines?), but more waste than usual was incurred. Even cabbage farmers in India, who rub elbows with starving neighbors had excess food waste secondary to people losing their jobs and being unable to buy the produce. But the COVID19 food crisis was not limited to third world countries—it hit hard in the United States too, with many people needing assistance from food banks as jobs dried up and people became unable to afford basic needs (Martin, NPR, Sep 27, 2020). It is estimated that nearly 1 in 4 households in America have experienced food insecurity this year (Silva, NPR, Sep 27, 2020).
Our food System Creates Mineral Deficient Foods
To specifically illustrate how our food system fails in producing food with maximal nutritional value—even in the absence of a Pandemic– we can talk about minerals (i.e., iron, zinc). Because our food system generates foods that are deficient in minerals, over 60%, 30% and 15% of the World’s seven billion people are iron, zinc and selenium deficient, respectively (White and Broadley, 2009). Rates of mineral malnutrition are especially high in Asia and Africa (Muthayya, et al.,2013), where soil degradation is especially severe and has significantly decreased the nutritional value of crops (Lal, 2009). Iron, zinc and selenium are just three of the minerals that the human body needs for overall health and wellness—there are many more, but are beyond the scope of this article. Using iron, zinc and selenium as examples, here are some of the profound effects that they can have on our health in general and can specifically affect one’s course through physical therapy/rehabilitation:
Iron is critical for proper nerve functioning, temperature regulation, immune system function—just to name a few important things. It is also critical for the ability to brain derived neurotrophic growth factor to signal other neurons and assist one’s body with learning new motor patterns—a concept known as neuroplasticity. After neurological injury (i.e., stroke) or in the presence of a degenerative neurological condition (i.e., Parkinson’s Disease) it is especially important that good nutrition be part of a physical rehabilitation program so that the body can optimally learn and perform new movement skills.
Zinc plays important roles in motor function (again, especially important for physical rehabilitation!), immune system function, mood and improving attention span (both of which are critical for learning!).
Selenium is very important for cognitive function, immune system support and thyroid metabolism. Thyroid metabolism is critical in maintaining one’s energy and mood and motivation for effortful things such as physical rehabilitation.
More than likely, you or someone you know are affected by one or more of these deficiencies. And with improved nutrition, their overall quality of life and ability to maximize their potential could be greatly enhanced.
WORKING TOWARDS SOLUTIONS
The solution lies in getting to the root of the problem—literally. To summarize in the simplest way possible: 1) The problem begins with our soils, which are being more and more nutrient depleted through the years and crop plants do not have access to enough nutrients to produce a nutritious end product. 2) We then transport food long distances from farm to table, during which it loses more nutrition. 3) We then throw away a lot of food either as it spoils enroute to supermarkets, during prep or after it spoils in individual households; the food that goes to the landfill rots and produces greenhouse gases rather than being composted by mother nature to replenish the soil for growing the next crop. This means that we need a three-part solution which includes the following 1) bringing the farm closer to the table, 2) reducing overall food waste and 3) properly composting unavoidable food waste in order to replenish our soils with the nutrients needed to grow the next nutritious crop.
There are solutions in the works on bigger scales through the regenerative agriculture movement, which is shifting farms away from traditional industrial farming. Regenerative agriculture includes methods that do not apply chemicals and fertilizers at massive scales, involve no till methods to preserve our soils and, overall, work with mother Nature rather than against her. A review of regenerative agriculture is beyond the scope of this article and you can learn more about that here: Dr. Mark Hyman. Can regenerative agriculture really heal humans and the planet?. While regenerative agriculture could greatly improve the quality of the foods that are being produced and prevent degradation of the land, it requires wide adoption across the United States to make it effective in improving public health which will take time and it does not necessarily solve the fact that food would still be traveling 1000’s of miles to market. We need a solution in the interim that people can act on now and have healthy food on their table quickly.
So what is a concerned physical therapist to do? Let’s first talk about the role of a physical therapist in patient nutrition.
A physical therapist’s role in patient nutrition
It’s been slow for the masses—and even those within the physical therapy profession—to realize and embrace that it is within our scope of practice to educate patients on nutrition. In fact, in a seminal paper published back in 2009, physical therapist Elizabeth Dean, stated that “….physical therapists are uniquely qualified to lead in the assault on lifestyle conditions” (Dean 2009). She also goes on to note that in leading the assault on lifestyle conditions, physical therapists are positioned to promote the health of communities. The American Physical Therapy Association’s stance on the role of physical therapists in patient nutrition is that “it is within the professional scope of physical therapist practice to screen for and provide information on diet and nutritional issues to patients, clients, and the community.” (APTA). While physical therapists certainly don’t replace registered dieticians who can come up with very specific nutritional plans, physical therapists can be instrumental in screening for nutritional red flags and educate patients on what avenues might be good to go down with their nutrition as well as what specifics may be important to pay attention to given a patient’s unique situation. For example, those with rheumatoid arthritis may want to consider a Mediterranean Diet which has been shown to reduce overall levels of inflammation in the body (Arthritis Foundation).
However, a physical therapist’s job becomes more difficult when the problem has deeper roots than someone simply not eating the right foods. Even when all of us eat the “right foods” we are likely not getting a full complement of vitamins and minerals due to our failing food system.
So can a physical therapist still play a role in solving this problem? If we take an unconventional approach, I believe the answer is yes. We need to add some elements to our education—which include empowering people to produce some of their own food. And YES. The great majority of people living in all kinds of climates and parts of the country CAN do this.
What I am doing to change the face of nutritional education
As a former professor and researcher at Idaho State University (Pocatello, ID, USA), I began developing a method for sustainable agriculture that can be implemented in even the smallest of urban apartments. My students and I determined that by composting household wastes (i.e., vegetable scraps, paper, coffee filters), we could reduce the waste of a single person household by 46% all while generating compost that we could utilize to grow nutrient rich greens—microgreens specifically. To do this, we used a commercially available vermicomposter from Uncle Jim’s Worm Farm (https://unclejimswormfarm.com). Yes—vermicomposting means composting with worms.
In doing so, individuals could reduce their dependence on buying produce from the supermarket that had traveled 1000’s of miles from the farm where it was produced using methods that are resource heavy and degrade soils. All the while, individuals could increase their food security and nutritional intake by bringing their farm and table right next to each other.
For those of you who haven’t heard of microgreens, they are the edible seedlings that are usually harvested seven to fourteen days after germination when they have two fully developed cotyledon leaves (Xiao et al. 2012). A wide variety of herbs (e.g., basil, cilantro), vegetables (e.g., radish, broccoli, mesclun) and even flowers (e.g., sunflowers) are grown as microgreens. Microgreens are generally more flavorful, some of them quite spicy, than their mature counterparts and have grown in popularity among culinary artists for adding texture and flavor accents to salads, sandwiches and other dishes (Treadwell et al. 2010; Wallin, 2013). The increasing culinary demand as well as the ease with which microgreens can be grown, even by inexperienced gardeners in urban settings, has piqued interests in growing and eating them. Interest in microgreens has also been generated by popular websites (e.g., Warner, 2012) touting the findings of Xiao et al.(2012), which indicate that microgreens may have four to 40 times the amount of some nutrients and vitamins as the vegetables a mature plant would produce. However, Xiao et al.(2012) note that the nutritional aspects they measured varied widely among microgreen types, providing fodder for future study and Weber (2016) noted that the methods used to grow microgreens (i.e., soil, compost, hydroponic) can significantly impact their nutritional value. Additionally, a systematic comparison of the environmental impacts (i.e., water use, nutrient demand) of microgreen cultivation methods has not been conducted and should be considered alongside their impacts on nutritional value when deciding how to grow microgreens and if they provide a nutrient-rich crop that can be sustainably produced.
You can also use these methods to produce baby greens which are a more mature stage of growth than the microgreen stage.
If each one of us could begin producing even some of our own produce using sustainable methods for composting household waste, we could greatly reduce out impact on the environment, increase our food security, relying less on produce that is transported 1000’s of miles and increase our nutritional intake. I call this distributed Agriculture—each household operating as its own little producer. Distributed agriculture makes one more resilient to environmental and socioeconomic change that is going on in the world outside of our homes. We specifically looked how growing and consuming broccoli microgreens could reduce impact on the environment relative to consuming broccoli vegetable that is produced in California’s Central Valley. To summarize quickly, broccoli microgreens can go from seed to harvest in 7 days (93-95% less time than needed to produce broccoli vegetable), there is no need for fertilizer, distance of transport from farm to table is zero, and the mineral nutrition the microgreens is 1.73 times that of the vegetable with respect to iron, zinc, magnesium and calcium among other minerals (Weber, 2017). The full summary of this data was published in Frontiers in Nutrition in 2017 (Weber, 2017).
In addition to the above benefits, growing one’s own food has been shown to be great for reducing stress and enhancing a sense of pride in being able to be more self-sufficient. The therapeutic effects of growing one’s own food have been proven in many studies and in case you didn’t know there is a form of therapy called Horticultural Therapy. The therapeutic effects span across all ages and include improved concentration, memory, cognitive function, fine motor skills, personal satisfaction as well as decreased heart rate, stress, and anxiety (Haller et al. 2019).
If you are interested in learning more about the methods for taking charge of your nutrition and growing your own produce at home, please contact me. I am currently producing an online course and you can be the first to know when it is being released! I have had the pleasure of teaching/Lecturing about this topic within the past few years at County Extension Offices in Iowa and the Greater Des Moines Botanical Garden (Des Moines, IA, USA). Due to the pandemic and the widespread need of this information, I am hoping that a digital course will make this more accessible to the masses.
REFERENCES CITED AND RESOURCES FOR MORE INFORMATION
Patients with Parkinson’s Disease (PD) often develop respiratory weakness and lower lung capacities. This greatly diminishes quality of life, leading to difficulties with breathing, speaking, and swallowing. Respiratory weakness can also lead to one of the most common causes of death in people with Parkinson’s Disease –aspiration pneumonia—especially in the late stages of the disease.
Individuals with PD can experience over 50% decreases in maximum inspiratory pressure and maximum expiratory pressure, which is essentially the force with which one can inhale or exhale, respectively (Sapienza et al. 2011). Poor ability to inhale may be attributable to reduced respiratory muscle strength and increased chest wall rigidity (Sathyaprabha et al. 2005), which are two common characteristics of PD.
In short, living the best possible life with PD includes taking preventative measures to reduce PD’s impact on the respiratory system. There are currently no standard protocols for respiratory therapy for people with PD, but research is beginning to show some promise for exercising the respiratory system –just like one should exercise the rest of the body.
Respiratory Muscle Training (RMT)
Research on techniques to improve respiratory health is in its infancy, but some studies have indicated that a technique called Respiratory Muscle Training (RMT) may significantly improve respiratory muscle strength (Jones and Busse, 2012). RMT involves inhaling and/or exhaling against resistance through a device called a respiratory muscle trainer.
Proper posture for respiratory muscle training (source: Sapienza et al. 2011)
Research has shown that RMT can increase respiratory muscle strength (Sapienza et al. 2011 Reychler et al. 2016). Put simply, RMT can improves one’s ability to cough, breathe, swallow and talk at normal volume. This leads to the following improvements in quality of life:
A good strong cough = clearing secretions and foreign objects from the airways
Ease with swallowing=prevention of choking, aspiration (getting food into the airways) and subsequent infection and pneumonia that could develop.
Talking with adequate volume= improved communication and social relationships.
Two forms of RMT have been examined: inspiratory muscle strength training (strength for inhaling) and expiratory muscle strength training (strength for exhaling).
In a study of 60 participants, half of which were randomly chosen to utilize a expiratory muscle strength trainer (EMST) for 4 weeks while the other group utilized a sham device, EMST was found to increase maximum expiratory pressure by 27%, improve swallowing function (Sapienza et al. 2011). Other studies have also demonstrated that EMST can improve coughing and a reduction in incidence of aspiration (Troche et al. 2010; Pitts et al. 2009). In short, EMST can make critical improvements in strength that protect lungs from aspiration and subsequent pulmonary complications.
Studies of inspiratory muscle strength training in people with PD are currently underway (Ferro et al. 2019). However, a study that has been done on healthy adults over the age of 65 does demonstrates that (IMST) may have serious benefits in improving maximum inspiratory pressure (Reychler et al. 2016). Over the course of a 4-week IMST program, 16 participants were able to increase their maximum inspiratory pressure by 38% (Reychler et al. 2016). Over the course of the 4 weeks, participants performed 15 minutes of IMST maintaining a respiratory rate of 15-20 breaths per minute; each week of the program, the resistance on their training device was increased (Reychler et al. 2016).
A device on the market that allows one to perform RMT for inspiratory and expiratory muscles is THE BREATHER (click on image below to see in store and purchase):
To see a product demo video of THE BREATHER, click here.
Using such a device, improvements in respiratory muscle strength can seen in as little as 4 weeks, but it must be utilized at high frequency daily. For instance, in the Sapienza et al. (2011) study, participants performed 5 sets of 5 repetitions of EMST exercise, on 5 days per week. Although it takes dedication, improvement in respiratory muscle strength can be seen in a little as 4 weeks according to Sapienza et al. (2011). Similarly, healthy geriatric patients had improved inspiratory muscle strength over the course of 4-weeks when practicing IMST for 15 minutes on 5 days per week (Reychler et al. 2016).
Can other people besides those with Parkinson’s Disease benefit from RMT?
In addition to benefitting those with Parkinson’s Disease, RMT can improve quality of life for those with other neurodegenerative conditions (i.e., ALS (Lou Gherig’s Disease), multiple sclerosis, Huntington’s Disease; Jones and Busse, 2012)—-and even athletes and musicians without neurodegenerative conditions.
Weber Physical Therapy and Wellness can get you started on an RMT program. As an RMT patient, you can expect the following:
initial evaluation at which you will be trained in and provided with a home exercise program.
one visit with your therapist per week for 4-6 weeks to check in with your progress and to adjust your home exercise program.
Transition to self-guided home exercise program to continue on your own for maintenance and follow up with therapist only if needed.
Ferro et al. 2019. Effects of inspiratory muscle training on respiratory muscle strength, lung function, functional capacity and cardiac autonomic function in Parkinson’s disease: randomized controlled clinical trial protocol. Physiotherapy Research Int. 24(3). Doi: 10.1002/pri.1777.
Jones and Busse. 2012. Management of respiratory problems in people with neurodegenerative conditions: a narrative review. Physiotherapy. 98:1-12.
Pitts et al. 2009. Impact of expiratory muscle strength training on voluntary cough and swallow function in Parkinson disease. Chest. 135(5): 1301-1308.
Reychler et al. 2016. Randomized controlled trial of the effect of inspiratory muscle training and incentive spirometry on respiratory muscle strength, chest wall expansion and lung function in elderly adults. Journal of the American Geriatrics Society. Http://doi.org/10.1111/jgs.14097
Ribeiro et al. 2018. Breath stacking and incentive spirometry in Parkinson’s Disease: randomized crossover clinical trial. Respiratory Physiology and Neurobiology. 255: 11-16.
Sapienza et al. 2011. Respiratory strength training: concept and intervention outcomes. Seminars in speech and language. 32(11): 21-30.
Sathyaprabha et al. 2005. Pulmonary functions in Parkinson’s Disease. Indian Journal of Chest Disease Allied Sci. 47(4): 251-257.
Troche et al. 2010. Aspiration and swallowing in Parkinson’s Disease and rehabilitation with EMST: the ASPIRE study. Neurology. 75(21): 1912-1919.
It’s summer in Southeast, Idaho and the road-biking couldn’t be any better. Long country roads in the mountains to challenge the legs and sweet-smelling air to fill the lungs.
Early Summer in Southeast, Idaho
But wherever you are, I am sure that you want to enjoy road cycling too. Now and well into the future. Key to this, is staying injury and pain free. While cycling is associated with being low-impact and lower injury risk than other sports, there are still some issues that can crop up that would be best avoided to keep the joy in joy-riding. Below are 11 tips regarding bike fit and biomechanics that are important in avoiding pain and injury.
Saddle: Be sure that your saddle is level. If you are sliding too far forward, you will have too much weight being placed on your hands, arms and lower back. If the seat is tilted backwards, you may place strain on your lower back and experience pain in your own saddle area. The saddle should be a comfortable distance from the handlebars–if it is too close to the handlebars, more weight will be placed on the arms and mid back; if the saddle is too far from the handlebars, there will be more strain on the low back and neck. Saddle height should be placed by someone who can help you assess your knee angle when you are sitting in the seat. When your leg is in its most extended position (the point in peddling when your foot is at its lowest point going around the cranks) your ideal knee angle should be close to 35 degrees (see picture below) to lessen stress on the knee. Recommended knee angles for recreation cyclists are 35-45 degrees and for road cyclists are 30-35 degrees. Your knee should be slightly bent at the bottom of the pedal stroke.
Diagram from American Physical Therapy Association.
Diagram from American Physical Therapy Association.
2. Handlebars: The higher the handlebars, the more weight will be placed on the saddle. Taller riders should have lower handlebars in relation to the height of the saddle. Proper handlebar position allows for the shoulder to make a (roughly) 90 degree angle between the upper arm and trunk. Trunk angle for the road cyclist is 25-35 degrees and for comfort/recreational riding is 35-90 degrees.
3. Foot position on the pedal: The ball of the foot should be positioned over the pedal spindle for the best leverage, comfort and efficiency. A stiff-soled show is the best for comfort and performance.
4. Hand position: Change your hand position on the handlebars frequently for upper body comfort and prevent nerve compression in the hands and wrists. Use a controlled and relaxed grip. If you are experiencing numbness in your wrists or hands the above could be a problem–or you may have bike fit problems discussed above that put too much pressure through the arms and hands (e.g., short reach handlebars, handlebars placed too low, saddle tilted forward, saddle too far forward).
5. Cadence: Or sometimes known as revolutions per minute. Each foot should be going around the cranks at a rate of 80-90 revolutions per minute (advanced cyclists 90-105 revolutions per minute)–without bouncing up and down in the seat. Maintaining a high cadence places less stress on the lower back and knees.
6. Don’t rock your hips back and forth: Your should be using your core strength to stabilize your hips so that they are not rocking back and forth. You may notice yourself falling into this when fatigued. If you are doing this right out of the gate, you may have a bad bike fit. Rocking back and forth causes friction between you and the seat and can just get plain uncomfortable.
7. Anterior (front) knee pain: Possible causes of this include pedaling at too low of a cadence (see “5” above), overusing your quadriceps muscles, misaligned bike cleat (see “3” above) and muscle imbalance in your legs (strong quads and weak hamstrings).
8. Lower back pain: you may have tight hamstrings, low cadence overuse of quads, poor back strength and too long or too low handlebars.
9. Foot numbness or pain: you may be overusing the quads, have low cadence that places a lot of pressure through the feet or a maligned bike cleat.
10. neck pain: you may have too low of handlebars, handlebars that tare too far away or too close or your saddle may have a downward tilt.
11. liliotibial band pain (ITB): your saddle may be too high, bike cleats are maligned or you may have a leg length discrepancy.
If you feel as though you need some help with bike fit or that your pain is stemming from injury, despite a proper bike fit, your physical therapist is here to help. You do NOT need a referral from your doctor–or even use your insurance–to see me. Contact me to see if working with me on your bike issues is right for you—talking is always free.
2017 USA Triathlon National Championships in Omaha, Nebraska
Physical pain is common. Everyone will experience it at some point in his or her life. Often, pain will result from an injury and will resolve when the injury heals. This is normal. This is good news for the 84% of us who will likely experience something like low back pain in our lives. It will come and go and we will go on our marry way. But for many, this pain lingers and has become the most common cause of disability and time off work in people over the age of 45 (Balagué et al. 2012). Long term, or chronic pain, that results in disability is a much bigger issue. What’s worse is that many of these people end up relying on opioid drugs (prescription and not) in attempts to manage their pain.
Opioids and the crisis
Opioid use has sky-rocketed in recent years, and drug overdose deaths are on the rise. So much so that the Center for Disease Control (CDC) has declared that we are in the middle of an “opioid crisis” and it is an epidemic. This epidemic is not just affecting the heroin addict living in the back alley. It’s everyday people who rely on opioids to cope with pain (i.e., low back pain, knee pain). The statistics are staggering:
From 1999 to 2017, more than 700,000 people have died from drug overdose.
Around 68% of the more than 70,200 drug overdose deaths in 2017 involved an opioid.
In 2017, the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was 6 times higher than in 1999.
Despite this, it is important to note that THERE IS a time and place for taking opioids—for instance, following significant surgery or injury when managing pain is difficult without them. However, prolonged use of opioids long after recovery from surgery or traumatic injury can result in addiction and can cause people to rely on opioids long term. The reason that people become addicted to opioids is that they only mask the sensation of pain—they do not alter the source of the pain. This is not to mention that the withdrawal symptoms are severe. It’s hard to get off of opioids. This is the vicious cycle of addiction. Taking opioids long term also has side effects of depression, for which many people take more drugs. This is why there are important Questions to ask your doctor about pain medication when they are writing you a prescription. Even the most well-meaning doctors can send you down the road of addiction without meaning to.
Long story short, opioids are a “bandaid” for pain and getting to the root of the problem requires understanding why someone enters a state of chronic pain. If an injury is healed and there is no more tissue damage or new injury, then why can one still hurt? This is what is important to get a handle on. Many factors play a role in creating each person’s unique “pain experience” which includes emotions, thoughts and beliefs—it’s not just physical. Read on…
Research has shown that when people understand pain, they can better manage their pain. And when one can manage his or her own pain, he or she can take life by the horns again. Simply put:
“Know pain, know gain”—David Butler
This is especially true for people dealing with chronic pain. Many people have an overly simplistic view of how pain is experienced. And I say “experienced” very deliberately. As children, we learn that doing something such as touching a hot stove or stepping on a sharp object with bare feet creates pain. These two events are generally associated with tissue damage—the skin is compromised and you get a blister or a stab wound. But the shocking thing to most people is that this pain does not originate in the injured part of the body. Pain is an experience that is created in the brain once it interprets the signals that the rest of the body send to it. So when you step on a nail, the sensory cells send signals all the way up the spinal cord to your brain where you brain interprets this event as being painful. Obviously, this occurs in fractions of second and you generally pull your foot away from the nail. In this experience, the interpretation of pain is a good thing—it signifies that there is a threat in your environment (the nail) that you harm you.
The fact that pain is an experience that is created by the brain explains why two soccer players can experience the same injury on the field and one gets up and keeps playing while the other lays on the ground crying out for help. It also explains why people can experience pain in a body part without actual threat to it. Say you had a traumatic experience as a child when you stepped on a rusty nail with bare feet and you ended up in the hospital with pain and a raging infection in your foot. Now, when you so much as look at a rusty nail you experience pain in your foot. You foot is healed and the nail is no where near your foot. Danger is absent, injury is absent……but pain is ever present. This experience is created purely in the brain.
Below are a few videos from some of the World’s leading pain experts. Watch them to learn more about how your pain experience is created ….. and how you can take control.
Below, Professor Lorimer Mosely explains how pain works. Pain evolved as a protective mechanism to indicate when the body was in danger. However, when our experiences change the way that pain is experienced and skews what the pain is indicating, it can result in a maladaptive response—or extreme fear from harmless sensation (i.e., a tree branch brushing one’s leg on a hike).
Each part of your body is represented on a specific area of the brain. There is a part of your brain dedicated to being able to detect sensation of your left pinky finger—and every other part of your body. If you experience prolonged pain in your left pinky finger, the “sharpness” of left pinky’s representation on the brain is lost and you brain can no longer create a pain experience in just your left pinky. Maybe then your neighboring fingers begin to hurt and the pain becomes more widespread. This is phenomena is known as brian smudging as explained below by expert David Butler.
If you have recurring or ruminating thoughts of your pain, that is a sure recipe for making your pain worse. Yes—pain has a significant emotional component. These recurring thoughts have been termed “thought viruses”.
Myth: getting high tech imaging of your painful area will explain the source of your pain.
Professor Peter O’Sullivan explains the discrepancy between medical imaging and pain and how thoughts, and beliefs and movement habits actually matter more.
It’s only 1% of back pain that is really serious stuff….99% has no diagnosis based on scan”. Peter O’Sullivan.
Physical Therapy is a safe alternative to opioids for pain management
If you watched the video above with Professor Peter O’Sullivan, you will have learned that many people with low back pain get medical imaging (i.e., MRI, X-rays, CT scans) that lead them to believe that their backs were really “messed up” structurally. As a result, they developed fear of further injury and starting moving (or not moving) in ways that actually exacerbated their pain—-it wasn’t the “bulging disc” that might have been found on imaging.
“Pain does not equal structural injury” –Prof. Peter O’Sullivan
Restoring healthy movement patterns in conjunction with understanding pain is essential to managing back pain. Physical therapists can help you do both. Even better, physical therapy can not only get you moving better again, they can get you back to an more active lifestyle that includes activities that you love doing. This is why the CDC has recommended physical therapy as a safe alternative to opioids for pain management.
Resources for helping managing chronic pain have been compiled by the ChoosePT movement organized by the American Physical Therapy Association (APTA).
If you would like to delve deeper into these topics, here are two books that I would highly recommend. Click on the images to see details.
Weber Physical Therapy and Wellness supports the ChoosePT movement. If you are experiencing chronic pain and would like a free consult to see how physical therapy can help you, please get in touch or schedule a free consultation: Schedule Appointment
References and helpful websites:
Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. The Lancet. 2012;4(379): 482-91.
Rundell SD, Davenport TE. Patient education based on principles of cognitive behavioral therapy for a patient with persistent low back pain: a case report. J Orthop Sports Phys Ther. 2010:40:494–501.
Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis [erratum in: N Engl J Med. 2013;369:683]. N Engl J Med. 2013;368:1675-1684.
Longo UG, Franceschi F, Berton A, et al. Conservative treatment and rotator cuff tear progression. Med Sport Sci. 2012;57:90–99.
You’ve had your baby. Other than the sleepless nights, you’re absolutely smitten. But just when it seems that you couldn’t possibly have any more love to divvy out, you’d really like to give some love to your running shoes and favorite trails.
But are you physically and mentally ready for running?
This is the million-dollar question.
Truth be told, medical guidelines for determining readiness for you to return to running are in their infancy—pun intended. Relatively speaking, there have not been a lot of extensive research studies to determine hard and fast guidelines for medical practioners to help guide you through this exciting and challenging transition in your life. However, physical therapists Tom Goom, Grainne Donnelly and Emma Brockwell, have compiled the evidence that does exist as well as their extensive clinical experience to help safely guide women back to running. What they have published is a beautiful foundation for providing advice to women at present and for building on as new research in post partum running reveals new information. I will summarize some key points from this publication below.
“Return to running is not advisable prior to 3 months postnatal or beyond this if any symptoms of pelvic floor dysfunction are identified prior to, or after attempting, return to running” (Goom et al. 2019).
Running is stressful on the body and so is child-birth. Doing these two things too closely back to back can have adverse consequences. This is evidenced by the prevalence of urinary incontinence, pelvic organ prolapse (POP), abdominal muscle separation and pain that are experienced by female runners after having a baby. Urinary incontinence and POP can result from the stress that is place on the pelvic floor muscles. For a review of the anatomy of the pelvic floor muscles click here. Post vaginal delivery, the levator ani muscles, which are part of the pelvic floor, take 4-6 months to reach maximum recovery. When you consider that the impact of running increases the risk 4.59 times of pelvic floor muscle dysfuntion (vs. low impact sports like cycling), you can start to see why it is recommended to wait at least a few months post child-birth prior to running. If you have had your baby via C-section, additional time for healing is needed. At 6 weeks post C –section, the uterine scarring is still very much healing and abdominal tissue, known as fascia, is only 51-59% as strong as it originally was. Even 6-7 month after a C-section, abdominal fascia is only 73-93% of its original strength.
What are some indicators of pelvic floor or abdominal wall dysfunction?
Urinary and/or fecal incontinence
Urgency that is difficult to defer
Heaviness/pressure/bulging/dragging in the pelvic area
Obstructive defecation: characterized by feeling that stool remains in your rectum even after trying to pass it, excessive straining, need to use laxative or enemas to pass stool
separated abdominal muscles and/or decreased abdominal strength and function
low back or pelvic pain
Ongoing or increased blood loss beyond 8 weeks post child-birth that is not linked to your menstrual cycle.
If you are experiencing any of these symptoms you are definitely not ready for running and should seek medical care.
If you are 3 months post child-birth and do not have any of the above symptoms, it is recommended that you have a complete health screening and risk assessment done to ensure readiness for graded return to running.
The screening process is recommended to cover the following:
Load and impact management assessment: Your physical therapist can assess you ability to walk, squat, hop, jog with good mechanics and without pain, incontinence or feelings of heaviness in the pelvic floor. Your pelvic floor, abdominal and leg strength should also be assessed.
Gait analysis: It recommended that your running form be reviewed to look for significant injury risk factors. This is something that an experienced physical therapist can provide for you.
Preexisting pelvic or lumbar spine dysfunction or hypermobility conditions (e.g., Ehlers Danlos): If you were having pelvic or low back issues or joint laxity prior to or during pregnancy, you should exercise caution in returning to running and this may exacerbate problems associated with joint laxity.
Fitness level: Generally speaking, women who maintained high levels of fitness before and during pregnancy, usually bounce back faster. If you were fairly sedentary and are now looking to increase your physical fitness post-baby—that’s awesome, but you’ll need to take that into consideration when trying to take up exercise and/or running.
Breathing: Proper breathing, which is important for running, may need to be restored post-baby to recreate proper synergy between pelvic floor, abdominal muscles and diaphragm.
Psychology: Postnatal depression is experienced by 20% of mothers and it needs to be considered in the context of return to running. Obsessive focus on returning to pre-pregnancy fitness and taking running to a level that is too intense for the stage of post partum recovery can result in injury.
Diastasis rectus abdominis: Core strength is important for efficient and injury free running. If you have separated abdominal muscles, you will need to rehab these to minimize injury risk with running.
Scar mobility: Adhesions in C-section scars can create tension, pain and alter the function of muscles in this region, resulting in subpar running mechanics.
Breastfeeding: maintains lower levels of estrogen and continued elevated levels of relaxin, which may or may not contribute to increased laxity of joints. Running should be timed carefully around breast-feeding so that you are not running with your breasts overly full, which can create discomfort. It should be noted here that vigorous exercise does not compromise the quantity or composition of breast milk.
Sleep: Seven to nine hours of sleep are recommended for anyone, but it is rare that new mothers get this many hours. Sleep deprivation impairs muscle strength, reduces protein synthesis and increases injury risk in any athlete.
Obesity: is a general risk factor for running injury and should be taken into account (BMI>30 increases injury risk).
Relative Energy Deficiency in Sport (RED-S): RED-S is formerly known as the “female athlete triad”. Energy deficiency occurs when one expends excess energy that is not replenished with adequate nutrition and rest. The post-partum world is full of energy expenditure via breast feeding, sleepless nights and social pressures to return to pre-pregnancy fitness. Adding running into this mix further depletes energy. Without adequate nutrition and rest, the risk of stress fractures, pelvic floor dysfunction and infertility is greatly increased.
Graded return to running
If you pass the above screening, you are ready to return to running! But this doesn’t mean that you lace up and blast out the front door like you used to. What is recommended is a graded return to running. This means slow…literally. The first time you run, it is recommended that you only run for 1-2 minutes at a slow pace. Slow pace means that you can carry on a conversation with a running partner if you needed to. In ramping up your running, you should focus initially on increasing your volume (distance or time spent running), rather than your intensity (how fast you are running). A general guideline is to not increase running volume more than 10% per week. An example of a good program to begin when you are returning to running is a “couch to 5K” program. Such a program gets you up to the 5K distance in about 9 weeks time. An example of a week one starter workout might be 20 minutes total, beginning with a 5 minute brisk walk, and then alternating brisk walking with 90 second bouts of slow running.
Your physical therapist can help
You physical therapist can help you through the above screening process, rehabilitative exercise and a safe, graded return to running. If you need pelvic floor rehab, it is advised that you see a physical therapist who is a pelvic health or women’s health specialist. However, most orthopedic physical therapists can assist you with the first line screening, strength testing and gait analysis. For gait analysis, it is recommended that you see a physical therapist who is experienced in this and understands running biomechanics. Your physical therapist(s) should work in conjunction with your OB/GYN to optimize your rehabilitation program, especially if you have symptoms listed above for pelvic floor and/or abdominal dysfunction.
Goom, Donnelly, and Brockwell. 2019. Returning to running postnatal–guidelines for medical, health and fitness professionals managing this population.