In my last entry I addressed how the physical therapist might initiate conversation about weight loss with their patient. However a plan to see your patient make a successful healthy lifestyle change that would facilitate weight loss and improved health must include information and behavioral strategies. In order to positively impact your patient and enable them to make changes that would improve their health, information alone is not enough. Research has demonstrated knowledge alone will not change behavior. Using behavioral strategies can boost the success of your patient.
APTA holds as ethically binding the principle that PTs “shall endeavor to address the health needs of society.”
It is important that the patient understands the benefits related to a healthy lifestyle change to avoid obesity related diseases and many other health issues. Equally important is for your patient to have a vision of the life that they want, activities that they would like to participate, things they have always wanted to do, but have been unable because of their weight or joint problems. Helping your patient set some goals that are important to them is one such behavioral strategy. Ask your patient to write down 4 to 5 specific things that are very important to them in regards to weight loss and improved health. Ask them to write them down on a small card that they can put in their pocketbook or wallet, and tell them to pull them out a couple times a day and read aloud.
While exercise is important dietary intakes are more important when it comes to weight loss. Simply counting calories has not been shown to be effective for long-term weight loss. However it is important that your patient is directed toward making good food choices. As physical therapists we can encourage increased fruits, vegetables, beans, and nuts to make up a large portion of their food intakes, and the avoidance of added sugars and refined carbohydrates. Research suggests this approach to food choices will facilitate weight loss and will decrease inflammation in the body. In order to be aware of their daily intakes, ask your patient to keep a food log over a seven day period, writing down everything that they eat and drink, then review their log with them and ask them how they might improve upon the choices that they’ve made.
APTA envisions that by 2020 consumers “will have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services.”
While we can provide information to our patient, which is important, research has shown knowledge alone will not change behavior. Suggest to your client to preplan their meals and do not bring foods in the home that are processed with added sugars and refined carbohydrates. When eating out suggest they choose a restaurant that has plenty of healthy choices and to avoid fast-food restaurants that sell the typical burgers and fries.
Knowledge alone will not change behavior.
Sadly, even as the health of our nation crumbles because of the explosion of chronic diseases related to obesity, there are many who are not willing to make the effort or take a stand to help those who need some direction and appropriate input with education and behavioral interventions promoting wellness. Health professionals seem to be pointing fingers at one another saying it’s not my job it’s someone else’s responsibility.
One of the questions that all physical therapists must ask themselves is how will they fulfill the responsibility of achieving the goals set forth by their association (APTA). The APTA holds as ethically binding the principle that PTs “shall endeavor to address the health needs of society.”
As we move forward our profession must be prepared to address our patient’s health needs by not only addressing their rehab needs related to function for diagnoses such as low back pain, knee osteoarthritis or a sprained ankle, but be ready to address the ‘whole’ person in terms of their health, fitness and wellness. The APTA envisions that by 2020 consumers “will have direct access to physical therapists in all environments for patient/client management, prevention, and wellness services.” Plan to be a beacon of hope for your patient who is often overwhelmed by obesity, disease and despair.
Every orthopedic physical therapist is confronted with the obese patient who is 80-100 pounds overweight and has osteoarthritis of the knees. After performing hundreds of straight leg raises along with other strengthening exercises, along with nonweightbearing activities such as cycling, and aquatic therapy, they too often continue to complain of knee pain. The reality is, until this patient unloads their weight-bearing joints they are not likely to experience any significant reduction in pain.
The subject of weight loss is often a difficult and sensitive one to bring up with your obese patient; however there are ways that you can present factual information and encourage your patient to make strides toward a decision of weight loss. I use an informational handout which highlights the relationship with osteoarthritis of the knees and body weight. I emphasize for every pound of body weight that they lose there is an equivalent reduction of 4 pounds of forces on their knee, and a 30% reduction in pain and 24% improvement in function with as little as 12 to 15 pound reduction in weight. I also appeal to my patient explaining studies have shown weight loss will decrease cartilage degeneration. Those that had the greatest weight loss during the study had the least amount of cartilage degeneration. In one study, those women of average height, for every 11 pound weight loss the risk of knee osteoarthritis dropped by about 50%.
However knowledge alone will not change behavior, so the second step would be to encourage them to make a decision to lose weight. You might ask them to write down all the benefits of being at a lower body weight. Then ask them to select 3 to 4 reasons which are most important to them. These might be to walk without knee pain, reduce their blood pressure medication, and be able to play with their grandchildren. You can then offer to help them set a realistic weight loss goal. Research suggests 5 to 10% reduction in their current body weight will significantly improve parameters of health. In my next article I will address how you might encourage behavioral changes that would facilitate weight loss.
During the TV show The Biggest Loser, the 14 participants lost a ridiculous amount of weight (average weight loss – 128 pounds) over a 30 week period, which is approximately 4 pounds per week. When we convert this into calories, this would be 14,000 calories per week. To be clear, every participant did not lose 4 pounds per week. This was the average weight loss among all of the participants. However, when eliminating this many calories in a short period of time, the body detects that it’s undergoing starvation and ‘a famine’ must be occurring. The participant’s stress hormone goes into overdrive, the body becomes more efficient at conserving energy and the risk of losing lean body mass is high. Utilization of unnecessary tissue for energy when energy intake is extremely low increases the risk of losing muscle. The participants experienced a significant amount of weight lost over a short period of time, which causes the body to reduce its lean body mass. Numerous studies have demonstrated that resistance training can increase lean muscle mass in both men and women and help boost the Resting Metabolic Rate (RMR). By trying to maintain as much of the lean body mass (LBM) with heavy resistance training, an individual can limit the amount of decreases in the RMR that accompany caloric-restricted diets.
Meta-analyses of weight loss programs have shown that diet plus exercise is a more effective approach than diet alone or exercise alone. Typically with weight loss diets that are performed without exercise, the composition of the weight loss is approximately 69% fat and 31% lean body mass (LBM), so if you lose 20 lbs., approximately 14 lbs. of the loss is fat and 6 lbs. is LBM. When aerobic exercise is performed in conjunction with a weight loss diet, 78% of the weight loss is loss of fat mass and 22% is from LBM. During a weight loss diet performed with both aerobic exercise and heavy resistance training the loss of body fat is approximately 97% and 3% LBM. Interestingly, the average percent fat mass (FM) loss by the participants in The Biggest Loser was approximately 80% while the LBM loss by the participants was approximately 20%. By limiting the loss of lean body mass and, subsequently, a reduction in the RMR, the amount of calories expended will better be maintained. In essence, resistance training encourages the body to gain or at least maintain muscle and burn fat, during a weight loss program. This positive change in body composition will increase the body’s ability to maintain a certain weight, once weight loss goals are achieved.
A goal should be to progressively increase the amount of resistance used during weight training, as this is the best way to hold muscle during weight loss diets. After a thorough warm-up, make sure that you use progressively heavier weights, working large muscle groups with compound movements for 10-12 repetitions. Resistance exercises like the leg press/squat, row, lat pull-down, hip and back extension/dead-lift, resistive abdominal crunches and chest press/bench press are exercises that work large muscle groups and are more effective in facilitating muscle growth.
You may have seen the headlines several weeks ago about 14 of the “Biggest Loser” contestants who were followed for 6 years and how they gained their weight back…well actually one did not gain back their weight. However 5 contestants gained all their weight back to within 1 percent of their previous weight and the rest gained back 70 percent of the weight they lost. I thought that this would be a good time to cover the “set-point” theory related to our body weight.
We all carry genes that are designed to preserve our species by encouraging us to eat foods that are high in fats and sugars, foods that are calorically dense. This is how we and other species survived famines eons ago. This gene coupled with a learned environment that teaches us the love of ice cream, pizza, fried chicken, French fries, pecan pie, Oreo cookies and the like is a deadly marriage. When this “fat” gene interacts with the environment that we live in where advertisements of high fat, high sugar and salt based foods are common place on the television, the result is the perfect storm or in scientific terms the perfect phenotype that leads to obesity. This “fat” gene coupled with a caloric rich environment has led to the obesity epidemic that we now face.
In the study the “Biggest Loser” contestants went through a significantly labor intensive exercise program with a suggested dietary intake. The environment that they were in was controlled (which is the biggest problem). Why?… because the contestants at some point in time must return to the same environment which led to their obesity problems. The very place that carries the same food temptations, and family or friends that enable their behavior, without a personal coach or the lens of a camera following them everywhere to hold them accountable. The genes and the learned behaviors that these participants carry without some constant management from an outside source will return each of these contestants to behaviors of old and unfortunately to their previous body weight.
If we were to take these same contestants and place them in a village in a West African country like Burkina Faso where they literally live off the land eating roots, beans and other plant based diets….these contestants would maintain their weight loss and would even continue to lose more weight until they achieved a stable weight corresponding to their gene interacting with that environment. The environment interacting with their gene coupled with past learned behaviors will dictate their actions. Obesity is a disease of addiction and to expect these contestants to return to an environment where the food industries rule is like expecting a drug addict to kick their habit, when every time they turn on the television they are bombarded with an advertisement about an addictive drug or drive by a billboard enticing them to indulge in the drugs of their choice.
The research of the ‘Biggest Loser’ focused on the reduction in the metabolism of each contestant. Indeed the contestants had a significant reduction in their metabolism which was to be expected. The resting metabolic rate (RMR,) which is how many calories are expended at rest, is correlated with the lean body mass each contestant carries. When weight loss is experienced there will be a reduction in body fat as well as the lean body mass. The amount of lean body mass that is metabolically active will dictate the RMR. Interestingly in the study of the ‘Biggest Loser’ contestants weight regain was not significantly correlated with metabolic adaptation at the competition’s end. This suggests that each contestants phenotype (their gene interacting with their environment) was primarily responsible for their weight regain.
In my next article I’ll cover the importance of maintaining as much lean body mass during a weight loss program.
The authors suggest that Heavy Resistance Training (HRT) with Ballistic movement patterns negatively impacts performance on the golf course.
In the past 10+ years, many elite golfers have succumbed to the notion that increasing strength and muscle mass improves performance on the golf course. We think not!
There are a host of professional golfers on extensive weight training programs who have seen a significant decline in performance.
How is that possible? Primarily because of two factors: changes in muscle girth, i.e., increased lean body (muscle) mass, and associated neurochemical adaptations in the brain and peripheral nervous system.
The SAID (Specific Adaptation to Imposed Demand) principle is widely accepted in physical science. Simply stated, the body specifically responds to the stresses placed upon it. For example, the calluses on the hands and feet are directly related to the skin’s response to overload, and overload stimulates growth (anabolism). Weight training stimulates changes in muscle size and strength, and biochemical changes in the central and peripheral nervous systems. It is estimated that one can increase strength as much as 20% in less than six weeks.
The nervous system adapts rapidly to resistance training, especially with heavy resistance weight training and resisted ballistic movements, like jump squats and rapid end-range forceful movements.
A similar response to stresses affects the nervous system by the process of neuroplasticity. Neuroplasticity is the brain’s ability to form new neural connections throughout life. This reorganization within the brain is directly related to how the body ages and the consistency of physical and mental stimulation. Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease, and rapidly adjusts their function in response to new situations, like exercise (particularly weight training), improved nutrition and absorption, and managed stress management.
Many experts believe that heavy-load resistance training, resulting in significant increases in body mass, can hinder body mechanics, including range of motion, motor control, and movement pattern changes particularly important to a coordinated golf swing. Heavy weight lifting changes motor learning, coordination, and body composition. Consider hitting a 90-yard wedge into the green with two added inches of muscle to the chest and upper back. That swing is not the same as before the added mass.
Motor control and coordination are also affected. Inappropriate exercise regimes change communication and motor sequencing patterns required to make correct ball contact, resulting in poorer performance.
Injuries compound the problem of bio-mechanics and a coordinated swing through the body’s self-protection reflex known as “protective guarding”, which alters movement patterns in an effort to reduce overloading the injured area.
So, put on muscle mass, have a few surgeries and it’s no wonder that the golf swing changes. Rather than aggressive strengthening for these injured golfers, we’d suggest a more nuanced fitness program that focuses on balanced and consistent nutrition, maintaining lean body mass, improving the quality of sleep (rest & recovery), and refraining from heavy weight resistance exercise and explosive/ballistic movements.
The results of heavy resistance, ballistic movement exercise training methods create increased muscle mass and alterations in motor control, coordination and timing, which negatively influences precise smooth movement patterns required to insure consistent ball striking.
Voluntary Exercise Induces a BDNF-Mediated Mechanism That Promotes Neuroplasticity
Fernando Gómez-Pinilla, Zhe Ying, Roland R. Roy, Raffaella Molteni, V. Reggie Edgerton
Journal of Neurophysiology Published 1 November 2002 Vol. 88 no. 5, 2187-2195 DOI: 10.1152/jn.00152.2002
Regulation of fiber size, oxidative potential, and capillarization in human muscle by resistance exercise
H. Green, C. Goreham, J. Ouyang, M. Ball-Burnett, D. Ranney
American Journal of Physiology – Regulatory, Integrative and Comparative Physiology Published 1 February 1999 Vol. 276 no. 2, R591-R596 DOI:
Jim Porterfield, PT, MA, ATC
Physical Therapist with 40 years of outpatient experience, Masters in Exercise Physiology, athletic trainer and co-author of Mechanical Low Back Pain, Perspectives in Functional Anatomy
Richard Mostardi, PhD
Human Physiologist, Researcher, and esteemed University Professor – Akron University
I’ve become much more familiar with trigger point referral patterns and treating these out the past couple years since I started using Functional Dry Needling techniques. A couple of the more common trigger points I end up dry needling and/or using Graston Technique to treat in the shoulder are the infraspinatous and teres minor. Active trigger points in these muscles can refer pain to the anterior and middle shoulder, and on occasion will also refer pain down the arm.
Check out the typical trigger points and referral patterns below:
A current patient of mine presented with R shoulder and scapular pain of 2 year duration. Trunk rotation was limited to 50% bilaterally (dysfunctional and painful – DP) and R shoulder medial rotation extension (MRE) reach only to L4 (DP). Palpation of the infraspinatous trigger point (most superior and lateral) referred significant pain to the anterior shoulder and slightly down the lateral arm reproducing her typical pain. The teres minor trigger point referred pain to the middle deltoid area.
Post trigger point dry needling of these trigger points the patient’s trunk rotation improved to 90% (dysfunctional still but non-painful now) and R shoulder MRE to T9 (still DP but much less pain).
Following up with corrective exercises, in this case thoracic rotation mobility and scapular stabilization, full trunk rotation was achieved without pain and R shoulder MRE improved even more to T7.
On the average how many pounds do US adults put on during the holidays? 2-3 pounds? 4-5 pounds? After following 165 adults during the holidays, researchers demonstrated the average weight gain was .48 kg or just a little over 1 pound. Another study showed 195 adults gained only .37 kg or .81 pounds during the holidays, however those who were overweight or obese gained more and 14% put on more than 2.5 kg (5 pounds). While the magnitude of weight gain during the holidays does not seem significant, the problem is holiday weight gain stayed with those that gained and has been found to explain 51% of annual weight gain. These findings suggest that holiday weight gain is a contributor to the rising prevalence of obesity. Adding a pound of extra weight each year for 10-20 years might explain that upward progression in your blood pressure over the years or the increase in your blood glucose levels. It might also be contributing to the increase in joint pain involving the weight bearing joints like the ankles, knees, hips and low back.
Perhaps a much bigger problem is cardiac mortality during the holidays. Research statistics demonstrate that Christmas and New Year’s holidays are a risk factor for cardiac and non-cardiac mortality. There may be a number of reasons for the increase in risk during this time period including, increased calorie intake from high saturated fats and sugar sources that often accompany parties and festivities, stress levels from the business of the season, as well as potentially delaying medical treatment because of the holidays.
Ways to avoid holiday weight gain start with preplanning. Eat a low calorie snack that’s filling like a large apple before going to a holiday party. This way you’ll stifle any hunger drive that would push you to overeat. Bring your own snacks or deserts when going to a party. Avoid alcohol which often unleashes any inhibitions and hinders good judgement in food choices. Instead choose low calories beverages, teas and coffees. Use a small plate to put your food on, and preplan not to go back 2 and 3 times to fill your plate. For those foods that are extra rich, but you want to try, take just a taste, a small spoon. Stay active during the holidays by planning a number of family walks through planned outings each day rather than sitting endlessly in front of the television.
By first acknowledging that holidays are a difficult time that can cause you to gain weight and increase your health risk puts you in control to make some changes by preplanning your holiday eating and activity. This is the time of year when I reflect with gratitude on my health and the health of my family. I hope you all have a happy, healthy and safe holiday this year.
Knowing that chronic disease is a major problem causing a financial drain on our economic healthcare system is the first step. Recognizing the underlying root causes of chronic disease is the second step. Implementing a program, addressing chronic disease within your physical therapy practice, with your patients is obligatory, if we are going to have any impact on preventing these diseases and helping our patients improve their function and quality of life.
A 48 year old patient who comes to us with osteoarthritis of the knee, who is also 80 pounds overweight, can do stationary cycling, straight leg raises, quad sets, and closed kinetic chain activities, however until they significantly decrease their body weight the adverse effects related to cumulative forces on the knee will continue.
Introducing your patients to the idea that their lack of appropriate exercise, their food choices and body weight are significant contributors to their problem will open the door for addressing the causes of their condition. Educate your patients on the benefits of a healthy lifestyle change, which includes increased exercise/activity and weight loss by providing your patients with the following information.
Inform your patients that just a 5-10% reduction in their current weight will significantly improve parameters of health including:
- Reduction in blood pressure 5 mmHg
- Increase in HDL 5 mg/dL
- 40 mg/dL reduction in triglyceride
- .5% reduction in HbA1C
Let your patient know that there is evidence that physical activity may be associated with a lower risk of several common forms of cancer, most notably colon and breast cancer.
Tell your patient that regular exercise decreases blood pressure in approximately 75% of hypertensive persons with an average decrease of 11 and 8 Hg mm for systolic and diastolic blood pressure respectively.
Inform your patient of the strong evidence from randomized controlled studies that moderate physical activity combined with weight loss and an improved diet can confer a 50-60% reduction in risk of developing diabetes among those already at high risk.
Also let your patients know that studies demonstrate an inverse association with fruit and vegetable intake and the risk of cardiovascular disease and all-cause mortality.
Finally, offer to help your patient set realistic weight loss goals, 5-10% of their initial weight has demonstrated improvements in parameters of health. Provide your patient with a wellness packet that helps them track their exercise and provides information on good food choices. Offer to help your patient track their weight loss and lifestyle changes involving exercise and food choices as they progress with their physical therapy program.
This type of intervention addresses the ‘whole’ person and has the potential to have both an immediate and future positive impact on your patient. As physical therapists, we truly become an instrument for healing our patients when we are addressing chronic disease.
Lifestyle choices are at the root cause of chronic disease. The World Health Organization indicates physical inactivity and lack of exercise is 1 of the 10 leading risk factors for death worldwide. Other factors contributing to chronic disease are poor nutritional dietary choices, smoking and excessive alcohol consumption.
A publication in the Journal of American College of Cardiology demonstrated that among 20,721 men who were followed for 11 years those that avoided smoking, consumed an abundance of fruits, vegetables, whole grains and legumes, had moderate alcohol consumption, exercised regularly, had very little belly fat, had an 86 percent lower risk of heart attack compared with those that did not demonstrate these conditions.
Research suggests that at least 30% of cancers can be prevented by consuming an abundance of fruits and vegetables and avoiding processed meats, beef and pork, avoiding smoking and tobacco products, exercising regularly, eliminating alcohol and keeping body weight in a healthy range.
The Centers for Disease Control and Prevention reported that in 2011, 36% of adolescents and 38% of adults said they ate fruit less than once a day, while 38% of adolescents and 23% of adults said they ate vegetables less than once a day. Additionally in 2012 more than 42 million adults or 1 in 5 indicated they currently smoked cigarettes, while 38 million adults reported binge drinking an average of 4 times a month. Research has correlated these behaviors with chronic disease which leaves little doubt that lifestyle choices are a major factor.
Research from the journal Preventing Chronic Disease reported that 46 percent of Americans over age 50 engage in no leisure-time activity and only 8 percent of Americans over age 50 meet the criteria for including both aerobic and strength training activity into their lifestyle. The repercussions of lack of exercise and poor dietary choices have led to a national obesity epidemic along with its many associated diseases.
Physical therapists are in a unique profession where we can work on encouraging our patients in making behavioral changes by introducing healthy living habits.
In my last entry I wrote about the significant increase in chronic diseases and its relationship to the number of specialists that people sought out for help. This massive increase in prevalence of chronic diseases coincides with the projected economic drain of chronic disease on the United States Healthcare system.
It is estimated that 7 of the top 10 causes of death in 2010 were from chronic diseases. The Agency for Healthcare Research and Quality reported that 86% of all health care spending in 2010 was for people with one or more chronic medical diseases. During this same period heart disease and stroke accounted for $193.4 billion in direct medical costs, while the National Cancer Institute reported cancer care cost of $157 billion and this doesn’t even consider the costs related to nursing home costs and loss work days. In 2012 the American Diabetes Association reported the cost of diabetes was $245 billion of which another $69 billion was the estimated loss in productivity secondary to decreased work days.
ARTHRITIS is one of the most common causes of disability according to Morbidity and Mortality Weekly Report and is also one of the most common diagnoses seen by physical therapists. It was estimated that total costs related to arthritis in 2003 was $81 billion of which approximately $47 billion was tied to costs related to lost earnings.
With more people experiencing chronic diseases that cause disability the subsequent decrease in the workforce directly affects our healthcare system. With less people working and paying taxes the staggering healthcare costs will no longer be sustainable. It is the tax on those in the workforce that is holding up the governmental healthcare system. The workforce is also what sustains affordable insurance for the private sector as well. A smaller workforce will promote rising healthcare costs. As physical therapists we must be ready to address these chronic diseases with preventative interventions incorporated into our practice. We can help reduce the economic drain of chronic disease.