Researchers have investigated back pain in golf and potential risk factors.  An article published in the July 2010 Journal of Orthopaedic and Sports Physical Therapy indicates weakness in trunk extensors and hip muscles may be the differing factor between golfers with and without back pain.^[3]  Trunk extensors are the muscles that run up and down the back and hold a person erect and provide stability and control.  The golf posture challenges these muscles to stabilize the spine in the address position and throughout the swing.  Without these muscles working optimally, you’re at risk for developing pain.  Differences in hip rotation range of motion between hips and improper coordination of movement between the hips and low back are also seen in golfers with back pain.^[4]  Of course, other factors can contribute to the development of low back pain in golfers, including technique, level of conditioning, skill level, and equipment to name a few.

Physical therapists help golfers overcome back pain.

The first way I tackle back pain in my golfing clients is to ask a few questions about their style of play and practice:

• How much time do you spend practicing, and how do you structure your practice?
  • Research has indicated that prolonged putting practice can fatigue the trunk extensors and affect the kinematics of the swing.^[5] When these muscles are fatigued, they do not stabilize the spine as well and can contribute to a back strain or disc disease.   I’m not saying to stop practice putting…. but you may not want to practice this for 30 minutes and then practice anything using your full golf swing… i.e. going long with the driver since your muscles will not be able to support your back as well.  This also goes for your pre-round routine.  Don’t get there an hour early and stay hunched over your putter and then try and smash-drive your golf ball into smithereens.  Practice a little putting to get a feel for the greens and leave the longer practice sessions for another time.
• How many times a week do you play?
  • Playing more than 3 times per week?  Your back pain could be simply due to overuse.  Playing 3 times per week and then practicing a few more days is a lot of twisting around your spine.  Too much twisting in a short period of time can lead to an injury.  Allow yourself to rest from golf and stay active with another activity.  Do cross training, strength training, or participate in another non-rotational sport.
• How do you warm up?
  • If the answer to this question is a drive-thru for your grande low-fat 2-pump latte ten minutes before that 7AM tee time, then Houston, we have a problem.  Not warming up before an early morning tee time is especially problematic.  While we sleep, the discs in our back swell.  Once we are upright for at least 1 hour, the discs return to normal height and become less swollen.  Placing load and stress on the discs, as the golf swing does, when they are swollen increases the risk of tearing or herniating them.  Wake up early and stay standing for at least 1 hour prior to playing golf. If you don’t wait this amount of time you are really setting yourself up for a disc injury.  Just think about it as actually enjoying your breakfast and getting mentally prepared for the best game of your life.
  • Don’t hold your stretches when warming up.  If you hold your stretches you can induce muscular weakness and research has shown that this type of stretching as a warm-up impairs the golf swing kinematics, resulting in a less supported spine and reduced performance.  Do your stretches, but do them “dynamically” which means continuously moving, never holding.

The other component of my treatment approach to back pain in golfers is a comprehensive physical therapy evaluation.  In particular, I look at hip mobility, flexibility, strength in the trunk and core, movement patterns, and posture.  As a TPI-certified medical professional, I also assess golf setup posture or address position and screen the swing.  If technique is an issue, I send my clients to a PGA Golf Professional.  Don’t let back pain keep you from playing golf.  If you have any pain, consult with a physical therapist that specializes in sports and orthopaedics.  Take care of your back and enjoy golf for years to come.

References

1. Foster,Larry. (2004). Dr. Divot’s Guide to Golf Injuries. North Salem, NY: Doctor Divot Publishing.

2. Parziale JR, Mallon WJ. Golf Injuries and Rehabilitation. Phys Med Rehabil Clin N Am 17 (2006) 589–607.

3. Tsai YS, Sell TS, Smoliga JM, et al. (2010). A Comparison of Physical Characteristics and Swing Mechanics Between Golfers With and Without Back Pain. Journal of Orthopaedic and Sports Physical Therapy. 40(7): 430-438.

4. Harris-Hayes M, Sahrmann SA, & Van Dillen LR. (2009). Relationship Between the Hip and Low Back Pain in Athletes Who Participate in Rotation-Related Sports. J Sports Rehabil. 18(1):60-75.

5. Evans K, Refshauge KM, Barrett R, & Adams RD. Swing Kinematics in Skilled Male Golfers Following Putting Practice.  J Orthop Sports Phys Ther. 2008;38(7):425-433.

1. Foster,Larry. (2004). Dr. Divot’s Guide to Golf Injuries. North Salem, NY: Doctor Divot Publishing.
2. Parziale JR, Mallon WJ. Golf Injuries and Rehabilitation. Phys Med Rehabil Clin N Am 17 (2006) 589–607.
3. Tsai YS, Sell TS, Smoliga JM, et al. (2010). A Comparison of Physical Characteristics and Swing Mechanics Between Golfers With and Without Back Pain. Journal of Orthopaedic and Sports Physical Therapy. 40(7): 430-438.
4. Harris-Hayes M, Sahrmann SA, & Van Dillen LR. (2009). Relationship Between the Hip and Low Back Pain in Athletes Who Participate in Rotation-Related Sports. J Sports Rehabil. 18(1):60-75.
5. Evans K, Refshauge KM, Barrett R, & Adams RD. Swing Kinematics in Skilled Male Golfers Following Putting Practice.  J Orthop Sports Phys Ther. 2008;38(7):425-433.

What is the cause of this disease?

• This disease presents most often in the early adult, 20-30 years old and more often in women
• Most of the people who are affected by MS live in the northern latitudes
• The disease is autoimmune, meaning the body attacks itself, however, we’re not sure exactly why.

What are the symptoms of this disease?

• Vertigo, double vision, changes in sensation, weakness, fatigue, forgetfulness, pain, sexual dysfunction, personality changes, loss of balance, incoordination, anxiety, muscle spasms, speech changes, tremors, numbness and tingling, urinary incontinence, problems swallowing or breathing
• … this is not even an exhaustive list of the symptoms of this disease
• Symptoms can be infrequent and vague in the beginning, and can be any combination of the above symptoms

What happens over the course of the disease?

• Two types of MS are characterized by periods of relapses and remissions.  For some, symptoms emerge during a relapse period but once in remission, symptoms disappear completely.  For others, symptoms emerge during a relapse period but once in remission, residual symptoms remain that do not get better or go away.
• Another form of MS is a steady, progressive decline in brain and spinal cord function without cycles of relapses and remissions

How is it diagnosed?

• There is no definitive test for MS.  It often takes years to reach a diagnosis, during which time the patient is left to wonder why he/she is experiencing such strange symptoms.  Neurologists primarily make a diagnosis by exclusion, history of symptoms, and MRI of the brain.  Many times, patients are relieved to have some semblance of an explanation as to what is causing their symptoms.

We do not know how to stop MS.

• Although treatments have gotten better, there remains no cure for this disease.

I’m riding this weekend to help someone answer these questions and in gratitude that I nor any of my family have been afflicted by this disease.  If you would like to help answer these questions too, you can go here to donate.  To read stories about those who have this disease, you can go here.

Thanks to D Sharon Pruitt of Pink Sherbet Photography on Flickr for the picture.

References

National Multiple Sclerosis Society  http://www.nationalmssociety.org/index.aspx

“Multiple Sclerosis” http://www.mayoclinic.com/health/multiple-sclerosis/DS00188

1. Weak Back Muscles
2. Tight Hips
3. Loss of Balance
4. Low endurance
5. Weak Legs
6. Stiff Shoulders
7. Weak Hips

Most of the exercises below are yoga moves.  I incorporate yoga poses into many of my treatments.  Overall, it is one of the most multitasking activities out there, improving flexibility, strength, core stability, balance, coordination, and stress levels.  I highly recommend you make yoga a part of your workouts to improve health long term.

Chair Pose/ Squats

www.youtube.com/watch?v=Ur-W02QtIRU

Triangle Pose: This is great for not only hip flexibility, but also balance, especially when looking up.  Only reach down the leg as far as you can comfortably and without losing your balance.

www.youtube.com/watch?v=UVE5zW4RsK8

Child’s Pose: Do this one with your arms extended straight out in front to stretch your arms

www.youtube.com/watch?v=NwzE_J-3JOI

Clamshells: You can do this one without the band to start and work your way up to using resistance as you get stronger.

www.youtube.com/watch?v=njthA4SVOT8

Rowing: The person in this video gives some good variations on rowing, an exercise to strengthen the upper back muscles, by changing his standing position to incorporate balance.  Though, I would go much more slowly and controlled with the movements.

www.youtube.com/watch?v=1SgomK3sb98

Bridging: This previous post gives you lots of variations on the bridge exercise.  This exercise will strengthen the glutes and stretch the hip flexors, which can become stiffer as we get older.

To improve endurance, be sure to incorporate aerobic activities into your workouts.  In other words, exercise that will challenge the heart and increase your breathing.  Swimming and cycling are good activities to work on your endurance and they have lower impact on your joints.  Shoot for 15-30 minutes at least at a time and be sure you feel like you are working hard, though not so hard that you can’t talk while doing it.

When you are designing your anti-aging exercise program it is important to do them regularly, 3 times a week minimum.  Yoga and strength exercises should be done in 3 sets of reps of 8-15 with a good 5-10 second hold for the yoga poses.  It’s also important to make sure that your exercises are a real challenge, because challenging yourself is what will ultimately bring about the changes your body needs.  Don’t just be active, be active in the right ways with the right exercises to avoid mobility problems like inability get out of a chair or step up and down curbs.  If you need more tips on exercises, find a good personal trainer that is in tune with exercising for prevention.  Or you could ask your physical therapist for a good recommendation.

Thanks to ClevelandSGS on Flickr for the picture.

As we age our muscles lose elasticity and strength.  Our joints become stiffer and compacted.  We develop arthritis.  These are things that are inevitable and cannot be changed, however, you can decrease the speed at which these events occur and improve or maintain your mobility throughout life by staying active, strong, and limber.  Did you know that you can improve your strength at ANY age?  Even if you’re 90 years old you can get stronger by doing resistance exercises and lifting weights, even as age is taking strength away!

www.youtube.com/watch?v=fTrUrFdepuQ

As a physical therapist, I’ve noticed that there are certain areas of the body that tend to lose flexibility and strength as we get older.  Here’s a breakdown of the most common age-related mobility problems I have noticed in my evaluations.

• Inability to Stand Up Straight/ Increased Thoracic Kyphosis
  • Another term people use is a “hunched” back, where the upper part of the back is rounded more than normal.  This is in part due to poor posture and prolonged positioning, which can lead to a permanent change in spinal and shoulder alignment.  Most clients with this problem mention they have to sleep with 2 or more pillows at night due to this change in the spine.  This can worsen over time and cause problems at other areas including the neck, shoulders, and low back.
• Inability to Raise Arms Overhead
  • Maintaining the ability to reach for things in your cupboard or get a pullover on without straining your shoulder requires good range of motion and flexibility
• Difficulty Getting out of a Low or Soft Chair
  • As leg strength decreases this activity gets harder and harder and most people start to rely more on their arms to push themselves up, or to unsafely use momentum to propel themselves up.  Also hip inflexibilities can make getting out of chairs much more difficult.
• Waddling Gait
  • This may also look like a limp and may be related to arthritis, but when our hips get weak they start to cause a waddling gait which places undue stresses on the hips, knees, and low back
• Feeling unsteady
  • As strength, flexibility, and reaction time declines, so does balance, though balance can be improved through exercise.  Falls is a serious problem among the elderly, so we should all be working on our balance from an early age to combat the risk of falling as we age.
• Inability to take the stairs or get up a curb
  • Weak glutes, hamstrings, and quads in particular will make this activity much harder.  Although there should always be a ramp, some places do not have one or it is not conveniently located, so it’s important to maintain this skill to stay safe and prevent falls.
• It’s hard to walk long distances
  • Aerobic conditioning is very important to maintain through the golden years to maintain endurance for walking, whether it be for several hours to shop or to get all your errands done in one day.  Many of my clients who have this problem have to sacrifice efficiency and plan for much more time to get everyday chores done due to low endurance.

These are the most common problems I have seen in physical therapy related to aging and prolonged inactivity.  The good news is with physical therapy I have helped clients overcome these obstacles through customized exercises to improve quality of life and independence.  If you have one of these problems, find a physical therapist to get a customized plan to make improvements and prevent disabilities!  If you’re looking to prevent these problems and maintain your quality of life, check back next week.  I’ll post exercises and tips to help prevent these commonly-seen problems and help you get started on a plan to maintain your independence and mobility for as long as possible!

• The United States spent $7 Billion in 2000 in healthcare costs to treat shoulder pain
• Rotator cuff tears increase in incidence after the age of 40 and up to 40% of the population over 60 years old has a full-thickness rotator cuff tear
• 78% of patients with rotator cuff tendinitis were treated successfully with non-operative treatments including a combination of medication and physical therapy
• 75% of those with a large rotator cuff tear retear the muscle after surgical repair
• 70% of full-thickness rotator cuff tears are expereinced in those that do light work and are relatively sedentary

The risk factors for rotator cuff tears and tendinitis:

• age-related degeneration
• muscle atrophy
• poor posture
• smoking
• repetitive overuse
• shoulder impingement and rotator cuff tendinitis
• impaired shoulder mechanics
• anatomical variation of the shoulder

The research indicates those that do best after a rotator cuff surgery are patients that are relatively young and have an acute injury.  In other words, don’t wait months and months to get treatment for this condition, because it may be too late to do surgery if you need it.  If you think you may have done something to your shoulder and you are over 40, definitely schedule an appointment with your physical therapist or physician.  If a rotator cuff tear is suspected, your physician may order a test to confirm the diagnosis.  Research indicates that diagnostic ultrasound and MRI are the most effective and are equally effective at diagnosing rotator cuff tears.  Diagnostic ultrasound is cheaper than MRI, but most physicians order an MRI because diagnostic ultrasound requires the technician to be highly trained and skilled.  If you have to pay for this out-of-pocket and are concerned about the cost, ask your physician if they know where to send you for a diagnostic ultrasound.

One article mentioned a study of outcomes following surgical repair of rotator cuff tears.  They found that satisfaction and function (improved flexibility, range of motion, and ability to reach overhead) improved even in the presence of a failed surgery!  They attributed this in part to the fact that after a patient undergoes surgery they are much more committed and compliant with exercises to strenghten the rotator cuff and shoulder.  The exercises are soooooo important!   As a physical therapist, I see many people with shoulder pain including those with rotator cuff tendinitis, rotator cuff tears, and after surgery to repair a rotator cuff tear.  This condition is extremely painful, but can be managed successfully in physical therapy with a combination of manual therapy and exercises.  Physical therapy can help you overcome developing rotator cuff tears in almost all of the risk factors listed above.  Wake up and smell the muscles!  Be sure to pump up your shoulders with resistive exercise to keep them strong and prevent a painful condition, the rotator cuff tear.

References

1. Hemang Yadav,  Shane Nho,  Anthony Romeo,  John D MacGillivray.  Rotator Cuff Tears: Pathology and Repair.  Knee Surgery, Sports Traumatology, Arthroscopy.  Heidelberg:Apr 2009.  Vol. 17,  Iss. 4,  p. 409-421

2. J Winslow Alford. Exploring treatment options for rotator cuff disorders. The Journal of Musculoskeletal Medicine.  Darien:Mar 2009.  Vol. 26,  Iss. 3,  p. 99-103 (5 pp.)

3. Boissonnault WG, Badke MB, Wooden MJ, Ekedahl S, Fly K. Patient Outcome Following Rehabilitation for Rotator Cuff Repair Surgery: The Impact of Selected Medical Comorbidities. JOSPT 2007; 37(6): 312-319.

4. Long JL, Ruberte Thiele RA, Skendzel JG, Jeon J, Hughes RE, Miller BS, Carpenter JE. Activation of the Shoulder Musculature During Pendulum Exercises and Light Activities. JOSPT 2010; 40(4): 230-237.

Link to knee anatomy.  Note all of the muscles surrounding the knee to give it stability.

Video showing the knee joint, including the muscles surrounding it, and arthrosis (degenerative arthritic changes).

www.youtube.com/watch?v=l9sS4wfD-AU

www.youtube.com/watch?v=k1hlY0EMYJw

To make your runs more efficient and prevent an injury, participate in other activities and exercises to strengthen, stretch, and stabilize key areas of the body.  It’s important to remain flexible in the hips and lower legs to prevent a host of running conditions from plantar fasciitis to iliotibial band syndrome.  To maintain good linear motion and prevent fatigue, strength train, particularly at the hip and core, but also postural muscles to maintain a neutral and straight spinal position.

Diversifying Activities:

1. Pilates: It builds hip and core strength,which is important to maintain good running form, in addition to working on your posture

2. Yoga: Don’t like to stretch? Try yoga. You’re stretching multiple muscle groups in a session and it’s more fun that holding a quad stretch for 30 seconds. Additionally yoga can benefit your body by reducing stress and improving balance.

3. Strength Training: Hard to run up that hill? You need to work on your strength. Use weights and get stronger.  Also work on the muscles in your back to maintain a good posture while running.

4. Bike: Looking to work on your endurance in other ways?  Try another endurance sport that requires good leg strength- cycling.  Try some interval training for variety.

So, yes, you may have to take days out of the week to do exercise that does not involve running.  If you’re unsure of what to do, a physical therapist can evaluate your running mechanics and look at your strength and flexibility to make a customized exercise program to fit your needs.  In the long term, running less will make you a better runner.  Diversifying your activities will improve your form, making you more efficient and faster, and keep your body more balanced and free of musculoskeletal injuries.

If you want a yoga and pilates breakdown, visit PTJess’ blog here for yoga and here for pilates

More on the chicken guy whoa.  Would like to know the end of the story and how he finished that marathon…

How long have you been practicing OT?
I have been practicing O.T. for 35 years. I graduated from the University of Pennsylvania School of Allied Medical Profession, May, 1975.

Why did you become an OT?
I became an OT for several reasons. I really enjoy working with people and also had always wanted to become a teacher growing up.  This   profession combines both of my ambitions working with people and teaching.

What setting do you practice in?
I practice OT in an outpatient clinic setting in Milwaukee, Wisconsin where I am fortunate to work with a wonderful, skilled team of professionals (OT’s PT’s and Speech Pathologists).

What are your clinical areas of expertise?
I have several areas of expertise in OT: I have a clinical specialty in arthritis which was achieved through my Master of Science Degree. Another specialty is in Lymphedema/Edema which I was certified in during 1995 and 1996.  Lymphedema is the abnormal accumulation of fluid that causes swelling most often in arms or legs. The condition develops when lymph nodes are missing, impaired, damaged or removed.  The third area of expertise is in upper extremity orthopedics.

How would you define Occupational Therapy?
Occupational Therapy is an allied health profession that promotes health by enabling people to perform meaningful and purposeful activity to help them achieve quality of life.  For example, OT’s may work with upper extremities to increase motion, strength, dexterity and sensation so the person may perform self-care activities independently.  OTs work to promote health, prevent injury and disability, and develop, improve, or restore the highest possible level of independence of each client.

What is the difference between Occupational and Physical Therapy?
I am asked this question very often. Occupational Therapy assists individuals in performing tasks in their daily living and work environments to increase safety and functional ability. They work with people who have disabling physical, mental, social, or emotional problems and assist them in achieving a high level of function in those areas. Physical Therapy focuses on walking, balance, and general movement.  PTs work with the lower body, back and neck. They provide services where function has been impaired by injury, disease or environmental factors. They , too help to restore physical, social, emotional and pyschological well-being of a client.  Their goal is to restore mobility and functional ability to a specific body part. Both OTs and PTs work as a “team” to achieve the highest level of function for the client.

How are you celebrating Occupational Therapy month?
I am celebrating O.T. month by raising money for cancer research.  We all have been touched by cancer in some way whether by our own health, a family member, friend, or patient we have treated.  I feel very strongly that a cure for cancer is in our near future and that by raising money for cancer research we can one day find a cure. I will be in Washington, DC in May for The Race for Hope a run/walk for brain cancer research and the Relay for Life a cancer walk in June, in Milwaukee.

The AOTA brand tagline is “Living Life to IT’s Fullest.”  How have you helped your patient do just that?
I feel that every one of my patients whether they have Lymphedema, arthritis or a fracture, want to be able to live their life to the fullest.  My goal is to work with each one to accomplish their goals whether its pain relief, decrease swelling or increase strength in an arm or hand. Ultimately, they want to regain control/independence in their life.  By assisting them in attaining their goals they are able to regain satisfaction and quality in their life.

In your years of practice, what is the most interesting goal you have helped a patient achieve?
I recently had a wonderful patient, a businessman who had a malignant brain tumor. His goal was to be able to button his dress shirt independently
so he could attend a company board meeting. He did achieve his goal!

If there was one piece of advice you could give to someone going through occupational therapy what would it be?
Appreciate every accomplishment made in OT however large or small that brings you closer to achieving your goals.  Remember that each day is a gift so live your life to its fullest!!

We’ve heard you’re a bit of an American Idol fan..Who’s your pick to win it all?
My pick is Lee Dwyze, a rocker from Chicago.

You can find Susan at HealthReach Rehabilitation Services 414-964-4777.

The right piece of music will certainly motivate, but it can be a useful tool in other ways in physical therapy.  Singing while performing exercises can help breathing and endurance while recovering from a heart transplant.  Parkinson’s Disease causes an inability to initiate movement and using musical cues including a metronome and songs has helped me keep these clients from slowing down and keep them moving.  During vestibular rehab I have clapped out rhythms according to a desired frequency of head movement for exercises to improve dizziness and balance disorders.  Research has found that 20 minutes a day of listening to relaxing music (tempo of 60-80 beats per minute) can decrease perceived pain levels in those who have chronic pain related to osteoarthritis.  I tend to believe when your therapist sings “Hurts So Good,” it makes stretching more bearable after a total knee replacement. Music can be a helpful adjunct to creating a healing environment and there is an entire profession (music therapy) devoted to incorporating the therapeutic benefits of music into treatment programs.  I haven’t worked with a music therapist, but if you are one or have worked with one and want to share your experience, leave a comment at the bottom.

Music has its place and purpose, even in physical therapy, and sometimes in unexpected ways.  Although music can be used to do more than motivate, I do get it.  Quad sets just aren’t that much fun on their own.  Which is why you should stick a few earbuds in and jam to the tunes that get you motivated, inspired, and ready to work.

My song: Mysterious Ways U2

Top 10 Therapy Playlist
1. Back in Black ACDC
2. Eye of the Tiger Survivor
3. The Distance Cake
4. Stronger Kanye West
5. Immigrant Song Led Zeppelin
6. Can’t Stop Red Hot Chili Peppers
7. Cold As Ice Foreigner
8. Where Are We Runnin’ Lenny Kravitz
9. Evenflow Pearl Jam
10. Hurts So Good John Cougar Mellencamp

What music motivates you to move?  What’s your song?  Leave a comment below!

References and Links

http://www.musictherapy.org/

http://musictherapywisconsin.org/

Pacchetti et al. “Active Music Therapy in Parkinson’s Disease: An Integrative Method for Motor and Emotional Rehabilitation” Psychosomatic Medicine 62:386-393 (2000).

Ruth McCaffrey, & Edward Freeman. (2003). Effect of music on chronic osteoarthritis pain in older people. Journal of Advanced Nursing, 44(5), 517-524,445.

Sustained Positions Self-Check

1. During the course of a day, try to be consciously aware of the positions you put yourself in- start from the bottom up: feet, knees, hips, back, shoulders, neck.  Are you forward, backward, bent in any certain position for a prolonged period?
2. Make a note of your preferred and comfortable postures.  Do you tend to slouch?  Does your back round?  Do you jut your head forward?  Is your head turned one way or the other?
3. When you are seated do you always cross one leg?  Do you feel weight on one buttock versus the other?  Do you prefer to prop yourself up on one elbow versus the other?
4. Do you have a preferred sleeping position?  Do you always lie on one side?  Are your back and legs rotated? If you sleep on your belly (not a good sleeping position and not recommended by me) do you always have your head turned left or right?
5. When you have to stand for a long time in one spot where do you place your weight?  Are you more on one leg versus the other?  Do you put more pressure on the balls or heels of your feet?  Are your feet rolled inwards or outwards?

If you find certain asymmetries, for instance you always sleep on your right side or when you stand you feel most of your weight on your heels, try to correct them.  The goal here is to keep the body balanced.  If you always sleep on your right side, try to sleep on your left side sometimes.  If you feel more than 50% of your weight on your heels, try to shift your weight on your feet so you feel equal weight between the balls of your feet and the heels.  Our bodies have subtle preferences such as these that over time can lead to musculoskeletal problems.  If you can catch them now and do something about them, you may be able to prevent a painful condition down the line.