Training Around the Owies: An “Active Rehab” Workout
Some time ago, a TH reader emailed me to ask if I could develop a workout for a disabled trans person. Since I have spent a few years dabbling in “active rehab” type training programs for clients and website readers with injuries and degenerative diseases, I liked the challenge immediately. The reader has a few different physical limitations, which require various approaches. For example, some can be altered over time, given proper modalities. Others must be taken “as is” since they are unlikely to change, and may even degenerate further in future.
The basic rules of active rehab are pretty simple.
- Use a variety of strategies. If one thing doesn’t work, try something else.
- Be adaptable, creative, and an exercise kleptomaniac. You may be able to modify common exercises in order to be able to do them. You may also be able to steal exercises from a variety of disciplines (dance, martial arts, weight training, etc.) to compose a full exercise regime.
- Aim to increase and/or maintain a good, functional range of motion in all joints. This may require months of gradually improving range. See next point.
- Work within the limits of your ability. If your range of motion is limited, either because things just won’t go any farther, or because doing so causes pain, then work up to the edge of your range, and over time, try to increase it. If you can only do 15 min of exercise before fatiguing, then do it. Better yet, try two shorter sessions of 10 min with a rest in between.
- Keep moving. Do whatever you can do that doesn’t cause undue pain. As long as you’re not in an acute stage of something (e.g. twenty minutes after an operation, or immobilized by a back spasm, or lying under the wheels of a truck, etc.), total inactivity is usually the worst thing you can do. Move as frequently as possible, within your limits.
Let’s start by laying out the things we had to consider in designing the program. You may find that you share one or more of these concerns, so that you can adapt some of the advice given to yourself.
#1: Disc degeneration in spine.
What this means: In between each of the vertebrae of the spine are fluid-filled discs. Over time, or with a degenerative condition, these discs can go from being elastic and spongy to thin and dry. The disc may rupture and the contents leak. This can be quite painful if it presses on a spinal nerve. It may also contribute to problems with extremities.
How to work around it: Axial loading is to be avoided. In other words, any exercise which places a load on the shoulders/upper back, and presses down along the length of the spine, is bad. This would include avoiding leg press machines, calf raise machines, and squatting with a bar on the back. Lifting in spinal flexion (rounded back, like the guy from Notre Dame) is also to be avoided. This is good advice in general for anyone, but especially so if there are disc issues. Also avoid going from full flexion to full extension (in other words, rounded back to very arched back with belly and bootay sticking out) in a single movement.
Prevention/rehab: While disc degeneration can be painful (though often spinal problems are surprisingly asymptomatic and pain-free-folks can even be unaware that they have them!), it is essential to keep the body moving to prevent loss of further mobility. Gentle strengthening of the area, including abs, obliques, and spinal erectors, is useful. Squatting motions can be done using only bodyweight. If additional resistance is desired, light dumbbells can be held at sides, and/or lifter can try out the Super Squats Hip Belt from Ironmind . This is a belt that goes around the hips and distributes the weight across the pelvis instead. Feels weird at first, but very useful.
#2: Knee laxity from previous injury.
What this means: Connective tissue is what holds the knee together. When it becomes stretched through an injury, it does not return to its previous tightness, and the knee is more likely to pop out of joint. It affects both mechanical function of the knee, as well as proprioception (awareness of where the body is and what it’s doing at any given moment). This means that further injury is a risk.
Contraindicated exercises: Anything single-legged, standing on the bad leg.
How to work around it: Knee bracing with a neoprene brace can help keep the knee stable during movement.
Prevention/rehab: Two-legged proprioception training, strengthening muscles around the joint.
#3: Patellofemoral syndrome.
What this means: This is kind of a catchall term for pain occurring when the kneecap (patella) doesn’t slide smoothly in the femoral groove (groove in thighbone). It can happen from overuse, from structural problems with the skeleton, from tightness around the joint (iliotibial band can be a culprit here) or from injury (see #2). Pain is caused by the patella making contact where it shouldn’t, and is usually felt somewhere around or under the kneecap. Characteristic features include pain after long periods of sitting (referred to as “movie theatre knee”), and when going up or down stairs. PF is also related to chondromalacia patella, which occurs when the cartilage under the kneecap degenerates or is ground down. CP can demonstrate itself in a crunching or clicking in the knee during movement, as well as PF-like pain.
Contraindicated exercises: Weighted leg extensions, running (especially downhill)
How to work around it: Avoid problem movements as much as possible, use good technique when going up and down stairs (try to “sit back” and push weight through heel, not toe). PF is usually a solvable problem, luckily. Ice the knee when it hurts.
Prevention/rehab: Strengthening muscles around the joint, stretching legs and hips, losing weight if possible, daily self massage of thigh with a rolling pin.
#4: Weakness in left leg and foot.
This is probably related to #1-3, so addressing problems there might help.
#5: Limited choice of available activities and equipment.
The reader lives in a small town with limited facilities and exercise classes (no tai chi, for example). Swimming would be a good option for some people but isn’t doable since the reader is FTM post chest surgery and doesn’t yet feel comfortable doing it, especially given the locker room issues. The exercises I give below are either bodyweight or dumbbell exercises, which require a wall, a bit of floor space, and a step.
#6: Sedentary lifestyle, overweight.
This is relatively solvable with attention to regular exercise and proper nutrition.
On to Part 2!
Part 2: Training and Diet Program
Let’s get the diet out of the way first. I define “diet” as a regimen of proper nutrition which is primarily a lifestyle, and secondarily a means of achieving particular goals. I do not endorse any kind of brand-name short-term drastic caloric restriction. To be successful, a good diet must address the needs of each person, both physiological and psychological, and be maintainable over the long term. As I see it, there are two goals here. The first one is to achieve a healthy body weight, for self-image, overall fitness, and to relieve some pressure on joints. The second is to supplement to assist the healing and regeneration process.
Here are my suggestions for achieving these things.
General eating plan:
- Go to Fitday (www.fitday.com) and set up an account to keep track of intake. I love this site; it’s an invaluable tool for making sure I eat enough protein and fruit/veg.
- Aim for 10 x bodyweight in calories daily. A 150 lb person would thus eat 1500 calories daily. Folks who are very overweight can get away with eating fewer calories per lb. of bodyweight, as low as around 8 x bodyweight.
- Get some lean protein at every meal. This means: dairy products, eggs, chicken (boneless chicken thighs are ultra cheap and go great in stews, soups, and curries), tuna and other fish (tuna is great because it’s cheap and goes on special regularly at grocery stores), lean cuts of beef and pork. A tub of whey protein is also handy to have on hand, since a daily protein shake is quick, convenient, and a good source of quality protein. When I go to work I carry along a plastic cup with a lid, containing protein powder. Once at work, I either buy some skim milk or pour water into the cup, shake, and drink. It’s the perfect midafternoon snack.
- Get lots of fruit and veggies.
- Reduce intake of refined carbohydrates: white bread, white rice, pasta, baked goods, juices and sodas, sugary sauces, candy and junk food. Replace with whole grains (e.g. brown rice, whole wheat pasta and breads, oatmeal, buckwheat, etc.) and fruit/vegetables.
- Drink 8-10 glasses of water daily. This will help to keep discs hydrated and the body to deal with waste products.
- Glucosamine sulfate, 1000 to 2000 mg daily. Glucosamine has been pretty conclusively shown to help in regeneration of connective tissue, which applies to both knee and back issues.
- Fish oil, 5-8 g daily. Fish oil is a natural anti-inflammatory and will help reduce the inflammation that causes pain.
- MSM, 1-3 g daily taken with food. Also an anti-inflammatory, helps ease joint pain.
- Magnesium, 100-200 mg daily will help alleviate spasming and cramping if that is a problem with the back.
It is quite easy and relatively inexpensive to get a good workout at home. I suggest the purchase of adjustable dumbbells with a few small plates (2.5 lbs., 5 lbs. plates to start) and a Swiss ball. Though the reader says he doesn’t feel very enthusiastic about a stationary bike, it’s also a handy thing to do for cardio work and general conditioning. It will also help strengthen the muscles around the knee joint. If possible, a recumbent bike (where the user sits upright to pedal, and legs are parallel to floor) is better for folks with back problems than a conventional bike, where the user is bent over.
There should be some activity performed every day for at least 10 minutes, and preferably closer to 15-20. The key is to keep things moving. However this can be interpreted in any way: walking, gentle cycling, weights, yoga, dancing to music, gardening, etc. Note that I say activity here, not “workout” or “training”. Variety is important to keep things fresh, keep interest up, and avoid overuse injuries.
Home weights workout
This is a workout that could be done 3 times weekly.
- Warmup 5 min of light cardio: walking, etc.
- Standing pelvic tilt exercise to warm up back, 10 in each direction
- Swiss ball wall squats within comfortable range, 2 sets of as many as you can do, working on improving range of motion. To add resistance, hold dumbbells. Add reps and increase range, rather than add weight, though, for the first few months.
- Overhead press with light dumbbells done standing, or seated on swiss ball, or standing leaning against ball, 2 sets x 12-15 reps
- One-arm body-supported row with dumbbell, 2 x 12-15
- Pushups, 2 sets of as many as you can do (to increase difficulty of these, you can elevate your feet, or wrap a loop of elastic tubing around yourself so that it encircles your back, runs down along both your arms, and your hands are resting on it) More on pushups
- Bridge on ball, 2 x 15, progress to bridge + leg curl, 2 x 15
- One-leg calf raise on step, 1 x 15
- Cool down, more light cardio, and/or daily exercises as indicated below.
- 10-20 min of activity of choice, plus the following.
- Stretch hips, front and back of thigh, and iliotibial band.
- Seated knee extension on ball, 1 x 12-15 reps on sore knee side
- Do 1-2 exercises from this list: http://www.orthoassociates.com/spine_recovery_protocol.htm
- To increase the proprioceptive demands on the body, do some exercises with eyes closed, and/or wear a knee brace (the feel of it will help awareness of what the knee is doing)