Encouraging patients to “break from comfort” to stay fit and prevent injury can be a challenge in an increasingly sedentary society.
When it comes to well-being and physical fitness, the nation as a whole has made some progress during the past 2 decades. The younger populations are smoking less, they are exercising more, and despite recent reports that we are metabolically less healthy than past generations, life expectancy has risen during the past 50 years. “Fast-casual” eateries are offering healthy and tasteful alternatives while traditional fast food venues have responded by offering more healthy choices. The health club industry has provided timely solutions, with the no-frills, less expensive, smaller clubs finding their niche. Baby Boomers are hiking and running, and are concerned about maintaining health, fitness, and independence as they look at retirement.
If people expect to live longer, yet have more sedentary lifestyles, how can they maintain musculoskeletal fitness? In general, compared to our grandparents, the nation spends more time in cars, sitting, and moving less.1 Since 1970, sedentary jobs have risen from about 20% of the work force to more than 40%.2 Time spent in front of some type of video display has quadrupled, with six in 10 working adults now using a computer on the job and nine in 10 children using computers in school.3
Given that the population is sitting more, but has more healthy choices, the difficulty of maintaining well-being and preventing injury points toward the mental challenge involved. Watching our parents suffer with debilitation should be enough motivation to get up and go. But is it? Society is flooded with gadgets and widgets, offering time management and healthy solutions to food choices while simultaneously taunting the population with time-wasting television, texting, fast food, video games, and procrastination products. What society offers in solutions is quickly countered by products and ideas inviting sloth, making the mental challenge as difficult as the physical.
Abraham Maslow wrote in the 1970s that people are motivated by a hierarchy of needs, starting with the most basic physiological needs such as food, water, safety, and security. He wrote that the second level is the need to belong with social interaction, followed by the need for self-esteem, and finally topped with the need for self-actualization. All too often, patients can fall out of motivation to take care of themselves. Rehabilitation professionals can have the most influence then, with reminders to patients to break the comfort zone to achieve security, the ability to get out with friends, to feel better about themselves, or even to achieve consistency in an exercise program, finally playing golf again after a knee replacement for instance. All too often, physical rehabilitation is doused with a dose of mental motivation, as many a football coach, doctor, or teacher may concur.
With rising financial responsibilities of co-pays, deductibles, and cost-sharing health plans, society has helped rehabilitation professionals to motivate patients to get out of comfort in order to achieve self-actualization, to simply stay physically independent.
GETTING OUT OF THE COMFORT ZONE
Physical demands on technologically re-engineered jobs and at home are down, and obesity and metabolic diseases are on an upward trend, so signs point to problems on the horizon with physical well-being. Our 21st century, and its warm and fuzzy comfort zone, has cast a wider net over us all, while few entertain the idea of leaving this zone for even a brief period of time.
Robert M. Yerkes and John D. Dodson wrote about the “comfort zone” in 1908.4 To maximize performance, relative anxiety is required, when stress levels are slightly higher than normal. This optimal anxiety falls just outside the comfort zone, and is needed in order to explore and achieve higher levels of performance. Anyone who has pushed themselves in college to stay up later to study, or run an extra 10 minutes each week to prepare for a race, is a testimony to improving results. With the advent of electronic pads, phones, and technology replacing a host of the previous generation’s physical tasks, the motivation to climb out of the comfort zone just does not happen.
Some simple strategies suggested by experts outside the rehab industry to help motivate clients to break out of their comfort zones and encourage the expansion of mind and body include:
• Public speaking
• Lead when not asked to lead
• Rationalize differently: Instead of why “not” to do, rationalize why “to do”
• Mentally make comfort zones a prison, not comfort
• Lean into discomfort
• Be comfortable being uncomfortable
• Choose challenge over comfort
• Even though it is harder, think solutions, not problems
BARRIERS, BREAKS, AND HEALTH
Simply put, staying in society’s diminishing physical task environment is a recipe for disaster unless there is a willingness and consistent motivation to collapse the comfort zone walls.
Our bodies were made to locomote, but society offers an abundance of opportunity to move less. The human body has more than 200 bones, making up joints filled with synovial fluid, cartilage, ligaments, and tendons, while surrounded by muscle. Most tissues get their nutrition through blood, but the articular cartilage cells rely on synovial fluid to deliver nutrients, and synovial fluid is only efficient when a joint moves, flushing the ends of bones and joints.
Joints, muscles, and tendons are designed to help us move, so finding ways to get active outside your comfort zone on a daily basis is critical for your physical well-being. In short, comfort zone breaks are needed in all areas of life to break barriers. If it is good health that patients/clients desire, cognizant breaks must be planned to help bolster achievement.
Creating timed breaks in the 168-hour week requires planning, commitment to part of a lunch break, walking up and down stairs, waking up earlier or getting to bed later, committing specified times to return e-mails or texts, or even sacrificing a reality television show to discover exercise.
WHAT IS MUSCULOSKELETAL HEALTH AND HOW CAN WE OFFER SOLUTIONS?
The World Health Organization suggests health is both the absence of disease and a state of complete physical, mental, or social well-being. The musculoskeletal system is one aspect of this state of health. It consists of:
1. Muscular strength (dynamic)
a. Defined as the maximum force a muscle or muscle group can generate at a specific velocity.
2. Muscular endurance
a. Ability of a muscle or muscle group to perform repeated contractions against a load for an extended period of time.
3. Muscular flexibility
a. Dynamic flexibility is the opposition or resistance of a joint to motion, that is, the forces opposing movement rather than the range of movement itself.
b. Static flexibility is the range of motion about a joint, typically measured as the degree of arc at the end of joint movement.
MUSCULAR STRENGTH
Muscular strength is needed as we age, and the loss of muscular strength has effects on the ability to walk, climb stairs, transfer, push or pull, and even help transfer loved ones. Research demonstrates that strengthening exercises are safe and effective for women and men of all ages, even those who are not in perfect health. There is significant evidence that individuals with health concerns such as heart disease or arthritis may benefit the most from an exercise program that includes lifting weights a few times each week.
Strength training, particularly in conjunction with regular aerobic exercise, also can have a profound impact on a person’s mental and emotional health. Signs that it may be time to challenge a patient/client’s strength may include burning of quads when climbing stairs, poor ability to hold a son/daughter (or grandchild) for a sustained period of time, the inability to hold the arms up when in the garden, or even difficulty carrying grocery bags into the house. In general, we encourage changes in frequency, intensity, time, and type of exercise (FITT factor) for achievements in muscular strength or muscular endurance.
Evidence-based gains in strength training include:
• Improved bone density
• Slowing of the aging process and osteoarthritis
• Development of strong bones in early years, crucial foundations that affect bone health in later years
• Increased overall perceived function and performance
• Decreased rate of injury for muscle strains and tears
• Decreased fall and fracture rates
The good news is that there are a lot of options, since strength training can be done at home or in the gym. Common choices, advantages, and disadvantages include:
• Closed chain activities are a push (or pull) of the body safely through its own body weight, including push-ups, pull-ups, abdominal crunches, and leg squats. Safe if done correctly, exercises utilizing body weight are simple and cost efficient, require no additional space, and are quantitative with repetitions, but may need added equipment as you progress. Alternatively, it can become uncomfortable to start, since individuals rarely push their body through motion against their body weight on a regular basis (such as a push-up or wall slide).
• Bands and tubing are inexpensive, found in most physical therapy clinics and retail sport stores, and provide the overload needed for strength gains. One of the simplest and most cost-efficient home products, bands and tubing offer resistance assistance, through the full range of motions, and increase resistance at end ranges where individuals sometimes are most weak. They are ideal for travel, and most physical therapy clinics sell resistive bands or similar products.
• Barbells, dumbbells, kettle balls, and a variety of free weights are found in most gyms, but are not very cost efficient with progressive gains. Furthermore, additional purchases are required sometimes to add more weight. Kettle balls differ from traditional balanced barbells in that they recruit more muscle activity with off center weight, and kettle ball programs are designed for full body functional strengthening (versus isolated weight training). A great motivator, kettle ball training offers a different perspective on weight training when traditional weight training becomes routine.
• Weight machines come in a variety of brands, each with actions that are designed to separate them from their competitors. Often at PTW, we recommend biangular units or other products that work multiplane activity, requiring the user to stabilize through correct motion. Traditional single plane units offer advantages of same motion resistance, permitting safe motions.
To achieve strength, the body needs to be stressed, which means leaving the comfort zone. If patients/clients want results, they must first become comfortable with being uncomfortable.
Selectorized weight resistance unit and cable portable unit products are ideal for clients who wish to continue to work in your clinic under light supervision or guidance, but no longer need skilled care. By using exercise units and weight racks in the physical therapy gym, members often can track their progress through their own record keeping, while relying on the skilled staff for occasional recommendations for upgrades to keep the program fresh, simple, and relevant to their goals.
Solutions may (and should) include:
1. Access to the rehabilitation professionals on a frequent basis. Physical therapists are driven by evidence. They can leverage that evidence and credibility to remind patients, wellness program participants, and cash-paying members about the importance of remaining strong to lift the grandkids, take care of their spouse, or being able to lift themselves out of bed at 90 years of age.
2. Self-pay programs that permit access to the clinic’s strength equipment, 3 to 5 days per week, guided as needed by the professionals. All our clinics offer a 1-week complimentary pass to try out our clinic, permitting an “outside the box” opportunity to strengthen in an environment different than the average health club.
PTW’s fitness option offers unlimited access, with client-requested one-on-one appointments made with an exercise specialist, who on the first visit quantifies the client’s fitness baseline measures (body fat, weight, blood pressure, sit reach), sets agreed-upon goals, and follows up at monthly intervals, at the client’s request. At $45 per month, this program is aimed as an entry to good fitness, offering our clients solutions to the costly personal training programs in our community. For the clients who seek help with specific conditions, such as obesity, osteoporosis, or balance, or simply want closer personal attention, we offer six wellness programs ($249), each personally designed for their functional deficits, their goals, with each visit scheduled one-on-one for 6 weeks.
3. Utilizing your hands to help a patient understand true muscle fatigue. Strategies such as manual resistive proprioceptive resistance will force a client to “dig deeper,” working the targeted muscle group harder than they imagined they could.
4. Rehabilitation professionals sometimes forget the meaning of progressive resistive exercise (PRE), permitting their patients or clients to perform the same weight, repetitions, or speed for consecutive visits, and/or not progressing during each visit. To build confidence with PREs, begin at 50% to 75% of repetition maximum and build each visit, each set. A set of dumbbells can be replaced by variable weight dumbbells, taking up less floor space.
MUSCULAR ENDURANCE
Muscular endurance is the ability to resist muscular fatigue or to persist in a physical activity, and often involves performing an activity for many repetitions. Often performed with lighter weights in a low-volume, high-repetition program, muscular endurance training helps to improve the ability to carry out activities for a longer period. Improved endurance is achieved by placing a greater than normal (outside the comfort zone) physical demand on the muscles, creating change and adaptation.
Evidence suggests benefits with both muscular and cardiovascular endurance, including:
• Improved muscle tone
• Decreased disease risks
• Increased energy
• Weight control
• Improved mood
Many products that take up a small amount of floor space include the “spinning bike,” elliptical trainers, cross trainers, and video game-based exercise products.
Some simple options to build muscular endurance may include:
1. Build on repetitions. For instance, with (closed chain) push-ups, adding a repetition each week, starting at 10 per day, will build your endurance, creating a platform for improved strength in your bench press.
2. Max out on repetitions at 50% of your 1RM once every other week, each time performing a specific activity to your maximum ability for repetitions. In the seated row example, a women performing eight repetitions at 60 pounds might consider once a week performing the seated row at 30 pounds for as many repetitions as her body permits (until she loses good form or muscle fatigue prevents additional repetitions).
3. Using the FITT factor, build on time for almost any endurance activity.
As a rehab professional, on a daily basis, you will need to challenge your patients to increase either resistance, time, grade, or speed, to demonstrate improvement and to motivate them toward achievement. Similar to your patients, your paying clients who offer you their trust to keep them healthy should be checked on a weekly basis, adjusting programs up or down to maintain gains while challenging the comfort zone.
MUSCULAR FLEXIBILITY
Flexibility can be improved at any age, although the rate of influence is less the older one becomes. Connective tissue changes limit flexibility, and it is considered the range in a joint or series of joints that is attainable in a momentary effort.
Static stretching involves reaching forward to a point of tension and holding the stretch. Although it has been used for many years to improve range and prevent injuries, there is some evidence that dynamic stretching is more effective in preventing injuries.
Dynamic stretching consists of functional based exercises that use sport-specific movements to prepare the body for movement. It involves moving parts of the body and gradually increasing reach, speed of movement, or both.
In summary, rehabilitation professionals have an obligation to educate the individuals they serve about dysfunction. They likewise have an obligation to communicate changes needed to overcome the dysfunction, and provide solutions that enable patients and clients to achieve higher levels of function and performance. Connections between dysfunction, the do’s and don’ts of what to do, come from the one-on-one education provided in each encounter and each conversation with patients. From that perspective, a physical therapist or any rehabilitation professional has the duty to help those they serve overcome barriers for the sake of performance gains. And, particularly in this case, a duty to help them understand what it takes mentally and physically to shatter the threshold of the “comfort zone.” RM
Robert Babb, PT, MBA, is a practicing clinician of the Physical Therapy & Wellness Institute (PTW) in Lansdale, Pa, and owner of the PTW Institute. More on the organization can be found at www.ptwinstitute.com.
Tyler Haggerty, PT, DPT, is a clinical supervisor at the Physical Therapy & Wellness Institute (PTW) in Glenside, Pa.
References
1. Hill JO, Wyatt HR, Reed GW, Peters JC. Obesity and the environment: where do we go from here? Science. 2003;299(5608):853-855.
2. Brownson RC, Boehmer TK, Luke DA. Declining rates of physical activity in the United States: what are the contributors? Annu Rev Public Health. 2005;26:421-443.
3. US Census Bureau. Internet Use in the United States: October 2009. http://www.census.gov/population/www/socdemo/computer/2009.html. Accessed August 24, 2010.
