Suggestions
regarding musculoskeletal and biomechanical issues for the Nail-Patella
Syndrome individual
(Revised
June 2003)
I.
Introduction
A.
Disclaimer-the
information presented in this handout are suggestions only. Each participant must first seek the advice
of their physician before starting any kind of exercise regime where a thorough
evaluation can be performed to determine what is appropriate for them. Attendance of the presentation does not
qualify the participant in any way to perform any of the suggested information
without physician approval and proper supervision.
B.
Purpose-To provide
individuals with a comprehensive fitness program. The individual, along with supervision of their health care
provider, can select what is most appropriate for them. Some activities may not be appropriate and
therefore should not be done.
C.
Intent-To provide
the individual with the basic knowledge and components that make up a fitness
program.
D.
Recommendation-Due
to the extreme variability in NPS characteristics, it is highly recommended
that individuals have a MRI or scan done to determine the configuration of
their joints before engaging in any exercise program. It has been found that muscles/tendons, ligaments and even bony parts
are often missing or misplaced. Because
of this, exercises would need to be modified to accommodate this. The exercises presented in this document can
be further modified for this purpose and some may not be appropriate at all. This reinforces the importance of first
consulting with your physician before engaging in any exercise program.
II.
Handout
**STABILIZATION-this must be discussed before we begin discussion of
flexibility and strengthening. The
shoulder blades are the stabilizers for the upper extremities and the pelvis is
the stabilizer for the lower extremities.
You must position the shoulder blades in place before starting the
exercise for the upper extremities and also position the pelvis before starting
the exercise for the lower extremities.
By doing this, this allows one end of the muscles about to be exercised
to be fixed in place so that you can either stretch or strengthen from
there. You will get maximum benefit if
one end is anchored, so to speak, as compared to allowing both ends to move
around freely. This will make sense
when you get to each exercise below.
When you see the words “pull your shoulder blades down and in” and “pull
up and in with your abdominal muscles”, this is the STABILIZATION needed to
perform the exercises correctly.
A.
Flexibility
Stretching is a very important part of a well rounded
fitness program. It should not be
overlooked.
When to stretch:
Stretching should be done before and after any physical
activity to help prevent injury. It is
highly recommended for everyone to stretch DAILY.
How to stretch:
The correct way to stretch is to hold the stretch position
of the muscle or muscles for a relaxed, sustained duration of time, at least 30
seconds. STABILIZATION is important
here. Each stretch requires certain
areas to be stabilized in order to fully stretch the desired muscles. Do not stretch to the point of pain, it
should feel tight, not painful.
Bouncing is not appropriate, a sustained stretch is more
beneficial. Do not hold your breath
while stretching, it may raise your blood pressure. It’s a good idea to first walk around to warm up the muscles
before stretching. Since duration of
the stretch is the important factor, 30 seconds, it is not necessary to do more
than 3 to 5 repetitions. Therefore,
stretching does not take very long to complete. It is the duration of the stretch, not how many, that is
important.
Benefits of
stretching:
Increases range of
motion of joints
Decreases muscle tension
Prevents injuries such as strains
Prepares the body for more physical activity
Helps circulation
1.
Supine overhead
upper extremity with simultaneous single hip flexor stretch-
Lay on back, straighten one leg and pull up and in with
your stomach muscles then squeeze the buttock tight on that extended leg. Raise your arms overhead also and
stretch. After several repetitions,
switch and do the opposite leg.
2.
Prone press-up
Lay on stomach and slowly raise up to prop on elbows. Do this several times.
3.
Hamstring stretch
Lay on back next to an open door. Place one foot on the frame of door and slowly straighten the
leg. Keep other knee bent then switch
legs and repeat.
4.
Double knee to chest
Lay on back and slowly bring both knees toward chest and
hold there. Can place your hands under
the calf instead of what is pictured if pushing down on knees is painful.
5.
Standing wall heel
cord stretch
Face a wall and place one foot back with heel down and knee
straight. Bend front knee and slowly
lean into wall. Keep stomach pulled up
and in.
6.
Prone quad stretch
Place a rope around your ankle and hold onto it with
hands. Lay on your stomach and slowly
bend your knee then gently pull further with rope for further stretch.
B.
Strengthening
Adequate strength is necessary for people to carryout daily
activities without difficulty.
Strengthening specific muscles helps to strengthen, shape and tone the
body.
When to strengthen
Strengthening should be carried out when a weakness has
been determined in specific muscles and muscle groups. Weak muscles contribute to difficulties in
completing daily, recreational and athletic activities. Weak musculature also contributes to an
increase risk of injury to the body.
How to strengthen
Always warm up, stretch before beginning your strengthening
exercises. Proper technique while
strengthening is very important. Proper
positioning on Cybex/Nautilus/Universal gym equipment etc. is necessary to
avoid injury. Where applicable, be sure
to always have the axis of motion on the equipment in line with the axis of the
body part being exercised. When lifting
from a standing position, be sure to:
1) feet hip width apart. 2)
equal balance forward and behind.
3) keep knees in line with the
feet. 4) keep knees slightly bent, not locked. There should be no pain while performing strengthening exercises.
If using free weights, proper body positioning is very
important to strengthen the intended musculature and to avoid injury. Again, as previously mentioned STABILIZATION is vitally important to
strengthen correctly.
An important comment to note here is that strengthening via
the use of free weights is more beneficial when beginning a strengthening
program. Free weights strengthen
individual muscles when isolated and if there is any imbalances, free weights
do a better job. Larger strengthening
equipment such as cybex/nautilus/universal gym, all tend to work groups of
muscles and are usually completed bilaterally.
This bilateral workout tends to allow the stronger muscle groups to
dominate thereby not helping to strengthen the weaker group. Larger strengthening apparatus serve a
better purpose later in the strengthening regime.
How often
Three times per week with at least a days rest between
workouts. If you choose to workout
daily with strengthening exercises, then complete upper body strengthening one
day followed by the lower body on the next day. This method would allow a days rest for each part of the body.
Sets and repetitions
A set is a fixed number of repetitions. Best strength gains are achieved when 1 to 5
sets per exercise are completed. 3 sets
of 10 repetitions are considered beneficial for the average person. If more endurance is desired then increase
the repetitions to 15, 20, 25 and even higher per set while keeping the
resistance lower. Both strengthening
and endurance are achieved by doing this.
For NPS, it is RECOMMENDED that higher repetitions(for
endurance) with lower resistance be carried out particularly for the knee
joints. This MINIMIZES the compressive
forces on the joint thereby reducing irritation and still allowing
strengthening and endurance to occur.
SPEED is also a very important issue, the faster the repetitions the
better for minimizing the time that compressive forces are acting on the
joint. This same approach can be used
for any other joint where there may be abnormal joint mechanics taking place.
How much weight
Use as much weight as you can tolerate for 10
repetitions. The last repetition should
be fairly difficult to perform but done so correctly. Once you are able to do more then 10 repetitions comfortably,
then increase the resistance by the smallest increment available. You may need to drop down in your
repetitions to 6 or 8 reps and progress back up to 10 repetitions. You can progress to 2 sets of 10, then onto
2 sets of 15 or 20 reps and even higher reps to get the endurance component
while still strengthening.
CAUTION
Do not hold your breath while working with weights. Always exhale while performing the exertion
portion of the exercise. Always relax
other muscles not involved in the exercise.
Therefore, you will not substitute other muscles for help and take
energy away from the muscles you are trying to strengthen. It is best to work the larger muscle groups
first and progress downward to the smaller muscles. This is because the smaller muscles fatigue sooner than the
larger ones and you could tire out before finishing your program.
1.
Upper
Extremity
a.
Supine triceps
Lay on back with knees bent. Hold weights in your hands and point your elbows toward the
ceiling and keep them there. Fully
extend the elbows and repeat. Keep
shoulder blades placed down and in.
b.
Supine chest press
Lay on back with knees bent. Hold weight in both hands at chest level and extend your arms up
and down toward the ceiling. Keep your
shoulder blades down and in. This exercise
can be performed on a bench where you can drop your elbows lower to get more
stretch across the chest before lifting upward.
c.
Prone scapular
retractions
Lay on stomach with a towel roll under forehead. First squeeze down and inward with your
shoulder blades then lift hands off surface a few inches and hold. Relax then
repeat. You can progress to holding a
weight in your hands.
d.
Sitting abduction
raises with elbows bent
Sit up tall in chair with good posture and with weights in
hands. Starting with weights at
shoulder height, raise upward then downward to starting position and
repeat. Keep your shoulder blades down
and in and keep your stomach pulled up and in.
e.
Arm chair push-ups
Sit up tall on the front edge of a chair using good
posture. Place your hands on the arm
rests. Place your feet on floor behind
the knees and lean forward and push down with your hands into arm rests and
attempt to stand. Do not need to stand
up, this is just to work out the tricep muscle in the back of the upper
arm. This maneuver is also good for
WHEELCHAIR BOUND people as it teaches them the proper body positioning, for
transferring from the chair to another location.
f.
Standing bicep curls
Stand with weights in both hands held at your sides. Bend one elbow with palm up and then turn
the palm down and straighten the elbow.
Keep thinking “palm up and palm down” as you work the biceps. You can do one arm at a time or do both at
same time or alternate one up while the other down as pictured.
2.
Trunk and pelvis
a.
Posterior pelvic
tilts
Lay on back with knees bent. Pull up and in with abdominals to posteriorly tilt the
pelvis. Two pictures are shown here
only to visually demonstrate the posterior tilt. The second picture is the pelvis posteriorly tilted causing a
flattened back.
b.
Posterior pelvic
tilt for upper abdominals
Lay on back with knees bent. Pull up and in with your abdominals which flattens the back,
tilting the pelvis posteriorly and perform a small curl up and repeat.
c.
Posterior pelvic
tilt for lower abdominals
Lay on back with knees bent. Pull up and in with abdominals as above, then while maintaining
this, lift one leg up slightly then place it back down. Repeat with the same leg and complete before
moving onto the other leg.
d.
Sidelying hip
abduction with knees bent and over pillow
Lay on your side with a pillow between your thighs. First pull up and in with your abdominals
then raise your upper thigh up and outward from the pillow and return. Do same for other leg.
e.
Sidelying hip
adduction
Lay on your side and bend your top leg and place the foot
in front of bottom leg. Keep the bottom
leg straight. First pull up and in with
abdominals then lift bottom leg up a few inches then return. Do same for other leg.
f.
Prone gluteus lift
with knee bent and over a pillow
Lay on stomach with a firm pillow under your pelvis and
forehead resting on a towel roll. Bend
one knee then squeeze that buttock tight then lift that leg upward a few inches
and hold for 3 seconds and relax.
Repeat and do same for other leg.
g.
Prone gluteus lift
with leg straight
Lay on stomach with forehead resting on a towel roll. Squeeze one buttock tight then lift that leg
upward a few inches and return and repeat.
Do same for other leg.
h.
Prone opposite arm
and leg lifts
Lay on stomach with forehead resting on a towel roll. Squeeze buttock tight on one side and lift
leg upward at the same time you pull your shoulder blade down and in on
opposite arm and lift arm upward as pictured.
Arm and leg should be lifted upward at the same time. When done, then do same for other leg and
arm.
3.
Lower
Extremity
a.
Quad sets
Sit up tall with both legs straight. Pull up and in with your stomach muscles
then tighten both your thigh muscles as if you are trying to push the back of
your knees downward. You can place your
hand there to feel the back of knee push downward. Hold the contraction for up to 5 to 10 seconds.
b.
Short arc quads
Sit up tall with a firm roll under one knee. Turn that foot slightly outward. Beginning with the knee bent over the roll,
fully straighten the knee then relax and repeat. Do same for other leg.
Make sure to hold your stomach up and in.
c.
Straight leg raises
Lay on your back with one knee bent and other one
straight. Pull up and in with the
abdominals then lift the straight leg up parallel with the other thigh then
lower and repeat. To facilitate more of
the inside(medial) muscles, turn the foot outward on the straight leg before
you lift. Do same for other leg.
d.
Standing double leg
mini squats
Stand with your back to a wall and your feet approximately
6 inches from the wall. Feet are
shoulders width apart and perform a slight squat. Hold this position until you feel fatigue in the quad muscles
just above the knee. Repeat. Keep stomach tucked in and shoulder blades
down and in.
e.
Mini step-ups,
forward, sideways and backwards
Place a phone book on floor and stand facing it. Shift your weight to one heel and step up
onto the phonebook with the other foot using good posture form and holding your
stomach muscles up and in. By being on
your heel this prevents you from “pushing off” and making the exercise
easier. Step up and then down
repeatedly until you feel fatigue in the front thigh muscles then do same for
other leg. As pictured below, you can
do this by stepping sideways and also backwards. The backward one is the most challenging.
C.
Cardiovascular
Endurance
Cardiovascular exercise, also known as “aerobic” exercise,
is probably the most important aspect of a total fitness program. Strength and flexibility are also important
but it is aerobic exercise that keeps the heart and lungs strong and more
efficient. Aerobic training also keeps
body fat levels down. Aerobic
activities are those activities that demand oxygen and that utilize large
muscle groups in a continuous, rhythmic fashion. Aerobic exercise causes the body to burn fat for its fuel during
the activity. Examples of aerobic
exercise are walking, swimming, indoor and outdoor bicycling, treadmill,
stairstepping machine etc. Of course,
jogging and running are also aerobic but are much harder on the joints. Before engaging in any aerobic activity, it
is important to first warm up by completing general stretching or flexibility
exercises and brief walking to prepare the body. Before starting any aerobic training, it is best to first check
with your doctor. This is particularly
true if you have a history of heart disease or are over the age of 35 and/or
have not engaged in any regular exercise.
If you have any other concerns regarding your present health status, it
is best to check with your doctor.
Key components of an
aerobic workout are:
1.
Know your target
heart range.
2.
Type of
activity-choose an activity which is BEST SUITED for you based on your medical
history and your interests.
3.
Duration-it is best
to carryout your aerobic activity for at least 20 minutes or longer to achieve
aerobic benefits.
4.
Frequency-it is best
to complete your aerobic activity 3 times per week or more in order to gain any
benefit.
5.
Progression-aerobic
exercise should be progressed by either increasing the intensity or the
duration or a combination of the two in order to further your progress and
condition your cardiovascular system.
Determining your
target heart range:
220 –
age = MHR (Maximal heart rate)
MHR x
.5 = 50% of maximal heart rate (for beginners)
MHR x
.8 = 80% of maximal heart rate
50 to 80% of your maximal heart rate is considered a safe
target heart range to exercise aerobically in, unless otherwise indicated.
Monitoring your
heart rate:
Your pulse should be monitored regularly to ensure that you
are exercising properly in your target heart range and progressing as you
should.
Counting your pulse:
Place your first 2 fingers on your opposite wrist just
below the thumb. You should feel a
pulsating sensation, this is your pulse.
Count the beats for 6 seconds and multiply that number by 10, this is
your heart rate per minute and this rate should fall in your target heart
range.
As you become more fit, your heart rate will drop at the
same workloads. You will need to either
increase the duration as long as your heart rate is still in your target heart
range or increase the intensity of the activity to keep your pulse in your
target heart range.
How to choose the
right aerobic activity:
You must consider your interests and also your present
health status. Some activities are not
appropriate for certain health conditions, for example, jogging or running on
arthritic knees. It is also equally
important that you choose an activity that you like, therefore, you will be
more likely to continue the activity indefinitely.
Benefits of aerobic
exercise:
1.
Helps to decrease
body fat
2.
Helps to reduce
cholesterol levels
3.
Builds endurance
4.
Lowers the resting
heart rate
5.
Increases the
ability of the heart to supply oxygen to the body
6.
Increases lung capacity
7.
Helps with blood
pressure control
8.
Reduces stress and
tension
Do not be afraid to choose several different activities for
your aerobic conditioning. This will
allow you to use different muscles and offer variety to your program.
Remember that you do not have to complete your whole
program at one time. You can choose to
do your aerobic workout on certain days and do your strengthening exercises on
other days. Stretching is best to be
completed daily and you should always warm up before and after your aerobic
activity and strengthening exercises.
Just before meal time is a good time to complete an aerobic
workout since it helps to curb your appetite.
Examples of aerobic exercise are:
1.
Ergometer-also known
as indoor bicycle. For NPS knees, it is
best to place the seat high enough so that there is little bend in the knee
when the pedal is up but still keeping the foot on the pedal when the pedal is
down. This position will minimize
compressive forces on the knee joint and emphasize use of the vastus medialis
muscle which helps to pull the patella away from the outside of the knee where
it can cause pain. The same principle
can be applied for outdoor biking.
2.
Walking-While
walking, this is an opportunity to practice good posture technique. Also, good walking shoes with good arch
support and cushioning.
3.
Swimming-This
activity offers the least weight bearing through the joints because of the
buoyancy of the water. Arthritis
sufferers benefit from this activity.
Stretching, strengthening and aerobic conditioning can be completed in
the water. POOL TEMPERATURE is very
important. If swimming laps and you can
tolerate being in cooler water, pool temperature from 82 to 86 degrees is okay
for swimming laps. If performing
strengthening exercises such as arthritis classes, therapeutic pools etc., then
pool temperature around 90 to 92 degrees is more beneficial. If have a heart
condition, check with your doctor first to see if 92 degree water temperature
is a contraindication for you.
D.
Posture
Exhibiting proper posture for sitting, standing and while
doing your everyday activities is very important. It helps to maintain an equal balance of the muscles on the
skeleton. As we age, gravity takes it
toll on our bodies and if we do not use proper posture practices, muscles
imbalances begin to occur throughout the body and can be one of many reasons
for pain and can contribute to injuries.
Poor posture produces a forward head, forward or rounded shoulders, very
little curvature in the low back or just the opposite with extreme swayback,
locked in knees for standing and flat feet. These are just a few of the more
common observations.
Indicated below are examples of poor posture and good
posture. Awareness and simple cues can
begin to correct poor posture along with corrective exercises. NPS people can benefit tremendously from
this knowledge as it is known that there are bone and muscle structure
differences in the body.
Good Forward Forward with extreme back curve
(Poor) and knees locked in(common in
NPS)
