Welcome to my Blog! Well, not technically a blog- more like a collection of deep thoughts. Please understand that these are my personal opinions and beliefs. This blog does not create a patient-provider relationship and does not constitute medical advice. Please contact your Physician or local Physical Therapist if needed. Enjoy!
Rachel Miller, PT, DPT
Doctor of Physical Therapy, Certified Pilates instructor, and Founder of The Pilates PT
July 2016 Why you don't stay better after treatment
I hear it all the time. "I have had chronic (fill in your bothersome body part here) pain for years. When I get bodywork (soft tissue/fascial bodywork or mobilization/manipulation), it feels better for a day or two but then it comes back."
Sound familiar? Wondering WHY?? Here's my opinion. The manual work helps to get your body moving better again. But it is only a temporary fix. The problem becomes that you did not change HOW you move. This can mean a few things.
When someone is in chronic pain (months or years), often their body compensates for the pain. Examples are decreased weight bearing or stance time on the injured leg (limping), or often moving your hip and pelvis as one unit when protecting your back. These are our bodies go to patterns for protection. The problem is that even when the pain is gone, the body does not reset automatically. These faulty movement patterns can persist despite the resolution of pain. And they can quickly lead to other issues.
Another thing I see commonly is the lack of proper core stability and activation.
The manual work may have taken away some of the "tightness" but your body needs to get stability from somewhere, so most likely you revert to your old patterns because you did not replace that stability with something else. Commonly, I see the hip flexors (psoas) and the back extensors/quadratus lumborum are overworking to provide that stability and people need retraining- specifically finding their TA (inner abdominals) and gluts to help provide that stability.
And just like a lot of things in life, when something has been an issue for years, it is rarely a "quick fix." Similar to dieting, when you are on the diet you feel better and lose weight, and then many people stop the diet- and shocker- gain the weight back. Look at rehabilitation in the same way. If you had low back pain on and off for 10 years, you need to actively participate in your rehab- strengthen, stretch, get some good manual therapy- whatever you need to get better. But once PT ends, you need to continue some of those exercises or movement principles (like proper posture) in order to STAY better. It is a lifestyle change. What that entails- what exercises, stretches/self release work, and how often you need to do that varies from person to person. And it will also vary depending on your day to day activity- your body has different needs after driving 8 hours in a car, gardening for an afternoon, or playing a round of golf. Our bodies are dynamic- meaning constantly changing, hopefully in a good way.
October 2017 Mommy Tune Up
I can still remember the day when my first son was 6 months old. I was at a mommy exercise class with him in the stroller and I was having excruciating neck pain. Yes, even Physical Therapists are not immune to having their own issues. I went to my doctor that day and asked for a referral to Physical Therapy and scheduled an appointment for the next day.
Why did I let my neck pain get that bad? A combination of relaxin (a hormone that increases during pregnancy that relaxes your joints and ligaments), poor posture while nursing, lots of holding and carrying a growing baby and heavy carseat, and mommy guilt. As a first time mom, my focus was on my baby. It was difficult for me to make time to take care of myself- partly because of guilt, partly because of lack of childcare. When my neck started bothering me a month earlier, I should have addressed it. Luckily after a few sessions of Physical Therapy, I was much better.
The miracle of growing a baby is amazing, but pregnancy takes a toll on your body. As the baby grows, we grow- we gain weight, our posture changes, our bodies become more mobile (from the relaxin), and our hormones can make us a little emotional. Then, that baby has to come out one of two ways. I remember the overwhelming experience of holding my son after delivery. The doctors were busy "down there" doing something but I could care less. I had to ask at some point what they were doing, but I didn't even find out many details. My body had shifted to the lower priority at that moment- the problem is that in our healthcare system, it seems to stay that way. Most women follow up with their OBGYN a few weeks after delivery and that is it. You are sent home after a few quick days in the hospital and then you are on your own- hopefully with some friends or family to support you, but not always. When I went home, my body did not feel good at all. But isn't that normal? How do we know?
What about reconnecting your body? Changes in posture and the delivery process often create a more difficult connection with your abdominals and pelvic floor. Let me tell you, after years of being a Physical Therapist and Pilates instructor, they do not always magically reconnect. I had to work at it. Did you know other countries have women go to a PT for this reason after having a baby as part of their recovery? If you have pelvic pain or incontinence that persists after childbirth, talk to your OBGYN- there are women's health Physical Therapists that can likely help! And for ALL the moms out there- make sure you reconnect with your core- it is never too late! It is time for all of us to prioritize ourselves and our bodies. We can be better mothers if we take care of ourselves now. Go get that "mommy tune up."
July 2017 What is "Perfect Posture?"
Most of us know that we are supposed to have proper posture- whatever that is. You probably think "sit up straight" or "don't slouch." And when you try to sit up straight, most people lift from their chest. Think about what muscles are holding you up here- do you feel tension or tightness in your back? Try it- you will likely feel your back extensors having to tighten to hold you there. When we sit or stand in this position for a longer period of time- those muscles will likely get tired- and then you may feel some stiffness or soreness in your mid or lower back. Then we have the other extreme- the dreaded slouch. Rolling back on your pelvis, back is rounded, and the head juts forward. Also very common, right? Especially when sitting at a desk/computer or driving. Over time, this will lead to tightness in your chest (pecs) and neck extensors (muscles in the back of your neck), and likely weakness in your deep neck flexors and scapular muscles.
SO WHAT DO WE DO? Let's put this in perspective. Our bodies are designed to move. The problem becomes when we rely on our end ranges (slouching or locking into extension) all of the time. This is relying on your ligaments and muscle tightness to hold you up. It is NOT bad to sit either way for shorter periods of time (unless you have an active injury - but that is a different discussion for another time). What I believe has gotten lost is the neutral spine position. It is the natural curve of your spine- the position where your core is more likely to automatically activate. Look at a picture of a baby or young child sitting- we start with that perfect posture. It should feel comfortable- and easy- once you find it. But so many of us have forgotten what that feels like. I think about growing taller from the back of my body which drops the ribcage down in the front a little and then relax. When you find that perfect posture your body should "do less"- relax your shoulders, relax your back, relax your belly. All I ask is that you sit in the neutral spine position some of the time. You can relax on the couch, you can slouch, you can extend some of the time as well- just change it up. Humans were designed to move and our world has become very sedentary. So, MOVE more and take notice of your body throughout the day. What activities do you tend to slouch? overarch your back? Do you hold tension or tightness in your neck or shoulders or somewhere else? You are in charge of your body- so start paying attention to what is holding you up all day.
August 2016 Why stretching is an uphill battle
How many of you stretch regularly? How many of you know you should stretch regularly but don't feel like it helps? Here is what you need to know about stretching and flexibility.
I have heard from numerous patients that they have "never been flexible." I don't buy it. Let's think back to the beginning stages of life. I have yet to meet a baby that cannot put their feet in their mouth. I have yet to see a 2 or 3 year old that cannot easily play in a deep squat and stand up and touch their toes. All of the boys on my son's 5 year old soccer team can still touch their toes. So, when do we go downhill? My best guess as of now, is when we start to sit at school all day. Just like adults, kids sit to eat, sit on the bus/in the car, sit at a desk, sit to play videogames or watch TV. Kids have less gym and recess than they used to. Then add on growth spurts where their bodies are rapidly growing and their coordination and strength are struggling to keep up. This definitely influences flexibility. The other major contributor is the child's level of movement or sports, especially in the pre-pubescent window, the few years before the onset of puberty. Kids who are dancers or gymnasts tend to be more flexible because they are working on stretching and reinforcing big movements very regularly. Kids who are runners or weightlifters tend to be a little tighter. What you do at that time in your life sets the foundation for later. For example, I grew up dancing. I was very flexible. I stopped dancing regularly awhile ago and I have lost a lot of that flexibility. Which surprisingly, is a good thing. The more flexible you are, the stronger you need to be to support that flexibility. Pilates has helped me to better support the flexibility I do have and my body has a good balance to it now. But you have to work for that strength!
So, back to stretching. Why doesn't it work as well as it "should?" If you lengthen a muscle, but don't teach it how to work in that new range of motion, it is not going to stick! That is why I am a big fan of eccentric strengthening- working on strengthening the muscle WHILE it is lengthening. Much more effective than a static, passive stretch in my opinion. I'm not saying there is no place for static stretching. It feels good, and I think it is great to include throughout the day or in your exercise program, it just can't be expected to make big gains all by itself. The other major factor is the BIG PICTURE. Let's talk about hamstrings, because most of you know where they are, and because most of you probably have tight ones. Let's say you stretch your hamstrings with a nice, static stretch 3 times for 30 second holds on both legs (that's 3 minutes total). And let's say you do that every day, which is probably a generous assumption. What position are your hamstrings in for the other 23 hours and 57 minutes of the day? If you are sitting with your knees bent, or sleeping with your knees bent- how many hours does that add up to? Now, do you think your 3 minutes of stretching are going to have any chance of winning? You will have a better chance of improving your hamstring flexibility if you change your positioning throughout the day. Try to sleep with your legs a little straighter, sit with one or both legs out straight- on an ottoman, chair, whatever works. Stand and walk more! What position are you in right now? Start thinking about all the little changes you can make- they add up!
February 2018 Are your exercises REALLY helping you??
I see two common themes with core and glute exercises. First, people are doing the "right" exercises, just not the "right" way. One good example is a glute bridge. People think they are strengthening their glutes (which is their intention in this case), however it is often the back extensors that are doing a lot of the work. Glutes, and inner core muscles, for that matter are really hard for many people to find, and to FEEL. My question is always "Where do you feel this exercise?" Second, let's say you can now do the perfect bridge and your glutes are stronger. Great. Now, did that carry over to function automatically? Doubt it. Just because you have stronger muscles does not mean that you have changed your body's movement patterns. Glutes should be working with sit to stand, squats, walking, and more. But often, they are only doing the bare minimum - this is where you need to think about HOW you move and how to use your new strength functionally. Strengthening shouldn't only be happening at the gym. We are meant to lift, push, pull, and move. Not sure what your body is doing? THAT is what a wellness screen is for. My motto is get MORE out of what you are already doing- maximize your time and do what is BEST for your body. (Curious how to do a glute bridge- go to the videos tab above and check it out).
April 2018 What is your INNER Core?
This is a question that I am ALWAYS answering. So many people think that core strength is all crunches and planks. Those exercises are for your core BUT do not necessarily strengthen your inner core...
Your outer abdominal muscles (rectus abdominis - the six pack muscle and obliques- external and internal) are your movers. These muscles flex and rotate your trunk. Underneath all of those muscles is your transverse abdominis which is the front of your inner core. This muscle is different as its job is to stabilize, not move you. Your inner core also consists of your diaphragm, which you use to breathe, at the top, your pelvic floor at the bottom, and deep back muscles in the back. Your inner core should automatically activate when you load your body, but I have so many people that I see with and without injuries where this system is not working as it should. Common issues that are often a result of inner core weakness or dysfunction are incontinence, diastasis recti (abdominal separation), pelvic organ prolapse, and even some types of low back pain.
So how do you use your inner core? Just like any other muscle in the body, you have to train it. But the inner core does involve more thought as your brain needs to FIND these muscles first. Then, you work on strengthening and retraining then to activate first - before you move. I often start this process with core stabilization. Let's take the exercise below, marching, as an example. You could lay down on your back right now and march and use NO core. Or you could lay in a neutral spine position and use your breath and your brain to be very mindful of how you do the exercise. By definition, core stabilization means you are NOT moving your spine or pelvis. For marching, the only movement should be in one leg. What is interesting is the more you practice, the more abdominal work you can feel with this exercise as you are able to truly find and work the deeper, inner core. And don't think just because your outer core muscles are strong, that your inner core is too. They are very different and the inner core muscles are often ignored. Think about when you do core strengthening exercises, how do you feel afterwards? If I strengthen my outer abdominals, I feel a lot of muscle soreness the next day when I laugh or go to get up from a chair. But if I focus on my inner core, the next day I feel like my stomach is flatter and tighter- I can tell I worked my core even though it is more subtle.
There are videos in the "Video" section of this website- go there to see how to perform marching. I would also recommend watching the neutral spine video first so you make sure to set yourself up in the right position. Just like any other muscle, practice! Although the inner core requires a bit more focus and mindfulness. I hope you can figure out how to work from the inside out!
September 2016 Can you Fix your Flat Feet?
How many of you out there have flat feet or know someone who does? Medically speaking, this is known as excessive pronation, where you see no or minimal arch when you are standing. I used to have very flat feet, and remember getting custom orthotics when I was in elementary/middle school. After awhile, I stopped wearing them and was fine but still had "flat feet." But now, I have decent arches, no more flat feet! How did this happen? I will let you in on my secret...
Lateral hip strength! When I found Pilates, I started practicing the sidelying hip series regularly. This targets your deep hip external rotators (including piriformis), gluteus medius, and gluteus minimus. These muscles are often ignored but are very important. So, the first step is strengthening them. I always include some of these exercises in my group classes- just one more reason to come!
The next thing to think about is are you using that strength functionally? When you stand, are you letting gravity win and letting the arches collapse? Or are you using those hip muscles? Try this. Stand with your feet shoulder width apart. Let gravity win and the knees roll in and arches collapse. Then all I want you to do is activate the hip rotators- think about slightly externally rotating your femur. Just that little bit of activation should immediately restore your foot's arch. You should also feel your pelvic floor and transverse abdominis muscles kick in- these are subtle, don't look for anything too big. You should instantly feel taller and lighter. Feels good, doesn't it? Now try to keep it- oh, and breathe.
Yes, the height of your arch is going to be influenced by your genetics/structure. I still remember the girl in ballet class who had AMAZING feet, that was not me. Don't let gravity win and take your arches away. Be active, use your muscles the way they were designed to be used! Your feet, knees, hip, and low back will all thank you for it!
January 2017: New Year, New YOU
Happy New Year! It's the time of year to think about what changes you want to make, and what type of lifestyle you want to lead. Here are some scenarios that I often encounter and want to share with you:
1. NOT UNDERSTANDING HOW TO FIND VALUE IN HEALTHCARE.
Healthcare is complicated, and finding value can be difficult when you go to a medical procedure or appointment without knowing the cost or the quality of the medical provider.
- My advice: Let's talk about just Physical Therapy. At the Pilates PT, all appointments are one on one with me, an expert Physical Therapist who specializes in manual therapy and Pilates based PT. You know what the cost is before you even come, typically require less visits, and you still have the potential for reimbursement through your insurance (as an out of network provider) or from a Healthcare Spending Account. And insurance does not dictate or limit the care you receive- we do what we need to do to get you better. Specific numbers/coverage depends on your insurance plan, and I am happy to help you figure out what it all means.
2. "GIVING UP" AND LIVING WITH CHRONIC PAIN.
Many people with chronic pain have tried conservative treatments or even surgery without much success. They have accepted having limitations in their life because of their pain/symptoms.
- My advice: I know there is no such thing as the one perfect intervention for everyone. Just like a relationship, you need to work with the right person, at the right time, doing the right intervention for you. So, don't give up- try something different! I specialize in shoulder, spine, and pelvis/SI joint pain and often work with very complicated, chronic issues. I have had many successful outcomes and people are always thankful. Let this be the year that you prioritize yourself and take action!
3. NOT UNDERSTANDING THE POWER OF WELLNESS.
-My advice: Wellness can cover a few different scenarios. Typically, it is a term used for when someone does not have current pain but wants to work with a Physical Therapist either for injury prevention or for sport specific training. People with core weakness, which often occurs after having abdominal surgery, after having a baby, or with a history of back pain, or with poor posture often don't qualify for "medically necessary" Physical Therapy. But working with a Physical Therapist would be extremely beneficial for these issues. I always like to be the starting place- performing a wellness screen to identify your strengths and weaknesses and then start the process of educating and strengthening, and most importantly- teaching correct form. Then progress to working independently or with a personal trainer to continue to meet your goals.
This year should be about YOU (at least a little bit, right?). You should feel good, you should be able to do any exercise or activity you want to do without fear or pain. Here's hoping that you have a happy and healthy 2017!
March 2017 Inhale and Exhale...
Breathing. We all know it's important. We all do it- in fact, an average adult takes over 17,000 breaths every day. Even though it is something that we don't often think about, HOW we breathe is very important.
As a Physical Therapist, I often see breathing patterns that can contribute to someone's issues. For example, someone who breathes into their upper chest and overuses their accessory breathing muscles in their neck, will often have more neck tightness and pain. "Belly breathing" can contribute to "pressure related issues" such as hernias, diastasis recti (abdominal separation), pelvic organ prolapse, and a non-functional core. Now you are likely thinking, well, how should I breathe? In my opinion, I prefer 3 dimensional breathing- the lungs should expand forward- but also sideways and backwards. 3D breathing will help to mobilize the thoracic spine and the ribs.
A very important muscle for breathing is your diaphragm. Your diaphragm forms the top of your inner core, your pelvic floor is on the bottom, your deep back muscles in the back, and your transverse abdominis in front. These muscles must all work together to have a functional core- a core that is reflexive and kicks in automatically when you need it. Did you know that holding your breath is one of the most common ways to "cheat" when you are exercising? This is a sign of poor core stability, and will limit your ability to engage your core. As a Pilates instructor, I emphasize the importance of breathing- and often assign the breath pattern to an exercise. Pilates focuses on core strengthening, but also breathing, posture, and control. It is a great way to strengthen your inner core, as this muscle group is so different that many people have difficulty finding and strengthening it. Pilates on the equipment is very adaptable and can be appropriate for a wide variety of ages and fitness levels. But whatever type of exercise you doing, make sure to breathe!
June 2016 Core Beliefs
Have you ever had low back pain? Have you ever been pregnant and had a baby? Have you ever had back or neck surgery? Do you have incontinence (yes, even counting the tiny leak that happens when you sneeze or jump)? Do you have pelvic organ prolapse, diastasis recti, or a hernia?
If you answered yes to any of those questions, that tells me that your inner core is likely not functioning as well as it should be. Think of your inner core as a can of soda- your diaphragm is on the top, pelvic floor on the bottom, transverse abdominis (TA) in the front, and deep back muscles in the back. If there is a hole anywhere in the cylinder, you have a leak. Your inner core is meant to work together, and those muscles are meant to activate automatically- without you having to think about it. The problem is after an injury or other issue, your body doesn't have a magic "reset" button. The muscles don't always go back to how they should. Many times, you are left with some residual weakness and/or compensatory movement pattern. The good news is there is something you can do about it. First, you need to find the right muscles. Second, you need to strengthen them (which is a lot harder for your brain to figure out how to do then doing bicep curls at the gym). Lastly, is using those muscles functionally. If you have good posture, then those muscles should activate automatically and work together. You should not have to think about them. Easier said then done, but is possible with some help (from someone like me- wink wink).
There is a lot of talk about "the core" in back rehabilitation, but I want you to know that it is often a major contributor to one's hip pain, knee pain, foot and ankle pain, and shoulder pain. If you have chronic foot pain and treatment has only focused on the foot and you are not getting better, then you are likely missing something further up the chain (hello core, hello posture) and/or in your environment (shoes, lifestyle). You need to look at the big picture. So, you see- in my world, most roads lead to the core. Are you ready to update your body's map?