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2.      Prone press-up

Lay on stomach and slowly raise up to prop on elbows.

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 under stretching, 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-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.

               REPETITIONS-10 repetitions are considered average except when you wish to build more endurance.  Endurance improves when you increase the repetitions to 15, 20, 25 and more per set, and keeping the resistance lower.  Both strengthening and endurance are achieved.  For NPS, it is recommended that higher repetitions coupled with lower resistance be performed 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 is 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 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.

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 for 3 seconds and repeat.

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.

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.

f.        Standing bicep curls

Stand with weights in both hands.  With one arm fully extended and palm of that hand facing the body.  Bend elbow slowly rotating your palm upward to full flexion of elbow then extend the elbow rotating the palm towards the body again.   Keep shoulder blades down and in.

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.

3.      Lower Extremity

a.      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.

b.      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.  Do same for other leg.

c.       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.

d.      Mini step-ups, forward,  sideways and backwards

Place a phone book on floor and stand facing it.  Using good posture form and holding your stomach muscles up and in, step onto the book with your heel then step back down.  Do this until fatigue of quad muscles just above the knee.  Do same for other leg.  Can also do this moving sideways via a side step as shown and also backwards via a back step.  The backward step is the most challenging.  Use good posture for all.

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, stairmaster 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.

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                                 

    Good                                                 Poor

In conjunction with proper posture practices, as the saying goes, everything starts from the ground up, so the feet are very important with regards to the arch and NPS people. There should be proper arch support and this can be achieved if needed by the use of arch supports/orthotics.  Maintaining the proper arch helps keep the patella in its proper place allowing it to track as it should when bending and extending the knee.  When there is no arch, the patella tends to place itself laterally and can cause irritation/pain.    If not corrected, this could lead to degenerative changes in the knee such as osteoarthritis.

Another point to make here is NPS presents anywhere from no patellae to normal sized patellae and some people can have a decreased lateral ridge of the femur bone which can predispose the patella to track laterally just like mentioned above regarding the arch issue.  This makes strengthening the medial knee muscles and arch support even more important to counteract the lateral pull on the patella.

 It has been found that when there is pain in the knee due to any of these reasons just stated, it is best to minimize the time the knee is spent in a flexed position.  The flexed position of the knee is the position where there are the most compressive forces acting on the knee.  Be very careful not to sit too long without straightening your knees periodically to relieve this compression, otherwise, symptoms can increase.

E.     Body Mechanics

As with proper posture awareness, body mechanics play an equally important role in minimizing pain and injury to the body.  By utilizing proper posture positioning of the body along with good mechanics of moving about and foot placement, lifting activities are much easier and less likely to produce pain or injury.   Included in this handout is a sheet which demonstrates good body mechanics for lifting and points out the details that are important.   (See appendix A)

Good mechanics                         Poor mechanics

F.      Modalities

A modality is a method of application or the employment of any therapeutic agent.  In Physical Therapy, a modality refers to heat, cold, electrical stimulation, ultrasound etc.  Any one of these or combination of these can help with NPS symptoms and this can be determined by evaluating the symptoms, acute vs. chronic, severity, cause and many other factors.  Consult with your doctor regarding this. 

APPENDIX A

BODY MECHANICS

Your back has small joints and smaller muscles which makes it weaker than the larger joints in your legs where the muscles are bigger and therefore stronger.

            TO LIFT:

1.      Get close to the object.

2.      Face object directly.

3.      Bend your knees to lower self to object.

4.      Grip object securely.

5.      Keep spine straight.

6.      Let legs raise the object

7.      Once up, turn your feet to walk with object, do not twist.

8.      To place object down, lower with your legs.

Common mistakes made when lifting, which can cause injury:

1.      Bending forward at the waist with knees straight.

2.      Object is too far away from you.

3.      Bending then twisting with the object.

4.      Lifting and twisting at the same time.

5.      Off balance with the object.

6.      Object too heavy for 1 person or too bulky.

Skeleton picture from “Mechanical Kinesiology” by Jerry N. Barham, Copyright 1978.   Page 49.  (Modified from Anthony, C.P., and Kolthoff, N.J.:  Textbook of anatomy and physiology, ed. 9, St. Louis, 1975, The C.V. Mosby Co.)