Willibald Nagler

Maintaining good posture is important for everyone, but especially for older patients.

In general, flexor muscles are always stronger than extensor muscles. In the upper body, the muscles high in the chest become tight over time, which makes for a rounded back. The hip flexor muscles also become tighter over time. That is why many older people, especially those who have been sedentary, have a tendency to pull the trunk forward and have rounded shoulders.

Maintaining good posture as we age requires strengthening the upper back muscles, and a balance of strength between opposing muscle groups is essential.

Patients who are sedentary are at increased risk for poor posture, so it is important to encourage them to walk, which can also fend off osteoporosis.

A regular form of weight-bearing activity, such as walking, helps to maintain good posture as we age, and in order to continue weight-bearing activity, regular stretching of the hip flexors and adductors is necessary.

The muscles lose their elasticity as we get older, and we have to take more care of them. In younger people, perhaps less than 35 years old, if they stretch twice a week they are doing quite well, but people older than that really need to stretch every day.

If patients can lift light weights without pain, I recommend simple weight-lifting exercises. I do not recommend heavy weights, because senior patients often have difficulty raising their arms. Multiple repetitions (15 times) with a light weight are a good choice for senior patients because they are more aerobic than fewer repetitions with a heavier weight. Multiple repetitions also allow the muscles time to fill with blood, which happens more slowly with age.

For seniors, it is much better to do something moderate nearly every day than to do something more intense only twice a week. What often happens is that after a week of moderate daily exercise, people continue doing the exercises every day because they notice that they feel better, even after an injury has resolved.

I recommend that anyone who is unsteady on their feet use a cane to help them walk. It is better to walk with a cane and walk 2 miles than to limp along unaided for 500 meters. People should not be ashamed to use a cane if they need one. The important thing is to move comfortably, and if senior patients can build strength, they may no longer need the cane after a while. The tip of a cane of the correct length should strike 6 inches in front of the foot and 6 inches to the side of the foot when the patient's elbow is bent at a 30-degree angle.

Exercises for Improving Posture in Seniors

Scapular adductor stretch, 90-degree angle. This exercise will help to strengthen the upper back. Lie on your stomach with a pillow under your abdomen. Extend your arms out to a T, at shoulder height. Lift one hand at a time, hold for 5 seconds, then lower and relax. Start with 8 repetitions and work up to 12. When 12 repetitions become easy, add a 1-pound weight and start again with 8 repetitions. Gradually add weight as you gain strength over time.

Scapular adductor stretch, 45-degree angle. Lie on your stomach with a pillow under your abdomen, but this time extend the arms at a 45-degree angle from your body. Lift one hand at a time, hold for 5 seconds, then lower and relax. Start with 8 repetitions and work up to 12. When 12 repetitions become easy, add a 1-pound weight, and start again with 8 repetitions. Gradually add weight as you gain strength.

Upper back extensor strengthening. Stand with your back touching a wall and use your shoulder muscles to brace your head and shoulders against the wall. This movement should bring your shoulder blades closer together. Hold for 5 seconds, and then relax for 2 seconds. Repeat 12 times.

Standing hip flexor stretch. Start in a standing position, with your left hand on a table for support. Bend the right leg behind you, grasp the right foot with the right hand, and pull it toward your buttock to create a feeling of stretch in the upper hip and thigh. Bend the leg you're standing on if necessary. Tighten your stomach muscles while stretching and do not arch the back. Hold for 5 seconds. Start with 3 repetitions and work up to 6 or 7. Gradually increase the length of time you hold the stretch to 15 seconds.

Maintaining good posture is important for everyone, but especially for older patients.

In general, flexor muscles are always stronger than extensor muscles. In the upper body, the muscles high in the chest become tight over time, which makes for a rounded back. The hip flexor muscles also become tighter over time. That is why many older people, especially those who have been sedentary, have a tendency to pull the trunk forward and have rounded shoulders.

Maintaining good posture as we age requires strengthening the upper back muscles, and a balance of strength between opposing muscle groups is essential.

Patients who are sedentary are at increased risk for poor posture, so it is important to encourage them to walk, which can also fend off osteoporosis.

A regular form of weight-bearing activity, such as walking, helps to maintain good posture as we age, and in order to continue weight-bearing activity, regular stretching of the hip flexors and adductors is necessary.

The muscles lose their elasticity as we get older, and we have to take more care of them. In younger people, perhaps less than 35 years old, if they stretch twice a week they are doing quite well, but people older than that really need to stretch every day.

If patients can lift light weights without pain, I recommend simple weight-lifting exercises. I do not recommend heavy weights, because senior patients often have difficulty raising their arms. Multiple repetitions (15 times) with a light weight are a good choice for senior patients because they are more aerobic than fewer repetitions with a heavier weight. Multiple repetitions also allow the muscles time to fill with blood, which happens more slowly with age.

For seniors, it is much better to do something moderate nearly every day than to do something more intense only twice a week. What often happens is that after a week of moderate daily exercise, people continue doing the exercises every day because they notice that they feel better, even after an injury has resolved.

I recommend that anyone who is unsteady on their feet use a cane to help them walk. It is better to walk with a cane and walk 2 miles than to limp along unaided for 500 meters. People should not be ashamed to use a cane if they need one. The important thing is to move comfortably, and if senior patients can build strength, they may no longer need the cane after a while. The tip of a cane of the correct length should strike 6 inches in front of the foot and 6 inches to the side of the foot when the patient's elbow is bent at a 30-degree angle.

Exercises for Improving Posture in Seniors

Scapular adductor stretch, 90-degree angle. This exercise will help to strengthen the upper back. Lie on your stomach with a pillow under your abdomen. Extend your arms out to a T, at shoulder height. Lift one hand at a time, hold for 5 seconds, then lower and relax. Start with 8 repetitions and work up to 12. When 12 repetitions become easy, add a 1-pound weight and start again with 8 repetitions. Gradually add weight as you gain strength over time.

Scapular adductor stretch, 45-degree angle. Lie on your stomach with a pillow under your abdomen, but this time extend the arms at a 45-degree angle from your body. Lift one hand at a time, hold for 5 seconds, then lower and relax. Start with 8 repetitions and work up to 12. When 12 repetitions become easy, add a 1-pound weight, and start again with 8 repetitions. Gradually add weight as you gain strength.

Upper back extensor strengthening. Stand with your back touching a wall and use your shoulder muscles to brace your head and shoulders against the wall. This movement should bring your shoulder blades closer together. Hold for 5 seconds, and then relax for 2 seconds. Repeat 12 times.

Standing hip flexor stretch. Start in a standing position, with your left hand on a table for support. Bend the right leg behind you, grasp the right foot with the right hand, and pull it toward your buttock to create a feeling of stretch in the upper hip and thigh. Bend the leg you're standing on if necessary. Tighten your stomach muscles while stretching and do not arch the back. Hold for 5 seconds. Start with 3 repetitions and work up to 6 or 7. Gradually increase the length of time you hold the stretch to 15 seconds.

Maintaining good posture is important for everyone, but especially for older patients.

In general, flexor muscles are always stronger than extensor muscles. In the upper body, the muscles high in the chest become tight over time, which makes for a rounded back. The hip flexor muscles also become tighter over time. That is why many older people, especially those who have been sedentary, have a tendency to pull the trunk forward and have rounded shoulders.

Maintaining good posture as we age requires strengthening the upper back muscles, and a balance of strength between opposing muscle groups is essential.

Patients who are sedentary are at increased risk for poor posture, so it is important to encourage them to walk, which can also fend off osteoporosis.

A regular form of weight-bearing activity, such as walking, helps to maintain good posture as we age, and in order to continue weight-bearing activity, regular stretching of the hip flexors and adductors is necessary.

The muscles lose their elasticity as we get older, and we have to take more care of them. In younger people, perhaps less than 35 years old, if they stretch twice a week they are doing quite well, but people older than that really need to stretch every day.

If patients can lift light weights without pain, I recommend simple weight-lifting exercises. I do not recommend heavy weights, because senior patients often have difficulty raising their arms. Multiple repetitions (15 times) with a light weight are a good choice for senior patients because they are more aerobic than fewer repetitions with a heavier weight. Multiple repetitions also allow the muscles time to fill with blood, which happens more slowly with age.

For seniors, it is much better to do something moderate nearly every day than to do something more intense only twice a week. What often happens is that after a week of moderate daily exercise, people continue doing the exercises every day because they notice that they feel better, even after an injury has resolved.

I recommend that anyone who is unsteady on their feet use a cane to help them walk. It is better to walk with a cane and walk 2 miles than to limp along unaided for 500 meters. People should not be ashamed to use a cane if they need one. The important thing is to move comfortably, and if senior patients can build strength, they may no longer need the cane after a while. The tip of a cane of the correct length should strike 6 inches in front of the foot and 6 inches to the side of the foot when the patient's elbow is bent at a 30-degree angle.

Exercises for Improving Posture in Seniors

Scapular adductor stretch, 90-degree angle. This exercise will help to strengthen the upper back. Lie on your stomach with a pillow under your abdomen. Extend your arms out to a T, at shoulder height. Lift one hand at a time, hold for 5 seconds, then lower and relax. Start with 8 repetitions and work up to 12. When 12 repetitions become easy, add a 1-pound weight and start again with 8 repetitions. Gradually add weight as you gain strength over time.

Scapular adductor stretch, 45-degree angle. Lie on your stomach with a pillow under your abdomen, but this time extend the arms at a 45-degree angle from your body. Lift one hand at a time, hold for 5 seconds, then lower and relax. Start with 8 repetitions and work up to 12. When 12 repetitions become easy, add a 1-pound weight, and start again with 8 repetitions. Gradually add weight as you gain strength.

Upper back extensor strengthening. Stand with your back touching a wall and use your shoulder muscles to brace your head and shoulders against the wall. This movement should bring your shoulder blades closer together. Hold for 5 seconds, and then relax for 2 seconds. Repeat 12 times.

Standing hip flexor stretch. Start in a standing position, with your left hand on a table for support. Bend the right leg behind you, grasp the right foot with the right hand, and pull it toward your buttock to create a feeling of stretch in the upper hip and thigh. Bend the leg you're standing on if necessary. Tighten your stomach muscles while stretching and do not arch the back. Hold for 5 seconds. Start with 3 repetitions and work up to 6 or 7. Gradually increase the length of time you hold the stretch to 15 seconds.

Abdominal strength is important for everyone, but especially for older patients.

The abdominal muscles consist of several layers of overlapping fibers: the rectus abdominus, which runs from the ribs to the pelvis, the internal and external obliques, which weave diagonally along each side of the body, and the transversalis abdominus muscles, which extend across the abdominal cavity from side to side and front to back.

With age, the disks in the back become thinner, and the abdominal wall starts pouching, so it is important to keep the stomach muscles strong. This applies especially to the oblique muscles on the sides of the midsection, because they act like a basket to hold the abdomen in place.

Strong abdominal muscles can reduce unnecessary stress on the back and even the upper legs, as they do for the rectus femoris muscle that is used to bend the hip. In addition, weak stomach muscles can contribute to a swayback, which in turn can trigger muscle spasms. Remind patients that sit-ups alone will not change the circumference of the waist—aerobic exercise and diet are still needed in order to slim down.

The once-traditional method for doing a sit-up, with the legs straight out in front and the hands behind the head, is no longer considered an optimal position because it engages the hip flexors, which take away some of the work that the abdominal muscles should be doing.

Doing sit-ups with the knees bent is a much more effective way to strengthen the muscles because it isolates them and makes them work harder. However, as with any exercises, remember that pain and strain do not add value, but only leave you stiff and sore.

As with any abdominal exercises, it is important to inhale before starting the exercise, then exhale while contracting the stomach muscles and inhale again when releasing from the contraction. It is also important to avoid placing the hands behind the head, which puts undue pressure on the neck. These exercises should be done daily. It is especially important for senior patients to do something moderate every day rather than do something excessive only a few times per week.

Encourage patients to start with 3 repetitions of each exercise daily and work their way up to 10–15 repetitions. Once they reach 10–15 repetitions, remind them that maintaining this level of exercise consistently should preserve their abdominal strength.

In next month's column, I will discuss exercises to improve posture.

Strengthening Exercises

Back Tilt Position yourself on your hands and knees with hands directly underneath the shoulders and knees directly underneath the hips. Take a breath, and as you exhale, drop your head between your arms and draw the lower belly toward the back of the body. Hold for 5 seconds. Return to the starting position and relax for 4 seconds. Start with 3–5 repetitions, and gradually work up to 10.

Oblique Sit-Up Lie on your back with your arms at your sides, legs bent, knees slightly apart, and feet flat on the floor. Take a breath, and as you exhale, raise your head, upper back, and arms off the floor, reaching your left arm across the body toward the right knee. Roll up into a half sit-up, then back to the floor and breathe in. Repeat on the other side, reaching the right arm toward the left knee. Repeat the set 3–4 times, and work up to 10–15 repetitions.

Extended-Arm Sit-Up Lie on your back with your arms at your sides and your knees bent. Take a breath, and as you exhale, raise your upper body and bring your arms forward so they extend toward your knees and beyond your knees if possible. Release and roll your body back to the starting position. Repeat 3–4 times, and work up to 15 repetitions. Try to count to six as you lift up and again as you roll down. Later, you can hold the “up” position for 5 seconds, then relax for 4 seconds.

Crossed-Arm Sit-Up When you first attempt this exercise, you may need to secure your feet under a couch or heavy chair. Lie on your back with feet secured and arms crossed in front of your chest. Raise your upper body toward your knees, then lower it back to the floor. Repeat 3–4 times, working up to 10–15 repetitions. Avoid jerking movements; they can strain your back.

Abdominal strength is important for everyone, but especially for older patients.

The abdominal muscles consist of several layers of overlapping fibers: the rectus abdominus, which runs from the ribs to the pelvis, the internal and external obliques, which weave diagonally along each side of the body, and the transversalis abdominus muscles, which extend across the abdominal cavity from side to side and front to back.

With age, the disks in the back become thinner, and the abdominal wall starts pouching, so it is important to keep the stomach muscles strong. This applies especially to the oblique muscles on the sides of the midsection, because they act like a basket to hold the abdomen in place.

Strong abdominal muscles can reduce unnecessary stress on the back and even the upper legs, as they do for the rectus femoris muscle that is used to bend the hip. In addition, weak stomach muscles can contribute to a swayback, which in turn can trigger muscle spasms. Remind patients that sit-ups alone will not change the circumference of the waist—aerobic exercise and diet are still needed in order to slim down.

The once-traditional method for doing a sit-up, with the legs straight out in front and the hands behind the head, is no longer considered an optimal position because it engages the hip flexors, which take away some of the work that the abdominal muscles should be doing.

Doing sit-ups with the knees bent is a much more effective way to strengthen the muscles because it isolates them and makes them work harder. However, as with any exercises, remember that pain and strain do not add value, but only leave you stiff and sore.

As with any abdominal exercises, it is important to inhale before starting the exercise, then exhale while contracting the stomach muscles and inhale again when releasing from the contraction. It is also important to avoid placing the hands behind the head, which puts undue pressure on the neck. These exercises should be done daily. It is especially important for senior patients to do something moderate every day rather than do something excessive only a few times per week.

Encourage patients to start with 3 repetitions of each exercise daily and work their way up to 10–15 repetitions. Once they reach 10–15 repetitions, remind them that maintaining this level of exercise consistently should preserve their abdominal strength.

In next month's column, I will discuss exercises to improve posture.

Strengthening Exercises

Back Tilt Position yourself on your hands and knees with hands directly underneath the shoulders and knees directly underneath the hips. Take a breath, and as you exhale, drop your head between your arms and draw the lower belly toward the back of the body. Hold for 5 seconds. Return to the starting position and relax for 4 seconds. Start with 3–5 repetitions, and gradually work up to 10.

Oblique Sit-Up Lie on your back with your arms at your sides, legs bent, knees slightly apart, and feet flat on the floor. Take a breath, and as you exhale, raise your head, upper back, and arms off the floor, reaching your left arm across the body toward the right knee. Roll up into a half sit-up, then back to the floor and breathe in. Repeat on the other side, reaching the right arm toward the left knee. Repeat the set 3–4 times, and work up to 10–15 repetitions.

Extended-Arm Sit-Up Lie on your back with your arms at your sides and your knees bent. Take a breath, and as you exhale, raise your upper body and bring your arms forward so they extend toward your knees and beyond your knees if possible. Release and roll your body back to the starting position. Repeat 3–4 times, and work up to 15 repetitions. Try to count to six as you lift up and again as you roll down. Later, you can hold the “up” position for 5 seconds, then relax for 4 seconds.

Crossed-Arm Sit-Up When you first attempt this exercise, you may need to secure your feet under a couch or heavy chair. Lie on your back with feet secured and arms crossed in front of your chest. Raise your upper body toward your knees, then lower it back to the floor. Repeat 3–4 times, working up to 10–15 repetitions. Avoid jerking movements; they can strain your back.

Abdominal strength is important for everyone, but especially for older patients.

The abdominal muscles consist of several layers of overlapping fibers: the rectus abdominus, which runs from the ribs to the pelvis, the internal and external obliques, which weave diagonally along each side of the body, and the transversalis abdominus muscles, which extend across the abdominal cavity from side to side and front to back.

With age, the disks in the back become thinner, and the abdominal wall starts pouching, so it is important to keep the stomach muscles strong. This applies especially to the oblique muscles on the sides of the midsection, because they act like a basket to hold the abdomen in place.

Strong abdominal muscles can reduce unnecessary stress on the back and even the upper legs, as they do for the rectus femoris muscle that is used to bend the hip. In addition, weak stomach muscles can contribute to a swayback, which in turn can trigger muscle spasms. Remind patients that sit-ups alone will not change the circumference of the waist—aerobic exercise and diet are still needed in order to slim down.

The once-traditional method for doing a sit-up, with the legs straight out in front and the hands behind the head, is no longer considered an optimal position because it engages the hip flexors, which take away some of the work that the abdominal muscles should be doing.

Doing sit-ups with the knees bent is a much more effective way to strengthen the muscles because it isolates them and makes them work harder. However, as with any exercises, remember that pain and strain do not add value, but only leave you stiff and sore.

As with any abdominal exercises, it is important to inhale before starting the exercise, then exhale while contracting the stomach muscles and inhale again when releasing from the contraction. It is also important to avoid placing the hands behind the head, which puts undue pressure on the neck. These exercises should be done daily. It is especially important for senior patients to do something moderate every day rather than do something excessive only a few times per week.

Encourage patients to start with 3 repetitions of each exercise daily and work their way up to 10–15 repetitions. Once they reach 10–15 repetitions, remind them that maintaining this level of exercise consistently should preserve their abdominal strength.

In next month's column, I will discuss exercises to improve posture.

Strengthening Exercises

Back Tilt Position yourself on your hands and knees with hands directly underneath the shoulders and knees directly underneath the hips. Take a breath, and as you exhale, drop your head between your arms and draw the lower belly toward the back of the body. Hold for 5 seconds. Return to the starting position and relax for 4 seconds. Start with 3–5 repetitions, and gradually work up to 10.

Oblique Sit-Up Lie on your back with your arms at your sides, legs bent, knees slightly apart, and feet flat on the floor. Take a breath, and as you exhale, raise your head, upper back, and arms off the floor, reaching your left arm across the body toward the right knee. Roll up into a half sit-up, then back to the floor and breathe in. Repeat on the other side, reaching the right arm toward the left knee. Repeat the set 3–4 times, and work up to 10–15 repetitions.

Extended-Arm Sit-Up Lie on your back with your arms at your sides and your knees bent. Take a breath, and as you exhale, raise your upper body and bring your arms forward so they extend toward your knees and beyond your knees if possible. Release and roll your body back to the starting position. Repeat 3–4 times, and work up to 15 repetitions. Try to count to six as you lift up and again as you roll down. Later, you can hold the “up” position for 5 seconds, then relax for 4 seconds.

Crossed-Arm Sit-Up When you first attempt this exercise, you may need to secure your feet under a couch or heavy chair. Lie on your back with feet secured and arms crossed in front of your chest. Raise your upper body toward your knees, then lower it back to the floor. Repeat 3–4 times, working up to 10–15 repetitions. Avoid jerking movements; they can strain your back.

Acute torticollis, also known among some physicians as wry neck, is essentially a stiffness of the neck due to a muscular spasm.

In fact, an approximate translation from the Latin-based “acute torticollis” is twisted collar or twisted neck. This name sounds severe, but the condition itself is not as bad as it sounds.

Changes that occur with age can cause a stiff neck, but it is usually the result of a sudden or unusual movement of the neck. Although the problem is more frequent in older people, it can happen to people of any age.

A stiff neck can be frightening if it occurs suddenly, so it's important to reassure patients. They may be tempted to rush off to have expensive imaging scans, but these scans are rarely helpful. Lying in an MRI machine might actually make the problem worse. I rarely even order x-rays for a patient with acute torticollis—I usually just start them on exercises. A muscle spasm won't show up on an x-ray, anyway. The image will only show a straightening of the neck's natural curve due to the tightening of the muscles.

The trapezius muscle in the upper shoulder can contribute to a stiff neck, and neck exercises will engage this muscle.

The most effective immediate treatment for a stiff neck is to put ice on the area for 15 minutes, and then do neck exercises slowly and carefully to loosen the tight muscles. The ice helps to relieve the pain of an acute spasm. Wrap the ice pack in a towel to prevent skin irritation. I also recommend that people use a bag of small frozen vegetables, such as peas or corn, which conforms well to the neck's curves. (Just be sure to mark the bag so no one eats the vegetables by mistake!)

After a few days, patients can use a heating pad if the neck muscles still feel tight and painful, but it's better to use ice first to ease the immediate pain. Patients can also take aspirin, acetaminophen, or ibuprofen during the first few days after the injury.

It is important to do neck exercises slowly and carefully. The idea is to ease the muscles out of their spasm, not force them. Remind patients to breathe normally during the movements. If pain and stiffness of the neck do not subside after 3 days, patients should see a physiatrist or orthopedic surgeon.

In next month's column, I will discuss exercises to improve abdominal strength.

Limbering Maneuvers

Shoulder shrug. Sit in a straight-backed chair with your feet flat on the floor and your hands resting on your thighs. Slowly raise your shoulders toward your ears as far as you can without excessive straining, although the upward movement might hurt slightly. Relax for a count of 3. Keep the shoulders as loose as possible while relaxing. Repeat five times.

Trapezius muscle stretch. While sitting in a straight-backed chair, place your fingertips on your shoulders, raising your elbows to shoulder height, and spread your elbows back as far as you can, then bring them together in front of your chest and breathe out at the same time. Hold for 5 seconds. You should feel a gentle pull in the upper back and neck. Repeat five times.

Posterior neck stretch. Sit or stand in a relaxed position. Slowly turn your head to the right as far as possible without straining, then slowly bring it back to the middle. Rest for 2 seconds and breathe, then turn your head slowly to the left as far as possible and bring it back to the middle. The turning action should be slow, and should take 5 seconds. Repeat five times.

Neck stretch. Stand against a wall with your head in a level position just touching the wall. Slowly tuck your chin back into your neck as far as possible without excessive straining. Do not bring the chin down toward the chest or let the head fall forward. The movement should be horizontal only, and you should feel a slight pull in the back of the neck. Hold for 5 seconds, then relax for 2 seconds. Repeat five times.

Acute torticollis, also known among some physicians as wry neck, is essentially a stiffness of the neck due to a muscular spasm.

In fact, an approximate translation from the Latin-based “acute torticollis” is twisted collar or twisted neck. This name sounds severe, but the condition itself is not as bad as it sounds.

Changes that occur with age can cause a stiff neck, but it is usually the result of a sudden or unusual movement of the neck. Although the problem is more frequent in older people, it can happen to people of any age.

A stiff neck can be frightening if it occurs suddenly, so it's important to reassure patients. They may be tempted to rush off to have expensive imaging scans, but these scans are rarely helpful. Lying in an MRI machine might actually make the problem worse. I rarely even order x-rays for a patient with acute torticollis—I usually just start them on exercises. A muscle spasm won't show up on an x-ray, anyway. The image will only show a straightening of the neck's natural curve due to the tightening of the muscles.

The trapezius muscle in the upper shoulder can contribute to a stiff neck, and neck exercises will engage this muscle.

The most effective immediate treatment for a stiff neck is to put ice on the area for 15 minutes, and then do neck exercises slowly and carefully to loosen the tight muscles. The ice helps to relieve the pain of an acute spasm. Wrap the ice pack in a towel to prevent skin irritation. I also recommend that people use a bag of small frozen vegetables, such as peas or corn, which conforms well to the neck's curves. (Just be sure to mark the bag so no one eats the vegetables by mistake!)

After a few days, patients can use a heating pad if the neck muscles still feel tight and painful, but it's better to use ice first to ease the immediate pain. Patients can also take aspirin, acetaminophen, or ibuprofen during the first few days after the injury.

It is important to do neck exercises slowly and carefully. The idea is to ease the muscles out of their spasm, not force them. Remind patients to breathe normally during the movements. If pain and stiffness of the neck do not subside after 3 days, patients should see a physiatrist or orthopedic surgeon.

In next month's column, I will discuss exercises to improve abdominal strength.

Limbering Maneuvers

Shoulder shrug. Sit in a straight-backed chair with your feet flat on the floor and your hands resting on your thighs. Slowly raise your shoulders toward your ears as far as you can without excessive straining, although the upward movement might hurt slightly. Relax for a count of 3. Keep the shoulders as loose as possible while relaxing. Repeat five times.

Trapezius muscle stretch. While sitting in a straight-backed chair, place your fingertips on your shoulders, raising your elbows to shoulder height, and spread your elbows back as far as you can, then bring them together in front of your chest and breathe out at the same time. Hold for 5 seconds. You should feel a gentle pull in the upper back and neck. Repeat five times.

Posterior neck stretch. Sit or stand in a relaxed position. Slowly turn your head to the right as far as possible without straining, then slowly bring it back to the middle. Rest for 2 seconds and breathe, then turn your head slowly to the left as far as possible and bring it back to the middle. The turning action should be slow, and should take 5 seconds. Repeat five times.

Neck stretch. Stand against a wall with your head in a level position just touching the wall. Slowly tuck your chin back into your neck as far as possible without excessive straining. Do not bring the chin down toward the chest or let the head fall forward. The movement should be horizontal only, and you should feel a slight pull in the back of the neck. Hold for 5 seconds, then relax for 2 seconds. Repeat five times.

Acute torticollis, also known among some physicians as wry neck, is essentially a stiffness of the neck due to a muscular spasm.

In fact, an approximate translation from the Latin-based “acute torticollis” is twisted collar or twisted neck. This name sounds severe, but the condition itself is not as bad as it sounds.

Changes that occur with age can cause a stiff neck, but it is usually the result of a sudden or unusual movement of the neck. Although the problem is more frequent in older people, it can happen to people of any age.

A stiff neck can be frightening if it occurs suddenly, so it's important to reassure patients. They may be tempted to rush off to have expensive imaging scans, but these scans are rarely helpful. Lying in an MRI machine might actually make the problem worse. I rarely even order x-rays for a patient with acute torticollis—I usually just start them on exercises. A muscle spasm won't show up on an x-ray, anyway. The image will only show a straightening of the neck's natural curve due to the tightening of the muscles.

The trapezius muscle in the upper shoulder can contribute to a stiff neck, and neck exercises will engage this muscle.

The most effective immediate treatment for a stiff neck is to put ice on the area for 15 minutes, and then do neck exercises slowly and carefully to loosen the tight muscles. The ice helps to relieve the pain of an acute spasm. Wrap the ice pack in a towel to prevent skin irritation. I also recommend that people use a bag of small frozen vegetables, such as peas or corn, which conforms well to the neck's curves. (Just be sure to mark the bag so no one eats the vegetables by mistake!)

After a few days, patients can use a heating pad if the neck muscles still feel tight and painful, but it's better to use ice first to ease the immediate pain. Patients can also take aspirin, acetaminophen, or ibuprofen during the first few days after the injury.

It is important to do neck exercises slowly and carefully. The idea is to ease the muscles out of their spasm, not force them. Remind patients to breathe normally during the movements. If pain and stiffness of the neck do not subside after 3 days, patients should see a physiatrist or orthopedic surgeon.

In next month's column, I will discuss exercises to improve abdominal strength.

Limbering Maneuvers

Shoulder shrug. Sit in a straight-backed chair with your feet flat on the floor and your hands resting on your thighs. Slowly raise your shoulders toward your ears as far as you can without excessive straining, although the upward movement might hurt slightly. Relax for a count of 3. Keep the shoulders as loose as possible while relaxing. Repeat five times.

Trapezius muscle stretch. While sitting in a straight-backed chair, place your fingertips on your shoulders, raising your elbows to shoulder height, and spread your elbows back as far as you can, then bring them together in front of your chest and breathe out at the same time. Hold for 5 seconds. You should feel a gentle pull in the upper back and neck. Repeat five times.

Posterior neck stretch. Sit or stand in a relaxed position. Slowly turn your head to the right as far as possible without straining, then slowly bring it back to the middle. Rest for 2 seconds and breathe, then turn your head slowly to the left as far as possible and bring it back to the middle. The turning action should be slow, and should take 5 seconds. Repeat five times.

Neck stretch. Stand against a wall with your head in a level position just touching the wall. Slowly tuck your chin back into your neck as far as possible without excessive straining. Do not bring the chin down toward the chest or let the head fall forward. The movement should be horizontal only, and you should feel a slight pull in the back of the neck. Hold for 5 seconds, then relax for 2 seconds. Repeat five times.

The common term “rotator cuff” actually describes four small muscles in the shoulder: supraspinatus, infraspinatus, subscapularis, and teres minor. They hold the ball-and-socket shoulder joint in place while allowing the arm to rotate. Anyone can injure these muscles or the ligaments that hold them in place by doing something like suddenly lifting a heavy box with no preparation. Of course, an injury can also occur during sports that require shoulder-raising movements, such as tennis or baseball.

A rotator cuff injury usually involves a tearing of the supraspinatus. This small muscle above the lower part of the shoulder blade is also often the source of the symptoms. In the case of a full-blown rotator cuff tear, the patient may report having felt or heard a “pop” in the shoulder.

If you suspect a patient has torn a muscle or strained a ligament in the shoulder, surgery is not needed. If there is a gap between the muscle and the tendon where the two have separated completely, the patient will probably require surgery, but an injury this severe is rare.

Exercises that keep the rotator cuff muscles loose and also strengthen them will reduce the likelihood of future injuries. Healing may take at least 8 weeks.

The exercises should be performed twice daily. Patients can start Exercises 1, 2, and 3 immediately, but they should not start Exercise 4 until 10-12 days after the injury, to allow the initial swelling to subside.

Although MRI scans can show the exact location of a tear and might show some areas of swelling, nothing beats examining the patient. A history and physical are important to the diagnosis of all musculoskeletal injuries. Test the range of motion in the shoulder and rule out nerve damage from osteoarthritis of the neck. Ask the patient to raise his or her arms straight out to the side and lower them slowly. If the injured arm gives way too quickly, it is too weak to control the motion and might be torn.

One of the most important things to remember when rehabilitating a shoulder injury is to keep it moving. After applying ice for the first 2 days, patients can use a heating pad on the shoulder for 20 minutes before doing the exercises, in order to loosen the muscles.

In next month's column, I will discuss exercises for a stiff neck.

Exercises for the Rotator Cuff

External rotator strengthener. Lie on a bed on the side opposite the injured side, supporting your head on your uninjured hand. Hold a 1-pound weight in your right hand at waist level with the right elbow bent 90 degrees. In one motion, raise and straighten your arm to the side, keeping it parallel to the floor. Hold for 5 seconds, return to starting position, and relax for 3 seconds. Start with 8 repetitions and work up to 12. When this becomes easy, increase the weight by 1 pound and repeat. Do this exercise twice daily, beginning immediately after the injury occurs.

Anterior deltoid strengthener. Stand up straight, with the injured arm at your side, holding a 3-pound weight. Raise the arm straight up to shoulder level, until it is parallel to the floor. This motion strengthens the front of the muscle. Hold for 5 seconds, then lower and relax for 2 seconds. Start with 8 repetitions and work up to 12. When this becomes easy, increase the weight by 1 pound, and begin again at 8 repetitions.

Posterior deltoid strengthener. From the same starting position, holding the weight, raise the arm behind you. Hold for 5 seconds and relax for 2 seconds. This motion strengthens the back side of the deltoid muscle. Be careful not to force the arm too far backward. Start with 8 repetitions and work up to 12.

Lateral deltoid strengthener. Wait 10-12 days after the injury before beginning this exercise, but once you begin, do it twice daily along with the other exercises. From the same standing position as exercises 2 and 3, holding the weight, raise the arm laterally to shoulder height so it is parallel to the floor. Hold for 5 seconds, then lower the arm and relax for 2 seconds. Start with 8 repetitions and work up to 12.

The common term “rotator cuff” actually describes four small muscles in the shoulder: supraspinatus, infraspinatus, subscapularis, and teres minor. They hold the ball-and-socket shoulder joint in place while allowing the arm to rotate. Anyone can injure these muscles or the ligaments that hold them in place by doing something like suddenly lifting a heavy box with no preparation. Of course, an injury can also occur during sports that require shoulder-raising movements, such as tennis or baseball.

A rotator cuff injury usually involves a tearing of the supraspinatus. This small muscle above the lower part of the shoulder blade is also often the source of the symptoms. In the case of a full-blown rotator cuff tear, the patient may report having felt or heard a “pop” in the shoulder.

If you suspect a patient has torn a muscle or strained a ligament in the shoulder, surgery is not needed. If there is a gap between the muscle and the tendon where the two have separated completely, the patient will probably require surgery, but an injury this severe is rare.

Exercises that keep the rotator cuff muscles loose and also strengthen them will reduce the likelihood of future injuries. Healing may take at least 8 weeks.

The exercises should be performed twice daily. Patients can start Exercises 1, 2, and 3 immediately, but they should not start Exercise 4 until 10-12 days after the injury, to allow the initial swelling to subside.

Although MRI scans can show the exact location of a tear and might show some areas of swelling, nothing beats examining the patient. A history and physical are important to the diagnosis of all musculoskeletal injuries. Test the range of motion in the shoulder and rule out nerve damage from osteoarthritis of the neck. Ask the patient to raise his or her arms straight out to the side and lower them slowly. If the injured arm gives way too quickly, it is too weak to control the motion and might be torn.

One of the most important things to remember when rehabilitating a shoulder injury is to keep it moving. After applying ice for the first 2 days, patients can use a heating pad on the shoulder for 20 minutes before doing the exercises, in order to loosen the muscles.

In next month's column, I will discuss exercises for a stiff neck.

Exercises for the Rotator Cuff

External rotator strengthener. Lie on a bed on the side opposite the injured side, supporting your head on your uninjured hand. Hold a 1-pound weight in your right hand at waist level with the right elbow bent 90 degrees. In one motion, raise and straighten your arm to the side, keeping it parallel to the floor. Hold for 5 seconds, return to starting position, and relax for 3 seconds. Start with 8 repetitions and work up to 12. When this becomes easy, increase the weight by 1 pound and repeat. Do this exercise twice daily, beginning immediately after the injury occurs.

Anterior deltoid strengthener. Stand up straight, with the injured arm at your side, holding a 3-pound weight. Raise the arm straight up to shoulder level, until it is parallel to the floor. This motion strengthens the front of the muscle. Hold for 5 seconds, then lower and relax for 2 seconds. Start with 8 repetitions and work up to 12. When this becomes easy, increase the weight by 1 pound, and begin again at 8 repetitions.

Posterior deltoid strengthener. From the same starting position, holding the weight, raise the arm behind you. Hold for 5 seconds and relax for 2 seconds. This motion strengthens the back side of the deltoid muscle. Be careful not to force the arm too far backward. Start with 8 repetitions and work up to 12.

Lateral deltoid strengthener. Wait 10-12 days after the injury before beginning this exercise, but once you begin, do it twice daily along with the other exercises. From the same standing position as exercises 2 and 3, holding the weight, raise the arm laterally to shoulder height so it is parallel to the floor. Hold for 5 seconds, then lower the arm and relax for 2 seconds. Start with 8 repetitions and work up to 12.

The common term “rotator cuff” actually describes four small muscles in the shoulder: supraspinatus, infraspinatus, subscapularis, and teres minor. They hold the ball-and-socket shoulder joint in place while allowing the arm to rotate. Anyone can injure these muscles or the ligaments that hold them in place by doing something like suddenly lifting a heavy box with no preparation. Of course, an injury can also occur during sports that require shoulder-raising movements, such as tennis or baseball.

A rotator cuff injury usually involves a tearing of the supraspinatus. This small muscle above the lower part of the shoulder blade is also often the source of the symptoms. In the case of a full-blown rotator cuff tear, the patient may report having felt or heard a “pop” in the shoulder.

If you suspect a patient has torn a muscle or strained a ligament in the shoulder, surgery is not needed. If there is a gap between the muscle and the tendon where the two have separated completely, the patient will probably require surgery, but an injury this severe is rare.

Exercises that keep the rotator cuff muscles loose and also strengthen them will reduce the likelihood of future injuries. Healing may take at least 8 weeks.

The exercises should be performed twice daily. Patients can start Exercises 1, 2, and 3 immediately, but they should not start Exercise 4 until 10-12 days after the injury, to allow the initial swelling to subside.

Although MRI scans can show the exact location of a tear and might show some areas of swelling, nothing beats examining the patient. A history and physical are important to the diagnosis of all musculoskeletal injuries. Test the range of motion in the shoulder and rule out nerve damage from osteoarthritis of the neck. Ask the patient to raise his or her arms straight out to the side and lower them slowly. If the injured arm gives way too quickly, it is too weak to control the motion and might be torn.

One of the most important things to remember when rehabilitating a shoulder injury is to keep it moving. After applying ice for the first 2 days, patients can use a heating pad on the shoulder for 20 minutes before doing the exercises, in order to loosen the muscles.

In next month's column, I will discuss exercises for a stiff neck.

Exercises for the Rotator Cuff

External rotator strengthener. Lie on a bed on the side opposite the injured side, supporting your head on your uninjured hand. Hold a 1-pound weight in your right hand at waist level with the right elbow bent 90 degrees. In one motion, raise and straighten your arm to the side, keeping it parallel to the floor. Hold for 5 seconds, return to starting position, and relax for 3 seconds. Start with 8 repetitions and work up to 12. When this becomes easy, increase the weight by 1 pound and repeat. Do this exercise twice daily, beginning immediately after the injury occurs.

Anterior deltoid strengthener. Stand up straight, with the injured arm at your side, holding a 3-pound weight. Raise the arm straight up to shoulder level, until it is parallel to the floor. This motion strengthens the front of the muscle. Hold for 5 seconds, then lower and relax for 2 seconds. Start with 8 repetitions and work up to 12. When this becomes easy, increase the weight by 1 pound, and begin again at 8 repetitions.

Posterior deltoid strengthener. From the same starting position, holding the weight, raise the arm behind you. Hold for 5 seconds and relax for 2 seconds. This motion strengthens the back side of the deltoid muscle. Be careful not to force the arm too far backward. Start with 8 repetitions and work up to 12.

Lateral deltoid strengthener. Wait 10-12 days after the injury before beginning this exercise, but once you begin, do it twice daily along with the other exercises. From the same standing position as exercises 2 and 3, holding the weight, raise the arm laterally to shoulder height so it is parallel to the floor. Hold for 5 seconds, then lower the arm and relax for 2 seconds. Start with 8 repetitions and work up to 12.

A groin pull is actually an injury to one of the hip-adductor muscles on the inside of the thigh, which help bring the legs together.

A groin pull can be quite painful, but it is not dangerous. It can be painful for older patients who already have difficulty walking. At any age, the injury may become irritated when people are carrying something and walking downstairs, when they have little control over the adductor muscles.

In most groin-pull injuries, some muscle fibers in the hip-adductor muscles have been overstretched, and some might even have ripped. This type of injury will respond fairly quickly to gentle stretching, and the patient should recover in about 2 weeks. But if the injury occurs in the upper part of one of the adductors, where the tendon attaches to the pelvic bone, the area beneath the tendon can become inflamed, and healing could take as long as 6 weeks.

If the pain is very intense, advise the patient to use crutches for 2–3 days. For older patients or those who have trouble with crutches, I recommend using a walker. Also, advise the patient to apply ice to the injured area for the first 2 days after the injury takes place, and then switch to a heating pad, which can be applied for 15–20 minutes.

Be sure to rule out a hernia, which requires a different treatment. You can feel a hernia and can feel it enlarge when the patient coughs. If there's no palpable protrusion when the patient coughs, the problem is most likely a groin pull, rather than a hernia. In contemporary medicine, most people leave a hernia alone, especially if it is not too bothersome to the patient. Not all hernia repairs are successful, and the surgery can bring its own set of complications.

For one of the exercises, I recommend using a beach ball, something approximately 16 inches in diameter. A larger fitness ball works, too, but a very large ball may be difficult for older or less flexible patients to use. However, I don't recommend anything much smaller than 16 inches.

These exercises should be done three times daily for the first few days; then the patient can drop back to twice daily until the pain subsides. The adductor is a fairly large muscle, so healing is relatively rapid.

These exercises are safe for all patients, even following hip replacement.

Next month, my column will discuss exercises to rehabilitate a rotator cuff injury.

Exercises for a Groin Pull

Side-lying adductor stretch. Lie on the uninjured side, with knees slightly bent (about 45 degrees), supporting your head on one hand, using the other arm for balance. Slide the heel of the injured leg up to the knee of the uninjured leg, and gently raise the knee, rotating the hip joint. The upper thigh should be about at a 90-degree angle to the torso during this exercise. Hold for 5 seconds, then relax to the starting position. Repeat five to six times.

Back-lying adductor stretch. Lie on your back with your legs bent and feet flat on the floor. Starting with the uninjured leg, hook the foot of the uninjured leg behind the heel of the injured leg. Let the uninjured leg fall gently toward the floor, with gravity doing the work. Hold for 15 seconds. Return to the starting position and relax, then repeat for the other side. Start with three repetitions on each side, add one each day, working up to five repetitions on each side.

Seated ball stretch. Sit in a straight-backed chair with feet flat on the floor. Place a fitness ball, or a soft beach ball (about 16 inches in diameter) if you are less flexible, between your knees. Compress the ball with your knees and hold for 5 seconds, then relax for 3 seconds, still holding the ball gently between the knees. Start with 3 repetitions, and work up to 12.

Back-lying ball stretch. Lie on your back with knees bent and feet flat on the floor. Place a rolled towel or a smaller ball (about 12 inches in diameter, such as a soccer ball, if you are more flexible) between your knees. Attempt to squeeze the knees together and hold for 12 seconds. Repeat six to eight times.

A groin pull is actually an injury to one of the hip-adductor muscles on the inside of the thigh, which help bring the legs together.

A groin pull can be quite painful, but it is not dangerous. It can be painful for older patients who already have difficulty walking. At any age, the injury may become irritated when people are carrying something and walking downstairs, when they have little control over the adductor muscles.

In most groin-pull injuries, some muscle fibers in the hip-adductor muscles have been overstretched, and some might even have ripped. This type of injury will respond fairly quickly to gentle stretching, and the patient should recover in about 2 weeks. But if the injury occurs in the upper part of one of the adductors, where the tendon attaches to the pelvic bone, the area beneath the tendon can become inflamed, and healing could take as long as 6 weeks.

If the pain is very intense, advise the patient to use crutches for 2–3 days. For older patients or those who have trouble with crutches, I recommend using a walker. Also, advise the patient to apply ice to the injured area for the first 2 days after the injury takes place, and then switch to a heating pad, which can be applied for 15–20 minutes.

Be sure to rule out a hernia, which requires a different treatment. You can feel a hernia and can feel it enlarge when the patient coughs. If there's no palpable protrusion when the patient coughs, the problem is most likely a groin pull, rather than a hernia. In contemporary medicine, most people leave a hernia alone, especially if it is not too bothersome to the patient. Not all hernia repairs are successful, and the surgery can bring its own set of complications.

For one of the exercises, I recommend using a beach ball, something approximately 16 inches in diameter. A larger fitness ball works, too, but a very large ball may be difficult for older or less flexible patients to use. However, I don't recommend anything much smaller than 16 inches.

These exercises should be done three times daily for the first few days; then the patient can drop back to twice daily until the pain subsides. The adductor is a fairly large muscle, so healing is relatively rapid.

These exercises are safe for all patients, even following hip replacement.

Next month, my column will discuss exercises to rehabilitate a rotator cuff injury.

Exercises for a Groin Pull

Side-lying adductor stretch. Lie on the uninjured side, with knees slightly bent (about 45 degrees), supporting your head on one hand, using the other arm for balance. Slide the heel of the injured leg up to the knee of the uninjured leg, and gently raise the knee, rotating the hip joint. The upper thigh should be about at a 90-degree angle to the torso during this exercise. Hold for 5 seconds, then relax to the starting position. Repeat five to six times.

Back-lying adductor stretch. Lie on your back with your legs bent and feet flat on the floor. Starting with the uninjured leg, hook the foot of the uninjured leg behind the heel of the injured leg. Let the uninjured leg fall gently toward the floor, with gravity doing the work. Hold for 15 seconds. Return to the starting position and relax, then repeat for the other side. Start with three repetitions on each side, add one each day, working up to five repetitions on each side.

Seated ball stretch. Sit in a straight-backed chair with feet flat on the floor. Place a fitness ball, or a soft beach ball (about 16 inches in diameter) if you are less flexible, between your knees. Compress the ball with your knees and hold for 5 seconds, then relax for 3 seconds, still holding the ball gently between the knees. Start with 3 repetitions, and work up to 12.

Back-lying ball stretch. Lie on your back with knees bent and feet flat on the floor. Place a rolled towel or a smaller ball (about 12 inches in diameter, such as a soccer ball, if you are more flexible) between your knees. Attempt to squeeze the knees together and hold for 12 seconds. Repeat six to eight times.

A groin pull is actually an injury to one of the hip-adductor muscles on the inside of the thigh, which help bring the legs together.

A groin pull can be quite painful, but it is not dangerous. It can be painful for older patients who already have difficulty walking. At any age, the injury may become irritated when people are carrying something and walking downstairs, when they have little control over the adductor muscles.

In most groin-pull injuries, some muscle fibers in the hip-adductor muscles have been overstretched, and some might even have ripped. This type of injury will respond fairly quickly to gentle stretching, and the patient should recover in about 2 weeks. But if the injury occurs in the upper part of one of the adductors, where the tendon attaches to the pelvic bone, the area beneath the tendon can become inflamed, and healing could take as long as 6 weeks.

If the pain is very intense, advise the patient to use crutches for 2–3 days. For older patients or those who have trouble with crutches, I recommend using a walker. Also, advise the patient to apply ice to the injured area for the first 2 days after the injury takes place, and then switch to a heating pad, which can be applied for 15–20 minutes.

Be sure to rule out a hernia, which requires a different treatment. You can feel a hernia and can feel it enlarge when the patient coughs. If there's no palpable protrusion when the patient coughs, the problem is most likely a groin pull, rather than a hernia. In contemporary medicine, most people leave a hernia alone, especially if it is not too bothersome to the patient. Not all hernia repairs are successful, and the surgery can bring its own set of complications.

For one of the exercises, I recommend using a beach ball, something approximately 16 inches in diameter. A larger fitness ball works, too, but a very large ball may be difficult for older or less flexible patients to use. However, I don't recommend anything much smaller than 16 inches.

These exercises should be done three times daily for the first few days; then the patient can drop back to twice daily until the pain subsides. The adductor is a fairly large muscle, so healing is relatively rapid.

These exercises are safe for all patients, even following hip replacement.

Next month, my column will discuss exercises to rehabilitate a rotator cuff injury.

Exercises for a Groin Pull

Side-lying adductor stretch. Lie on the uninjured side, with knees slightly bent (about 45 degrees), supporting your head on one hand, using the other arm for balance. Slide the heel of the injured leg up to the knee of the uninjured leg, and gently raise the knee, rotating the hip joint. The upper thigh should be about at a 90-degree angle to the torso during this exercise. Hold for 5 seconds, then relax to the starting position. Repeat five to six times.

Back-lying adductor stretch. Lie on your back with your legs bent and feet flat on the floor. Starting with the uninjured leg, hook the foot of the uninjured leg behind the heel of the injured leg. Let the uninjured leg fall gently toward the floor, with gravity doing the work. Hold for 15 seconds. Return to the starting position and relax, then repeat for the other side. Start with three repetitions on each side, add one each day, working up to five repetitions on each side.

Seated ball stretch. Sit in a straight-backed chair with feet flat on the floor. Place a fitness ball, or a soft beach ball (about 16 inches in diameter) if you are less flexible, between your knees. Compress the ball with your knees and hold for 5 seconds, then relax for 3 seconds, still holding the ball gently between the knees. Start with 3 repetitions, and work up to 12.

Back-lying ball stretch. Lie on your back with knees bent and feet flat on the floor. Place a rolled towel or a smaller ball (about 12 inches in diameter, such as a soccer ball, if you are more flexible) between your knees. Attempt to squeeze the knees together and hold for 12 seconds. Repeat six to eight times.

In general, the hamstrings are so well-trained that they can take a lot of stress. However, hamstring pulls can occur when people are unprepared for sports that involve a lot of stopping and starting, such as basketball or tennis, or during other instances of sudden motion, such as sprinting to catch a bus or cross a street.

In some cases, even casual activities, such as walking after sitting on an airplane or in a car for a long trip, or walking down stairs carrying a heavy load, can cause a strained hamstring.

The hamstring works in tandem with the quadriceps muscle; when one contracts, the other relaxes. When the quadriceps muscle contracts so quickly that the hamstring can't relax in time, the result is a pulled hamstring.

It is important to rule out sciatica and osteoarthritis of the hip when examining a patient with hamstring pain. Patients with osteoarthritis of the hip are especially difficult to examine, because they may have pain throughout the hip area. Although an MRI will show a complete hamstring tear, a pull or strain will not be visible.

One noninvasive way to tell whether the hamstring has ruptured is to have the patient lie on his or her stomach and bend the knees to about 45 degrees. Observe the appearance of the hamstrings as they contract. If the contours are significantly different, the hamstring may be ruptured, and the patient should be evaluated by an orthopedist before exercising.

Patients with a pulled hamstring can start the first two exercises immediately after the injury. (See illustrations and instructions below, which you can photocopy for your patients.) Exercises 3 and 4, which involve light ankle weights, can be added to the first two exercises after a few days, once swelling has subsided.

I recommend the use of crutches for about a week. Patients can apply ice to the hamstring for the first day or so after the injury; after that, they are better off using a heating pad. A helpful strategy is to apply a heating pad to the injured area for 20 minutes before doing the exercises.

The following exercises stretch and strengthen not only the injured hamstring, but the quadriceps muscle as well. Remind patients that the quadriceps muscle has been inactive if they have been protecting the hamstring and that it quickly loses both strength and flexibility when it is not used. Also remind them to be cautious when stretching and to avoid exerting excessive force. Patients should stretch until they feel a slight pull but should stop short of feeling strain or pain.

Next month: Exercises to rehabilitate a groin pull.

Exercises for a Pulled Hamstring

Quadriceps extension. Lie on your back with your knees bent, feet flat on the floor and hip distance apart, and your arms relaxed at your sides. Slowly bring the knee of the injured leg toward your chest while pushing the small of your back into the floor. Keep the foot flexed, and slowly straighten the injured leg. You may need to lower the leg slightly to fully extend it. Hold for 15 seconds, then lower your leg and relax for 10 seconds. Repeat six times.

Seated forward bend. Avoid this exercise if you have back problems. Sit on the floor with your back against a wall and your legs straight out in front of you. Cross the left ankle over the right, and bend forward slowly from the waist, reaching toward the ankles. Hold the forward bend for 15 seconds, then relax and sit up for 5 seconds. Repeat six times, then cross the right ankle over the left, and repeat six times.

Front-lying leg raise, part 1. Lie on your stomach with a pillow under your abdomen and a 2-pound weight wrapped around your ankle, starting with the injured leg. Slowly bend the knee, raising the lower leg to a 45-degree angle with the floor. Hold the position for 5 seconds, and then relax. Start with 8 repetitions, and work up to 12. Do this exercise for both legs once daily.

Front-lying leg raise, part 2. Lie on your stomach with a pillow under your abdomen and a 2-pound weight wrapped around your ankle; begin with the injured leg. Slowly bend the knee, raising the lower leg to a 90-degree angle with the floor, raise the thigh off the floor and hold the position for 5 seconds, and then relax. Start with 8 repetitions, and work up to 12. Do this exercise for both legs once daily.

In general, the hamstrings are so well-trained that they can take a lot of stress. However, hamstring pulls can occur when people are unprepared for sports that involve a lot of stopping and starting, such as basketball or tennis, or during other instances of sudden motion, such as sprinting to catch a bus or cross a street.

In some cases, even casual activities, such as walking after sitting on an airplane or in a car for a long trip, or walking down stairs carrying a heavy load, can cause a strained hamstring.

The hamstring works in tandem with the quadriceps muscle; when one contracts, the other relaxes. When the quadriceps muscle contracts so quickly that the hamstring can't relax in time, the result is a pulled hamstring.

It is important to rule out sciatica and osteoarthritis of the hip when examining a patient with hamstring pain. Patients with osteoarthritis of the hip are especially difficult to examine, because they may have pain throughout the hip area. Although an MRI will show a complete hamstring tear, a pull or strain will not be visible.

One noninvasive way to tell whether the hamstring has ruptured is to have the patient lie on his or her stomach and bend the knees to about 45 degrees. Observe the appearance of the hamstrings as they contract. If the contours are significantly different, the hamstring may be ruptured, and the patient should be evaluated by an orthopedist before exercising.

Patients with a pulled hamstring can start the first two exercises immediately after the injury. (See illustrations and instructions below, which you can photocopy for your patients.) Exercises 3 and 4, which involve light ankle weights, can be added to the first two exercises after a few days, once swelling has subsided.

I recommend the use of crutches for about a week. Patients can apply ice to the hamstring for the first day or so after the injury; after that, they are better off using a heating pad. A helpful strategy is to apply a heating pad to the injured area for 20 minutes before doing the exercises.

The following exercises stretch and strengthen not only the injured hamstring, but the quadriceps muscle as well. Remind patients that the quadriceps muscle has been inactive if they have been protecting the hamstring and that it quickly loses both strength and flexibility when it is not used. Also remind them to be cautious when stretching and to avoid exerting excessive force. Patients should stretch until they feel a slight pull but should stop short of feeling strain or pain.

Next month: Exercises to rehabilitate a groin pull.

Exercises for a Pulled Hamstring

Quadriceps extension. Lie on your back with your knees bent, feet flat on the floor and hip distance apart, and your arms relaxed at your sides. Slowly bring the knee of the injured leg toward your chest while pushing the small of your back into the floor. Keep the foot flexed, and slowly straighten the injured leg. You may need to lower the leg slightly to fully extend it. Hold for 15 seconds, then lower your leg and relax for 10 seconds. Repeat six times.

Seated forward bend. Avoid this exercise if you have back problems. Sit on the floor with your back against a wall and your legs straight out in front of you. Cross the left ankle over the right, and bend forward slowly from the waist, reaching toward the ankles. Hold the forward bend for 15 seconds, then relax and sit up for 5 seconds. Repeat six times, then cross the right ankle over the left, and repeat six times.

Front-lying leg raise, part 1. Lie on your stomach with a pillow under your abdomen and a 2-pound weight wrapped around your ankle, starting with the injured leg. Slowly bend the knee, raising the lower leg to a 45-degree angle with the floor. Hold the position for 5 seconds, and then relax. Start with 8 repetitions, and work up to 12. Do this exercise for both legs once daily.

Front-lying leg raise, part 2. Lie on your stomach with a pillow under your abdomen and a 2-pound weight wrapped around your ankle; begin with the injured leg. Slowly bend the knee, raising the lower leg to a 90-degree angle with the floor, raise the thigh off the floor and hold the position for 5 seconds, and then relax. Start with 8 repetitions, and work up to 12. Do this exercise for both legs once daily.

In general, the hamstrings are so well-trained that they can take a lot of stress. However, hamstring pulls can occur when people are unprepared for sports that involve a lot of stopping and starting, such as basketball or tennis, or during other instances of sudden motion, such as sprinting to catch a bus or cross a street.

In some cases, even casual activities, such as walking after sitting on an airplane or in a car for a long trip, or walking down stairs carrying a heavy load, can cause a strained hamstring.

The hamstring works in tandem with the quadriceps muscle; when one contracts, the other relaxes. When the quadriceps muscle contracts so quickly that the hamstring can't relax in time, the result is a pulled hamstring.

It is important to rule out sciatica and osteoarthritis of the hip when examining a patient with hamstring pain. Patients with osteoarthritis of the hip are especially difficult to examine, because they may have pain throughout the hip area. Although an MRI will show a complete hamstring tear, a pull or strain will not be visible.

One noninvasive way to tell whether the hamstring has ruptured is to have the patient lie on his or her stomach and bend the knees to about 45 degrees. Observe the appearance of the hamstrings as they contract. If the contours are significantly different, the hamstring may be ruptured, and the patient should be evaluated by an orthopedist before exercising.

Patients with a pulled hamstring can start the first two exercises immediately after the injury. (See illustrations and instructions below, which you can photocopy for your patients.) Exercises 3 and 4, which involve light ankle weights, can be added to the first two exercises after a few days, once swelling has subsided.

I recommend the use of crutches for about a week. Patients can apply ice to the hamstring for the first day or so after the injury; after that, they are better off using a heating pad. A helpful strategy is to apply a heating pad to the injured area for 20 minutes before doing the exercises.

The following exercises stretch and strengthen not only the injured hamstring, but the quadriceps muscle as well. Remind patients that the quadriceps muscle has been inactive if they have been protecting the hamstring and that it quickly loses both strength and flexibility when it is not used. Also remind them to be cautious when stretching and to avoid exerting excessive force. Patients should stretch until they feel a slight pull but should stop short of feeling strain or pain.

Next month: Exercises to rehabilitate a groin pull.

Exercises for a Pulled Hamstring

Quadriceps extension. Lie on your back with your knees bent, feet flat on the floor and hip distance apart, and your arms relaxed at your sides. Slowly bring the knee of the injured leg toward your chest while pushing the small of your back into the floor. Keep the foot flexed, and slowly straighten the injured leg. You may need to lower the leg slightly to fully extend it. Hold for 15 seconds, then lower your leg and relax for 10 seconds. Repeat six times.

Seated forward bend. Avoid this exercise if you have back problems. Sit on the floor with your back against a wall and your legs straight out in front of you. Cross the left ankle over the right, and bend forward slowly from the waist, reaching toward the ankles. Hold the forward bend for 15 seconds, then relax and sit up for 5 seconds. Repeat six times, then cross the right ankle over the left, and repeat six times.

Front-lying leg raise, part 1. Lie on your stomach with a pillow under your abdomen and a 2-pound weight wrapped around your ankle, starting with the injured leg. Slowly bend the knee, raising the lower leg to a 45-degree angle with the floor. Hold the position for 5 seconds, and then relax. Start with 8 repetitions, and work up to 12. Do this exercise for both legs once daily.

Front-lying leg raise, part 2. Lie on your stomach with a pillow under your abdomen and a 2-pound weight wrapped around your ankle; begin with the injured leg. Slowly bend the knee, raising the lower leg to a 90-degree angle with the floor, raise the thigh off the floor and hold the position for 5 seconds, and then relax. Start with 8 repetitions, and work up to 12. Do this exercise for both legs once daily.

Some patients who present with lower back aches are actually suffering from sciatica, which has become something of a catchall term for upper hip/lower back pain. However, in patients with true sciatica, a pinched nerve is causing the pain.

The sciatic nerves come in two pairs—a pair for each leg. Each pair travels together down the leg to the back of the knee, where the pair divides and the nerves travel separately, one to the calf and the other to the foot.

There is a small opening in the spinal column where the nerves exit, and if the muscles push on one of the nerves in an awkward way, the pressure causes pain in the lower back or upper hip. The pain can be sharp or dull, and can involve one or both legs. It may radiate slightly down the leg, but radiating leg pain may signal osteoarthritis rather than sciatica and may need further evaluation. Sciatic pain due to nerve pressure has three possible sources: bony spurs on the surface of the vertebrae pressing on the nerve, pressure from a damaged spinal disk, and muscle spasms—particularly in the piriformis muscle, which may tighten enough to press on the nerves and cause pain.

MRIs and other scans in patients aged 45 and older will likely show some disk abnormality, but this is usually a function of age, and physicians should look for muscle tightness in a patient with pain in the piriformis region before presuming that a disk is causing the problem. An absence of pain above the buttock muscles can signal a tight piriformis, rather than bone spurs or disk pressure. Most patients request scans, but I don't put too much stock in them as a diagnostic tool for this type of pain.

A specific exercise program can help ease the pain of sciatica by strengthening weak muscles and loosening tight muscles.

In this month's column, we'll look at some exercises to relieve sciatica pain. (See illustrations and instructions below, which you can photocopy for your patients.)

The piriformis muscle is often the culprit in sciatica. Unfortunately, treatment of piriformis muscle tightness is not easy. Pain relief takes longer because the piriformis is a large muscle surrounded by the sciatic nerve, so the exercises to loosen the muscle will be painful at the first. However, once the muscle loosens, it will start to feel better as the nerve pressure recedes, and the pain should subside. Loosening tight hip flexors may also relieve sciatica pain.

This series of exercises should be done five or six times daily, 6 days per week. Evidence is strong that small amounts of stretching and strengthening exercises throughout the day are more effective in relieving pain than a longer bout of exercises once a day.

Exercises for Sciatica

Exercises for Sciatica

Side-lying hip stretch. Lie on a carpeted floor on your right side with knees bent to about 45 degrees. Place a pillow under your head. Slowly slide your top (left) leg toward your chest and lower that knee to the floor. Gently straighten the leg so the hip and knee are in line with your body, just above the bottom leg and lower your (left) foot to the floor. Repeat three times. Switch sides, and repeat with the right leg on top.

Buttocks pinch. Lie on your stomach with a pillow under your abdomen. Squeeze your buttocks together tightly, and hold for 5 seconds. Relax. Start with three repetitions, and work up to six repetitions. If this exercise is too difficult, use your hands to squeeze the buttock muscles together.

Back-lying hip flexor stretch. Lie on your back with knees bent and feet flat on the floor. Raise both knees toward your chest. Bring the right knee close to your chest, clasping your arms around it. Slide your left leg down onto the floor, straightening it as much as possible. Try to touch the floor with the back of the knee of the extended leg. Hold the position for 5 seconds. Slowly return to the starting position. Relax for 4 seconds. Repeat with the opposite leg. Start with three repetitions, alternating your legs, and work up to six.

Back-lying hip rotation. Lie on your back with legs together, knees bent, and feet flat on the floor. Gently lower both knees towards the floor on your right side. Do not strain, and do not use any muscular effort to hold your knees on the floor. Also, do not allow your shoulders to lift from the floor. Hold for 15 seconds. Return to the starting position and relax. Repeat on the left side. Start with three repetitions, alternating sides, and work up to six.

Some patients who present with lower back aches are actually suffering from sciatica, which has become something of a catchall term for upper hip/lower back pain. However, in patients with true sciatica, a pinched nerve is causing the pain.

The sciatic nerves come in two pairs—a pair for each leg. Each pair travels together down the leg to the back of the knee, where the pair divides and the nerves travel separately, one to the calf and the other to the foot.

There is a small opening in the spinal column where the nerves exit, and if the muscles push on one of the nerves in an awkward way, the pressure causes pain in the lower back or upper hip. The pain can be sharp or dull, and can involve one or both legs. It may radiate slightly down the leg, but radiating leg pain may signal osteoarthritis rather than sciatica and may need further evaluation. Sciatic pain due to nerve pressure has three possible sources: bony spurs on the surface of the vertebrae pressing on the nerve, pressure from a damaged spinal disk, and muscle spasms—particularly in the piriformis muscle, which may tighten enough to press on the nerves and cause pain.

MRIs and other scans in patients aged 45 and older will likely show some disk abnormality, but this is usually a function of age, and physicians should look for muscle tightness in a patient with pain in the piriformis region before presuming that a disk is causing the problem. An absence of pain above the buttock muscles can signal a tight piriformis, rather than bone spurs or disk pressure. Most patients request scans, but I don't put too much stock in them as a diagnostic tool for this type of pain.

A specific exercise program can help ease the pain of sciatica by strengthening weak muscles and loosening tight muscles.

In this month's column, we'll look at some exercises to relieve sciatica pain. (See illustrations and instructions below, which you can photocopy for your patients.)

The piriformis muscle is often the culprit in sciatica. Unfortunately, treatment of piriformis muscle tightness is not easy. Pain relief takes longer because the piriformis is a large muscle surrounded by the sciatic nerve, so the exercises to loosen the muscle will be painful at the first. However, once the muscle loosens, it will start to feel better as the nerve pressure recedes, and the pain should subside. Loosening tight hip flexors may also relieve sciatica pain.

This series of exercises should be done five or six times daily, 6 days per week. Evidence is strong that small amounts of stretching and strengthening exercises throughout the day are more effective in relieving pain than a longer bout of exercises once a day.

Exercises for Sciatica

Exercises for Sciatica

Side-lying hip stretch. Lie on a carpeted floor on your right side with knees bent to about 45 degrees. Place a pillow under your head. Slowly slide your top (left) leg toward your chest and lower that knee to the floor. Gently straighten the leg so the hip and knee are in line with your body, just above the bottom leg and lower your (left) foot to the floor. Repeat three times. Switch sides, and repeat with the right leg on top.

Buttocks pinch. Lie on your stomach with a pillow under your abdomen. Squeeze your buttocks together tightly, and hold for 5 seconds. Relax. Start with three repetitions, and work up to six repetitions. If this exercise is too difficult, use your hands to squeeze the buttock muscles together.

Back-lying hip flexor stretch. Lie on your back with knees bent and feet flat on the floor. Raise both knees toward your chest. Bring the right knee close to your chest, clasping your arms around it. Slide your left leg down onto the floor, straightening it as much as possible. Try to touch the floor with the back of the knee of the extended leg. Hold the position for 5 seconds. Slowly return to the starting position. Relax for 4 seconds. Repeat with the opposite leg. Start with three repetitions, alternating your legs, and work up to six.

Back-lying hip rotation. Lie on your back with legs together, knees bent, and feet flat on the floor. Gently lower both knees towards the floor on your right side. Do not strain, and do not use any muscular effort to hold your knees on the floor. Also, do not allow your shoulders to lift from the floor. Hold for 15 seconds. Return to the starting position and relax. Repeat on the left side. Start with three repetitions, alternating sides, and work up to six.

Some patients who present with lower back aches are actually suffering from sciatica, which has become something of a catchall term for upper hip/lower back pain. However, in patients with true sciatica, a pinched nerve is causing the pain.

The sciatic nerves come in two pairs—a pair for each leg. Each pair travels together down the leg to the back of the knee, where the pair divides and the nerves travel separately, one to the calf and the other to the foot.

There is a small opening in the spinal column where the nerves exit, and if the muscles push on one of the nerves in an awkward way, the pressure causes pain in the lower back or upper hip. The pain can be sharp or dull, and can involve one or both legs. It may radiate slightly down the leg, but radiating leg pain may signal osteoarthritis rather than sciatica and may need further evaluation. Sciatic pain due to nerve pressure has three possible sources: bony spurs on the surface of the vertebrae pressing on the nerve, pressure from a damaged spinal disk, and muscle spasms—particularly in the piriformis muscle, which may tighten enough to press on the nerves and cause pain.

MRIs and other scans in patients aged 45 and older will likely show some disk abnormality, but this is usually a function of age, and physicians should look for muscle tightness in a patient with pain in the piriformis region before presuming that a disk is causing the problem. An absence of pain above the buttock muscles can signal a tight piriformis, rather than bone spurs or disk pressure. Most patients request scans, but I don't put too much stock in them as a diagnostic tool for this type of pain.

A specific exercise program can help ease the pain of sciatica by strengthening weak muscles and loosening tight muscles.

In this month's column, we'll look at some exercises to relieve sciatica pain. (See illustrations and instructions below, which you can photocopy for your patients.)

The piriformis muscle is often the culprit in sciatica. Unfortunately, treatment of piriformis muscle tightness is not easy. Pain relief takes longer because the piriformis is a large muscle surrounded by the sciatic nerve, so the exercises to loosen the muscle will be painful at the first. However, once the muscle loosens, it will start to feel better as the nerve pressure recedes, and the pain should subside. Loosening tight hip flexors may also relieve sciatica pain.

This series of exercises should be done five or six times daily, 6 days per week. Evidence is strong that small amounts of stretching and strengthening exercises throughout the day are more effective in relieving pain than a longer bout of exercises once a day.

Exercises for Sciatica

Exercises for Sciatica

Side-lying hip stretch. Lie on a carpeted floor on your right side with knees bent to about 45 degrees. Place a pillow under your head. Slowly slide your top (left) leg toward your chest and lower that knee to the floor. Gently straighten the leg so the hip and knee are in line with your body, just above the bottom leg and lower your (left) foot to the floor. Repeat three times. Switch sides, and repeat with the right leg on top.

Buttocks pinch. Lie on your stomach with a pillow under your abdomen. Squeeze your buttocks together tightly, and hold for 5 seconds. Relax. Start with three repetitions, and work up to six repetitions. If this exercise is too difficult, use your hands to squeeze the buttock muscles together.

Back-lying hip flexor stretch. Lie on your back with knees bent and feet flat on the floor. Raise both knees toward your chest. Bring the right knee close to your chest, clasping your arms around it. Slide your left leg down onto the floor, straightening it as much as possible. Try to touch the floor with the back of the knee of the extended leg. Hold the position for 5 seconds. Slowly return to the starting position. Relax for 4 seconds. Repeat with the opposite leg. Start with three repetitions, alternating your legs, and work up to six.

Back-lying hip rotation. Lie on your back with legs together, knees bent, and feet flat on the floor. Gently lower both knees towards the floor on your right side. Do not strain, and do not use any muscular effort to hold your knees on the floor. Also, do not allow your shoulders to lift from the floor. Hold for 15 seconds. Return to the starting position and relax. Repeat on the left side. Start with three repetitions, alternating sides, and work up to six.

Frozen shoulder has several causes, including sports injuries (such as rotator cuff tears), and overuse injuries from occasional activities (such as gardening, painting, or pulling suitcases from the conveyor belt at the airport). Frozen shoulder is something of a catch-all term, rather than a specific diagnosis.

Tension is one of the worst offenders when it comes to frozen shoulder. If you have minor injuries and you are a tense person, a frozen shoulder can develop. I know of people who developed frozen shoulders before an important job interview. So one can't say that this problem is purely mechanical; there is often a psychological component involved.

Too much of an activity that you don't do every day, such as gardening or painting, can cause a frozen shoulder; it's the body's defense mechanism against overuse. Tendinitis or bursitis can be underlying causes as well. Frozen shoulder is often misdiagnosed as a pinched nerve, but imaging tests will be negative.

Frozen shoulder is one of the few injuries for which a heating pad can provide some relief. The best time to use a heating pad is immediately before doing exercises: 20 minutes of gentle heat can increase muscle movement by 15%–20%. That can make the difference between the patient being able to move the shoulder a little, or not at all.

Let's look at some exercises that can restore mobility to a frozen shoulder. (See illustrations and instructions below, which you can photocopy for your patients.)

Patients often don't seek help until they have lost substantial mobility in the shoulder. Emphasize that if they are diligent about doing their exercises 3–4 times daily for at least 4–6 weeks, they will probably see progress. For best results and motivation, patients should have a therapist assist with the exercises for the first few weeks.

Patients must loosen the adhesions that have formed in the sleevelike capsule that covers the shoulder joint (a condition called adhesive capsulitis), and exercises are the best way to do this. Encourage patients to go to the point of pain when stretching the shoulder, and remind them to breathe normally during the exercises and to relax completely between sets.

To prevent recurrence of frozen shoulder, patients should revisit the exercises periodically, even after returning to normal activities. Once the patient returns to daily activities, the movement associated with these activities should help keep the problem at bay. However, patients should be aware of what might trigger a relapse, such as carrying or pulling heavy objects.

Next month: Exercises to relieve the pain of sciatica.

Exercises for a Frozen Shoulder

Shoulder flexion, vertical. Either sit in a straight-backed chair or lie on a mat with knees bent and feet flat on the floor. Cradle the injured arm with the opposite hand. Slowly raise both arms above your head as far as possible. Allow your uninjured arm to do most of the lifting. Do not move past the point of pain. Hold your arms in the overhead position for 5 seconds. Relax. Repeat 6 times.

Shoulder flexion, horizontal. Sit in a straight-backed chair with feet flat on the floor. Cradle the injured arm with your opposite hand. Use the uninjured arm to slowly push the injured arm toward the injured side. Do not lift the arms upward; simply move them sideways in the direction of the injured arm. Hold for 5 seconds. Relax. Repeat 6 times.

Trapezius/rhomboid stretch. Sit in a straight-backed chair with feet on the floor. Place your fingertips on your shoulders, with right fingertips on the right shoulder and left fingertips on the left shoulder. Keep your hands in place, and try to touch your elbows together in front of your chin, at approximately shoulder height. Hold for 5 seconds. Relax. Repeat 6 times.

Trapezius stretch with towel. Sit in a straight-backed chair with feet flat on the floor. Hold a rolled-up towel behind your neck with your elbows bent, and hold one end of the towel in each hand. Slowly straighten your uninjured arm, which will pull the injured arm up. Try to point the elbow of the frozen arm toward the ceiling until you feel pain. Stop pulling and hold for 5 seconds. Relax. Repeat 6 times.

Frozen shoulder has several causes, including sports injuries (such as rotator cuff tears), and overuse injuries from occasional activities (such as gardening, painting, or pulling suitcases from the conveyor belt at the airport). Frozen shoulder is something of a catch-all term, rather than a specific diagnosis.

Tension is one of the worst offenders when it comes to frozen shoulder. If you have minor injuries and you are a tense person, a frozen shoulder can develop. I know of people who developed frozen shoulders before an important job interview. So one can't say that this problem is purely mechanical; there is often a psychological component involved.

Too much of an activity that you don't do every day, such as gardening or painting, can cause a frozen shoulder; it's the body's defense mechanism against overuse. Tendinitis or bursitis can be underlying causes as well. Frozen shoulder is often misdiagnosed as a pinched nerve, but imaging tests will be negative.

Frozen shoulder is one of the few injuries for which a heating pad can provide some relief. The best time to use a heating pad is immediately before doing exercises: 20 minutes of gentle heat can increase muscle movement by 15%–20%. That can make the difference between the patient being able to move the shoulder a little, or not at all.

Let's look at some exercises that can restore mobility to a frozen shoulder. (See illustrations and instructions below, which you can photocopy for your patients.)

Patients often don't seek help until they have lost substantial mobility in the shoulder. Emphasize that if they are diligent about doing their exercises 3–4 times daily for at least 4–6 weeks, they will probably see progress. For best results and motivation, patients should have a therapist assist with the exercises for the first few weeks.

Patients must loosen the adhesions that have formed in the sleevelike capsule that covers the shoulder joint (a condition called adhesive capsulitis), and exercises are the best way to do this. Encourage patients to go to the point of pain when stretching the shoulder, and remind them to breathe normally during the exercises and to relax completely between sets.

To prevent recurrence of frozen shoulder, patients should revisit the exercises periodically, even after returning to normal activities. Once the patient returns to daily activities, the movement associated with these activities should help keep the problem at bay. However, patients should be aware of what might trigger a relapse, such as carrying or pulling heavy objects.

Next month: Exercises to relieve the pain of sciatica.

Exercises for a Frozen Shoulder

Shoulder flexion, vertical. Either sit in a straight-backed chair or lie on a mat with knees bent and feet flat on the floor. Cradle the injured arm with the opposite hand. Slowly raise both arms above your head as far as possible. Allow your uninjured arm to do most of the lifting. Do not move past the point of pain. Hold your arms in the overhead position for 5 seconds. Relax. Repeat 6 times.

Shoulder flexion, horizontal. Sit in a straight-backed chair with feet flat on the floor. Cradle the injured arm with your opposite hand. Use the uninjured arm to slowly push the injured arm toward the injured side. Do not lift the arms upward; simply move them sideways in the direction of the injured arm. Hold for 5 seconds. Relax. Repeat 6 times.

Trapezius/rhomboid stretch. Sit in a straight-backed chair with feet on the floor. Place your fingertips on your shoulders, with right fingertips on the right shoulder and left fingertips on the left shoulder. Keep your hands in place, and try to touch your elbows together in front of your chin, at approximately shoulder height. Hold for 5 seconds. Relax. Repeat 6 times.

Trapezius stretch with towel. Sit in a straight-backed chair with feet flat on the floor. Hold a rolled-up towel behind your neck with your elbows bent, and hold one end of the towel in each hand. Slowly straighten your uninjured arm, which will pull the injured arm up. Try to point the elbow of the frozen arm toward the ceiling until you feel pain. Stop pulling and hold for 5 seconds. Relax. Repeat 6 times.

Frozen shoulder has several causes, including sports injuries (such as rotator cuff tears), and overuse injuries from occasional activities (such as gardening, painting, or pulling suitcases from the conveyor belt at the airport). Frozen shoulder is something of a catch-all term, rather than a specific diagnosis.

Tension is one of the worst offenders when it comes to frozen shoulder. If you have minor injuries and you are a tense person, a frozen shoulder can develop. I know of people who developed frozen shoulders before an important job interview. So one can't say that this problem is purely mechanical; there is often a psychological component involved.

Too much of an activity that you don't do every day, such as gardening or painting, can cause a frozen shoulder; it's the body's defense mechanism against overuse. Tendinitis or bursitis can be underlying causes as well. Frozen shoulder is often misdiagnosed as a pinched nerve, but imaging tests will be negative.

Frozen shoulder is one of the few injuries for which a heating pad can provide some relief. The best time to use a heating pad is immediately before doing exercises: 20 minutes of gentle heat can increase muscle movement by 15%–20%. That can make the difference between the patient being able to move the shoulder a little, or not at all.

Let's look at some exercises that can restore mobility to a frozen shoulder. (See illustrations and instructions below, which you can photocopy for your patients.)

Patients often don't seek help until they have lost substantial mobility in the shoulder. Emphasize that if they are diligent about doing their exercises 3–4 times daily for at least 4–6 weeks, they will probably see progress. For best results and motivation, patients should have a therapist assist with the exercises for the first few weeks.

Patients must loosen the adhesions that have formed in the sleevelike capsule that covers the shoulder joint (a condition called adhesive capsulitis), and exercises are the best way to do this. Encourage patients to go to the point of pain when stretching the shoulder, and remind them to breathe normally during the exercises and to relax completely between sets.

To prevent recurrence of frozen shoulder, patients should revisit the exercises periodically, even after returning to normal activities. Once the patient returns to daily activities, the movement associated with these activities should help keep the problem at bay. However, patients should be aware of what might trigger a relapse, such as carrying or pulling heavy objects.

Next month: Exercises to relieve the pain of sciatica.

Exercises for a Frozen Shoulder

Shoulder flexion, vertical. Either sit in a straight-backed chair or lie on a mat with knees bent and feet flat on the floor. Cradle the injured arm with the opposite hand. Slowly raise both arms above your head as far as possible. Allow your uninjured arm to do most of the lifting. Do not move past the point of pain. Hold your arms in the overhead position for 5 seconds. Relax. Repeat 6 times.

Shoulder flexion, horizontal. Sit in a straight-backed chair with feet flat on the floor. Cradle the injured arm with your opposite hand. Use the uninjured arm to slowly push the injured arm toward the injured side. Do not lift the arms upward; simply move them sideways in the direction of the injured arm. Hold for 5 seconds. Relax. Repeat 6 times.

Trapezius/rhomboid stretch. Sit in a straight-backed chair with feet on the floor. Place your fingertips on your shoulders, with right fingertips on the right shoulder and left fingertips on the left shoulder. Keep your hands in place, and try to touch your elbows together in front of your chin, at approximately shoulder height. Hold for 5 seconds. Relax. Repeat 6 times.

Trapezius stretch with towel. Sit in a straight-backed chair with feet flat on the floor. Hold a rolled-up towel behind your neck with your elbows bent, and hold one end of the towel in each hand. Slowly straighten your uninjured arm, which will pull the injured arm up. Try to point the elbow of the frozen arm toward the ceiling until you feel pain. Stop pulling and hold for 5 seconds. Relax. Repeat 6 times.

Ankle sprains aren't just for athletes. You can sprain your ankle doing anything—slipping on the soccer field, stepping off the curb, or falling over someone's outstretched foot.

People who tend to walk on the outside edges of their feet are especially prone to ankle sprains, and someone who has suffered multiple sprains may have permanently loosened the outer ligaments of that ankle, which makes it more susceptible to future sprains.

The most common type of ankle sprain is a grade I, or inversion sprain, and occurs when the foot suddenly turns under you, and your body weight comes down hard on the bone and ligaments of the ankle joint. In a grade II, parts of the ligaments actually may be torn.

In a grade I sprain, there is no rupture, and the ligaments are not injured, but the ankle muscles are overstretched.

This month, I'll focus on exercises to help rehabilitate a grade I ankle sprain. (See illustrations and instructions below, which you can photocopy for your patients.)

Never underestimate an ankle sprain. It is not dangerous, but if you don't take care of it, residual weakness and pain can linger almost indefinitely. Don't be fooled by the absence of pain in the ankle immediately after the sprain. For the first half hour or so, there may not be much pain and swelling, but it will get worse. Patients who are not at home when the sprain occurs should get home as quickly as possible—ideally by having someone drive them. During the first 24 hours, advise patients to keep the ankle elevated and apply an ice bag or cold pack for 20 minutes every hour while they are awake.

One way to assess the sprain is to ask a patient to try to touch his or her toes. If he or she can touch the toes and it does not hurt, it is probably grade I, but if toe touching hurts the ankle, it is probably grade II or III and will need more sophisticated care.

Patients should begin recovery exercises a day or two after the injury, once any swelling has gone down with help from ice and anti-inflammatories. Start without a weight, and then attach a 1-pound weight to the foot to improve strength as needed. Repeat these exercises 2–3 times a day, 6 days a week. Although this sounds like a lot, think about how much we move our ankles when walking normally during the day. While it's important to keep the muscles active, it is also important for patients to use crutches or a cane while the ankle heals, since the stress of bearing weight on the injured ankle can impede full recovery.

Next month: Exercises for a frozen shoulder.

Exercises for a Sprained Ankle

Seated ankle raise. Sit in a straight-backed chair, with a rolled-up towel under the thigh of the injured leg. Flex the injured foot toward your shin, forming a “V” shape between your shin and foot. Hold this flexed position for 5 seconds, then lower your foot and relax for 3 seconds. Start with 8 repetitions, and work up to 12. When this seems easy, attach a 1-pound weight to the foot, and start with 8 repetitions.

Side-lying ankle raise. Lie on your side with the injured leg on top. Flex the foot to the side (away from your bottom leg) without bending the leg. Hold the flexed position for 5 seconds, then lower your foot and relax for 3 seconds. The relax time is important, because it lets the ankle muscles recover. Start with 8 repetitions, and work up to 12. When this seems easy, attach a 1-pound weight to the foot, and start with 8 repetitions again.

Stomach-lying ankle extension. Lie on your stomach with a pillow under your abdomen. Bend the knee of the injured leg, and lift it to a 45-degree angle. Slowly extend your foot; try to point your toes up toward the ceiling. Hold the extended position for 5 seconds, then relax the foot for 3 seconds. Keep the leg raised at a 45-degree angle until you have done 8 repetitions. Work up to 12. When this seems easy, attach a 1-pound weight to the foot, and begin again with 8 repetitions.

Ankle sprains aren't just for athletes. You can sprain your ankle doing anything—slipping on the soccer field, stepping off the curb, or falling over someone's outstretched foot.

People who tend to walk on the outside edges of their feet are especially prone to ankle sprains, and someone who has suffered multiple sprains may have permanently loosened the outer ligaments of that ankle, which makes it more susceptible to future sprains.

The most common type of ankle sprain is a grade I, or inversion sprain, and occurs when the foot suddenly turns under you, and your body weight comes down hard on the bone and ligaments of the ankle joint. In a grade II, parts of the ligaments actually may be torn.

In a grade I sprain, there is no rupture, and the ligaments are not injured, but the ankle muscles are overstretched.

This month, I'll focus on exercises to help rehabilitate a grade I ankle sprain. (See illustrations and instructions below, which you can photocopy for your patients.)

Never underestimate an ankle sprain. It is not dangerous, but if you don't take care of it, residual weakness and pain can linger almost indefinitely. Don't be fooled by the absence of pain in the ankle immediately after the sprain. For the first half hour or so, there may not be much pain and swelling, but it will get worse. Patients who are not at home when the sprain occurs should get home as quickly as possible—ideally by having someone drive them. During the first 24 hours, advise patients to keep the ankle elevated and apply an ice bag or cold pack for 20 minutes every hour while they are awake.

One way to assess the sprain is to ask a patient to try to touch his or her toes. If he or she can touch the toes and it does not hurt, it is probably grade I, but if toe touching hurts the ankle, it is probably grade II or III and will need more sophisticated care.

Patients should begin recovery exercises a day or two after the injury, once any swelling has gone down with help from ice and anti-inflammatories. Start without a weight, and then attach a 1-pound weight to the foot to improve strength as needed. Repeat these exercises 2–3 times a day, 6 days a week. Although this sounds like a lot, think about how much we move our ankles when walking normally during the day. While it's important to keep the muscles active, it is also important for patients to use crutches or a cane while the ankle heals, since the stress of bearing weight on the injured ankle can impede full recovery.

Next month: Exercises for a frozen shoulder.

Exercises for a Sprained Ankle

Seated ankle raise. Sit in a straight-backed chair, with a rolled-up towel under the thigh of the injured leg. Flex the injured foot toward your shin, forming a “V” shape between your shin and foot. Hold this flexed position for 5 seconds, then lower your foot and relax for 3 seconds. Start with 8 repetitions, and work up to 12. When this seems easy, attach a 1-pound weight to the foot, and start with 8 repetitions.

Side-lying ankle raise. Lie on your side with the injured leg on top. Flex the foot to the side (away from your bottom leg) without bending the leg. Hold the flexed position for 5 seconds, then lower your foot and relax for 3 seconds. The relax time is important, because it lets the ankle muscles recover. Start with 8 repetitions, and work up to 12. When this seems easy, attach a 1-pound weight to the foot, and start with 8 repetitions again.

Stomach-lying ankle extension. Lie on your stomach with a pillow under your abdomen. Bend the knee of the injured leg, and lift it to a 45-degree angle. Slowly extend your foot; try to point your toes up toward the ceiling. Hold the extended position for 5 seconds, then relax the foot for 3 seconds. Keep the leg raised at a 45-degree angle until you have done 8 repetitions. Work up to 12. When this seems easy, attach a 1-pound weight to the foot, and begin again with 8 repetitions.

Ankle sprains aren't just for athletes. You can sprain your ankle doing anything—slipping on the soccer field, stepping off the curb, or falling over someone's outstretched foot.

People who tend to walk on the outside edges of their feet are especially prone to ankle sprains, and someone who has suffered multiple sprains may have permanently loosened the outer ligaments of that ankle, which makes it more susceptible to future sprains.

The most common type of ankle sprain is a grade I, or inversion sprain, and occurs when the foot suddenly turns under you, and your body weight comes down hard on the bone and ligaments of the ankle joint. In a grade II, parts of the ligaments actually may be torn.

In a grade I sprain, there is no rupture, and the ligaments are not injured, but the ankle muscles are overstretched.

This month, I'll focus on exercises to help rehabilitate a grade I ankle sprain. (See illustrations and instructions below, which you can photocopy for your patients.)

Never underestimate an ankle sprain. It is not dangerous, but if you don't take care of it, residual weakness and pain can linger almost indefinitely. Don't be fooled by the absence of pain in the ankle immediately after the sprain. For the first half hour or so, there may not be much pain and swelling, but it will get worse. Patients who are not at home when the sprain occurs should get home as quickly as possible—ideally by having someone drive them. During the first 24 hours, advise patients to keep the ankle elevated and apply an ice bag or cold pack for 20 minutes every hour while they are awake.

One way to assess the sprain is to ask a patient to try to touch his or her toes. If he or she can touch the toes and it does not hurt, it is probably grade I, but if toe touching hurts the ankle, it is probably grade II or III and will need more sophisticated care.

Patients should begin recovery exercises a day or two after the injury, once any swelling has gone down with help from ice and anti-inflammatories. Start without a weight, and then attach a 1-pound weight to the foot to improve strength as needed. Repeat these exercises 2–3 times a day, 6 days a week. Although this sounds like a lot, think about how much we move our ankles when walking normally during the day. While it's important to keep the muscles active, it is also important for patients to use crutches or a cane while the ankle heals, since the stress of bearing weight on the injured ankle can impede full recovery.

Next month: Exercises for a frozen shoulder.

Exercises for a Sprained Ankle

Seated ankle raise. Sit in a straight-backed chair, with a rolled-up towel under the thigh of the injured leg. Flex the injured foot toward your shin, forming a “V” shape between your shin and foot. Hold this flexed position for 5 seconds, then lower your foot and relax for 3 seconds. Start with 8 repetitions, and work up to 12. When this seems easy, attach a 1-pound weight to the foot, and start with 8 repetitions.

Side-lying ankle raise. Lie on your side with the injured leg on top. Flex the foot to the side (away from your bottom leg) without bending the leg. Hold the flexed position for 5 seconds, then lower your foot and relax for 3 seconds. The relax time is important, because it lets the ankle muscles recover. Start with 8 repetitions, and work up to 12. When this seems easy, attach a 1-pound weight to the foot, and start with 8 repetitions again.

Stomach-lying ankle extension. Lie on your stomach with a pillow under your abdomen. Bend the knee of the injured leg, and lift it to a 45-degree angle. Slowly extend your foot; try to point your toes up toward the ceiling. Hold the extended position for 5 seconds, then relax the foot for 3 seconds. Keep the leg raised at a 45-degree angle until you have done 8 repetitions. Work up to 12. When this seems easy, attach a 1-pound weight to the foot, and begin again with 8 repetitions.

Whiplash, an acute condition often associated with car accidents in which one car hits another from behind, also can occur as a result of a collision on a football or soccer field if someone is hit hard from behind by a fellow player. The impact of the collision engages the flexibility of the cervical spine; the head snaps forward or backward with the force of the blow and then whips back again.

Pain associated with whiplash may be severe at first and then abate overnight, only to return the next morning. In this condition, there is a temporary loss of the natural curvature in the neck, and the neck muscles are likely to go into spasms as a natural defense, to immobilize the area. The spasms can be very painful and can make treatment more difficult.

In 95% of whiplash cases, doctors can't distinguish any neurologic deficit, but whiplash is painful and frightening for the injured person, and the doctor can offer reassurance and stretching exercises to ease pain and promote healing.

A whiplash injury is purely muscular; an MRI or x-ray is usually not helpful in diagnosis. Images of younger patients generally show no changes in the neck, and images of older patients simply show osteoarthritic changes that were already present.

Immediately after injury, advise the patient to apply ice to the neck. Ice stops the nerves' ability to conduct the painful stimulus; thus, there are fewer nerve messages telling the muscles to tighten up.

In this month's column, I'll describe some exercises to relieve the pain associated with whiplash. (See illustrations and instructions below, which you can photocopy for your patients.)

The key to recovering from whiplash is to begin the limbering exercises right away. Much of the pain associated with whiplash occurs because people are told to wear a cervical collar, and they don't make any attempt to loosen their neck muscles for several days.

As soon as possible, usually 2–3 days after the injury, patients should start with some of the following exercises, and do them at least twice daily, without overextending themselves beyond where they feel pain. These exercises should be eased into gradually, following a doctor's instructions. The neck muscles are extremely sensitive to stretching, and overstretching will only exacerbate the spasms and pain. It is important to relax the muscles completely between repetitions of each exercise.

If the patient complains about numbness in any of the fingers, or pain shooting down into the arm, it is worth ordering an x-ray or MRI; the patient may have a more serious problem than whiplash and may need to be referred to a specialist.

Next month: Exercises to rehabilitate a sprained ankle.

Exercises for Whiplash

▸ Shoulder shrug. Sit in a straight-backed chair with your arms relaxed at your sides. Slowly (while counting to six) raise your shoulders as close to your ears as you can without excessive strain. Slowly lower your shoulders to the starting position. Repeat five times, counting to five, to relax completely between each repetition. Keep your fingers and shoulders as loose as possible.

▸ Side neck rotation. While standing up straight or sitting in a chair, stretch the neck by turning your head gently to the right while counting to three—not holding in a sideways position but returning to the center. Then turn your head to the left while counting to three, and return to the center. Begin with 4 or 5 repetitions, and work up to 10.

▸ Forward neck flexion. Sit in a straight-backed chair with your feet flat on the floor, arms relaxed at your sides, and head level and relaxed. Slowly lower your chin toward your chest, stopping when you feel pain. Hold this position, and breathe slowly. You should feel some relief of the pain and tension, then try to bring your chin down a little more and continue breathing slowly. When you can't lower your chin any farther, hold the final position for 5 seconds, then slowly raise the chin and relax. Start with three repetitions, and work up to six.

▸ Forward neck flexion, variation. After you have gradually brought your chin as close to your chest as possible, turn your chin toward your right shoulder, and hold for 5 seconds. Bring your chin back to the center, count to three, and then turn toward the left shoulder and hold for 5 seconds. Bring your chin back to the center again, then slowly lift your head back to a level position, and relax. Begin with three repetitions, and work up to six.

Whiplash, an acute condition often associated with car accidents in which one car hits another from behind, also can occur as a result of a collision on a football or soccer field if someone is hit hard from behind by a fellow player. The impact of the collision engages the flexibility of the cervical spine; the head snaps forward or backward with the force of the blow and then whips back again.

Pain associated with whiplash may be severe at first and then abate overnight, only to return the next morning. In this condition, there is a temporary loss of the natural curvature in the neck, and the neck muscles are likely to go into spasms as a natural defense, to immobilize the area. The spasms can be very painful and can make treatment more difficult.

In 95% of whiplash cases, doctors can't distinguish any neurologic deficit, but whiplash is painful and frightening for the injured person, and the doctor can offer reassurance and stretching exercises to ease pain and promote healing.

A whiplash injury is purely muscular; an MRI or x-ray is usually not helpful in diagnosis. Images of younger patients generally show no changes in the neck, and images of older patients simply show osteoarthritic changes that were already present.

Immediately after injury, advise the patient to apply ice to the neck. Ice stops the nerves' ability to conduct the painful stimulus; thus, there are fewer nerve messages telling the muscles to tighten up.

In this month's column, I'll describe some exercises to relieve the pain associated with whiplash. (See illustrations and instructions below, which you can photocopy for your patients.)

The key to recovering from whiplash is to begin the limbering exercises right away. Much of the pain associated with whiplash occurs because people are told to wear a cervical collar, and they don't make any attempt to loosen their neck muscles for several days.

As soon as possible, usually 2–3 days after the injury, patients should start with some of the following exercises, and do them at least twice daily, without overextending themselves beyond where they feel pain. These exercises should be eased into gradually, following a doctor's instructions. The neck muscles are extremely sensitive to stretching, and overstretching will only exacerbate the spasms and pain. It is important to relax the muscles completely between repetitions of each exercise.

If the patient complains about numbness in any of the fingers, or pain shooting down into the arm, it is worth ordering an x-ray or MRI; the patient may have a more serious problem than whiplash and may need to be referred to a specialist.

Next month: Exercises to rehabilitate a sprained ankle.

Exercises for Whiplash

▸ Shoulder shrug. Sit in a straight-backed chair with your arms relaxed at your sides. Slowly (while counting to six) raise your shoulders as close to your ears as you can without excessive strain. Slowly lower your shoulders to the starting position. Repeat five times, counting to five, to relax completely between each repetition. Keep your fingers and shoulders as loose as possible.

▸ Side neck rotation. While standing up straight or sitting in a chair, stretch the neck by turning your head gently to the right while counting to three—not holding in a sideways position but returning to the center. Then turn your head to the left while counting to three, and return to the center. Begin with 4 or 5 repetitions, and work up to 10.

▸ Forward neck flexion. Sit in a straight-backed chair with your feet flat on the floor, arms relaxed at your sides, and head level and relaxed. Slowly lower your chin toward your chest, stopping when you feel pain. Hold this position, and breathe slowly. You should feel some relief of the pain and tension, then try to bring your chin down a little more and continue breathing slowly. When you can't lower your chin any farther, hold the final position for 5 seconds, then slowly raise the chin and relax. Start with three repetitions, and work up to six.

▸ Forward neck flexion, variation. After you have gradually brought your chin as close to your chest as possible, turn your chin toward your right shoulder, and hold for 5 seconds. Bring your chin back to the center, count to three, and then turn toward the left shoulder and hold for 5 seconds. Bring your chin back to the center again, then slowly lift your head back to a level position, and relax. Begin with three repetitions, and work up to six.

Whiplash, an acute condition often associated with car accidents in which one car hits another from behind, also can occur as a result of a collision on a football or soccer field if someone is hit hard from behind by a fellow player. The impact of the collision engages the flexibility of the cervical spine; the head snaps forward or backward with the force of the blow and then whips back again.

Pain associated with whiplash may be severe at first and then abate overnight, only to return the next morning. In this condition, there is a temporary loss of the natural curvature in the neck, and the neck muscles are likely to go into spasms as a natural defense, to immobilize the area. The spasms can be very painful and can make treatment more difficult.

In 95% of whiplash cases, doctors can't distinguish any neurologic deficit, but whiplash is painful and frightening for the injured person, and the doctor can offer reassurance and stretching exercises to ease pain and promote healing.

A whiplash injury is purely muscular; an MRI or x-ray is usually not helpful in diagnosis. Images of younger patients generally show no changes in the neck, and images of older patients simply show osteoarthritic changes that were already present.

Immediately after injury, advise the patient to apply ice to the neck. Ice stops the nerves' ability to conduct the painful stimulus; thus, there are fewer nerve messages telling the muscles to tighten up.

In this month's column, I'll describe some exercises to relieve the pain associated with whiplash. (See illustrations and instructions below, which you can photocopy for your patients.)

The key to recovering from whiplash is to begin the limbering exercises right away. Much of the pain associated with whiplash occurs because people are told to wear a cervical collar, and they don't make any attempt to loosen their neck muscles for several days.

As soon as possible, usually 2–3 days after the injury, patients should start with some of the following exercises, and do them at least twice daily, without overextending themselves beyond where they feel pain. These exercises should be eased into gradually, following a doctor's instructions. The neck muscles are extremely sensitive to stretching, and overstretching will only exacerbate the spasms and pain. It is important to relax the muscles completely between repetitions of each exercise.

If the patient complains about numbness in any of the fingers, or pain shooting down into the arm, it is worth ordering an x-ray or MRI; the patient may have a more serious problem than whiplash and may need to be referred to a specialist.

Next month: Exercises to rehabilitate a sprained ankle.

Exercises for Whiplash

▸ Shoulder shrug. Sit in a straight-backed chair with your arms relaxed at your sides. Slowly (while counting to six) raise your shoulders as close to your ears as you can without excessive strain. Slowly lower your shoulders to the starting position. Repeat five times, counting to five, to relax completely between each repetition. Keep your fingers and shoulders as loose as possible.

▸ Side neck rotation. While standing up straight or sitting in a chair, stretch the neck by turning your head gently to the right while counting to three—not holding in a sideways position but returning to the center. Then turn your head to the left while counting to three, and return to the center. Begin with 4 or 5 repetitions, and work up to 10.

▸ Forward neck flexion. Sit in a straight-backed chair with your feet flat on the floor, arms relaxed at your sides, and head level and relaxed. Slowly lower your chin toward your chest, stopping when you feel pain. Hold this position, and breathe slowly. You should feel some relief of the pain and tension, then try to bring your chin down a little more and continue breathing slowly. When you can't lower your chin any farther, hold the final position for 5 seconds, then slowly raise the chin and relax. Start with three repetitions, and work up to six.

▸ Forward neck flexion, variation. After you have gradually brought your chin as close to your chest as possible, turn your chin toward your right shoulder, and hold for 5 seconds. Bring your chin back to the center, count to three, and then turn toward the left shoulder and hold for 5 seconds. Bring your chin back to the center again, then slowly lift your head back to a level position, and relax. Begin with three repetitions, and work up to six.