Scientific Substantiation

A. Claim: Lateral training enhances balance and stability as we age.

Reference point 1: Side Step Clinical Study, SciFit Corporation, Tulsa OK, 2015, see Conclusion page 2

Reference point 2: "The Recumbent Lateral Trainer: Why it provides superior benefits to hip and knee structures across the spectrum of hip performance outcomes” by Andy Baxter, MES, PRC, 2016, see page 2

Reference point 3: Fraix, M. Role of the musculoskeletal system and the prevention of falls, Department of Neuromusculoskeletal Medicine/Osteopathic Manipulative Medicine, Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Pomona, CA,2012,See ‘Strength & Balance Control’ and Table 1

Reference point 4: Reference point 3: Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show, Med Clin North Am, 2006, See Prevention Strategies, Exercise Interventions page 814 - 816

Reference point 5: Glute Medial Activation Data, Gait Kinematics and Muscle Firing Study, Department of Physical Therapy and Human Movement Sciences, Northwestern University, 2014, see Summary page 3

Reference point 6: “Lateral Strength and Stability are Essential to Proper Biomechanics” by Andy Baxter, MES, PRCS, 2018, see paragraphs 6-8

B. Claim: Unlike traditional cardio, lateral cardio machines strengthen the muscles that support knees

Reference point 7: Gait Kinematics and Muscle Firing Study, Department of Physical Therapy and Human Movement Sciences, Northwestern University, 2014, see Glute Medial Activation Data, page 2

Reference point 8: Anderson, Katherine, MSPT, What is the Gluteus Medius and Why Is It So Important, Viva Physiotheraphy, 2018, see page 1, paragraph one and page 2, “Rehabilitation and Prevention Exercises”

C. Claim: Unlike traditional cardio, lateral training helps support and protect the knees through healthy knee rotation.

Reference point 9: Smoliga, Jacob, DVM, PhD, Comparative impact on Hip Flexion, Knee Rotation, and Hip Abduction- Adduction using Lateral Cardio Trainers, Human Biomechanics and Physiology Laboratory, Congdon School of Health, Highpoint University, see Joint Function, page 3

D.Claim: Lateral training activates more muscles than traditional cardio machines such as treadmills and ellipticals.

Reference point 10: Comparative Heart Rate Reserve Attainment and Skeletal Muscle Activation, The Human Performance Lab, The University of Tampa, 2011, see conclusions pages 12-13

Reference point 11: Gait Kinematics and Muscle Firing Study, Department of Physical Therapy and Human Movement Sciences, Northwestern University, 2014, see Hip Abduction page 2 and figures 1 and 2, Glute Medial Activation

Reference point 12: Bouillon, Lucinda, PT, PhD, Comparison of Trunk and Lower Extremity Muscle Activity Among Four Stationary Equipment Devices, International Journal of Sports Physical Therapy, 2016, see conclusion.

E. Claim: Lateral training allows users to achieve targeted heart rates more quickly than traditional cardio such as ellipticals.

Reference point 13: Comparative Heart Rate Reserve Attainment and Skeletal Muscle Activation, The Human Performance Lab, The University of Tampa, 2011, SeeTargeted Heart Rate Results page 5 and conclusions page 12.

Reference point 14: Yadav, Alok Kumar, A Study to Evaluate Cardiovascular Responses By Using Treadmill and Ergonomic Bicycle Exercise in Young Adults, Indian Journal of Health Sciences and Biomedical Research, 2018, see Table 2 page 83.

F. Claim: Recumbent lateral trainers protect the hips.

Reference point 15: "The Recumbent Lateral Trainer: Why it provides superior benefits to hip and knee structures across the spectrum of hip performance outcomes” by Andy Baxter, MES, PRCS, 2016, see page 1-2

Reference point 16: Gluteus Minimus and Gluteus Medius Muscle Activity During Common Rehabilitation Exercises in Healthy Post Menopausal Women, Journal of Orthopaedic and Sports Physical Therapy, 2017 see abstract conclusion

Reference point 17: Monaghan, Brenda, Functional Exercise After a Total Hip Replacement (FEATHER), A Randomized Control Trial, BMC Musculoskeletal Disorders, 2012, see page 2, highlighted section

G. Claim: Lateral trainers work the muscles that other cardio machines ignore, such as the inner and outer thighs.

Reference point 18: Comparative Heart Rate Reserve Attainment and Skeletal Muscle Activation, The Human Performance Lab, The University of Tampa, 2011, see Vastus Lateralis Data page 8 and Adductors Data page 9

Reference point 19: Jakubsen, Markus, Muscle Activity During Leg Strengthening Exercise, Human Movement Science, 2013, see page 71 - 72

H. Claim: A lateral training workout burns more calories than a comparable cardio workout such as an elliptical.

Reference point 20: Robergs, Robert PhD and Kravitz, Len PhD, Making Sense of Calorie Burning Claims, IDEA Fitness Journal, seeWhat determines Caloric Expenditure during exercise, paragraph 5 and Can Certain Types of Exercise Burn More Calories Than Others, paragraph 16

Reference point 21: Comparative Heart Rate Reserve Attainment and Skeletal Muscle Activation, The Human Performance Lab, The University of Tampa, 2011, seeTable 1 Percentage of Increased Muscle Activity page 6

Reference point 22: Comparative impact on Hip Flexion, Knee Rotation, and Hip Abduction/Adduction with Lateral Cardio Trainers, Human Biomechanics and Physiology Laboratory, Congdon School of Health, High Point University, 2016see key findings page 1

Reference point 23: Fogoros, Richard, MD, and Waehner, Page, The Amount of Calories Muscles Burn, VeryWell Fit, 2019, see page 2, Use Compound Movements

I. Claim: Lateral cardio trainers provide a superior cardio workout to traditional machines such as treadmills and ellipticals

See reference points 1-23

Reference point 24: Comparative Heart Rate Reserve Attainment and Skeletal Muscle Activation, The Human Performance Lab, The University of Tampa, 2011, see conclusions page 12-13.

Reference point 25: Malacoff, Julia, Why You Should Add Lateral Exercises to Your Workouts, Shape Magazine, 2018, see pages 1-2

Reference point 26: Gait Kinematics and Muscle Firing Study, Department of Physical Therapy and Human Movement Sciences, Northwestern University, 2014, see page 3

Reference point 27: Logan, Scott, Recumbent Lateral Training: a New Direction in Fitness, 2018 Club Solutions Magazine, see pages 1-2

Reference point 28: Netter, Patrick, A Lateral Move to Up Your Mobility, The Gear Guru, 2018, see page 1-3

 

Reference Point No. 1

Side Step Study

Conducted by SciFit Corporation Recumbent Lateral Trainer March - April 2015

Introduction:

A Side Step Test (SST) is a simple fitness measuring agility in test subjects, conducted over one minute.   In this test, 18 male and female test subjects performed side step tests to get a baseline of their performance.  They then conducted workouts on a recumbent lateral trainer under the supervision of a physical therapist.

After an average of 4.5 weeks, 15 of the original test subjects re-took the side step study to measure their progress.

The subjects:

The subjects were male and female and ranged in age from 72 years old to 95 years old.  Some were experiencing age related decline, and some had notable health issue impacting balance and strength such as history of stroke, nerve damage or Parkinson’s Disease.

Subject Gender and #

Notable Medical issues

Date of Birth

Power Factor Before

Power Factor After

Improvement

Female 1

 

6/27/26

129.25

148.5

14.90%

Male 2

 

9/24/21

138.125*

161.25

16.70%

Female 3

 

9/20/30

310.5

434.625

40.00%

Male 4

 

10/18/20

107.5*

163.625

52.20%

Female 5

 

1/6/39

140

316

125.70%

Female 6

 

10/30/39

117.5

236.25

101.00%

Female 7

 

10/31/36

187.5

204.75

9.20%

Female 8

Nerve damage

8/27/32

134.75

144

6.9%

Female 9

 

7/24/40

226.875

315

38.80%

Female 10

Stroke

6/27/41

187.25

388.5

107.50%

Male 11

 

3/18/40

176.75

298.375

68.8%

Male 12

 

8/27/26

133.875*

221.875

66%

Female 13

 

 

153.75

-

-

Male 14

Parkinson’s

& Stroke

9/4/35

106.25

114.75

8%

Male 15

 

 

126.5

-

-

Female 16

 

11/18/31

142.5

264

85.26%

Female 17

 

1/28/43

157.5

383.375

144%

Female 18

 

 

151.25

-

-

 

*Denotes balance problems at baseline test; resolved with second test.

Table 1:  Power Factor Results

Results:
Every single subject who completed the study had improved power factor results ranging from a low of 6.9% from a test subject with nerve damage in both legs, to a high of 144% in a 72 year old female. The average improvement was 59%.

Three of the test subjects who had experience loss of balance in the first test were able to perform the second test without balance issues.

Conclusion:
Recumbent lateral trainers can quickly improve strength and stability resulting in improved balance and performance.

 

Reference Point No. 2

The Recumbent Lateral Trainer:
Why it provides superior benefits to hip and knee structures across the spectrum of hip performance outcomes
By Andy Baxter, MES PRCS 8/11/1

In evaluating the full spectrum of hip performance outcomes, let us first identify the outermost extremes of that spectrum. At one end of the spectrum we have mediolateral protective stepping performance, hip abduction torque, and trunk mobility as it relates to fall prediction and prevention in the frail and elderly. At the other end of that spectrum we can measure overall joint structure stability and performance as it relates to torque and power eccentric / amortization / concentric) in the elite athlete.

Addressing these outcomes, and all that lie between them, will almost invariably require a study of the specific musculature known as the hip abductors – Glute Medius, Glute Minimus and Tensor Fascia Latae (TFL). Secondary and tertiary effects of tight and/or weak hip abductors are malalignment of the knee and low back as they relate to the Iliotibial Band (ITB) origin and insertion.

There currently exist many exercises that attempt to address tight and/or weak hip abductors. Shortcomings of the current skew are myriad; side planks are isometric, side leg raises and clam shells are open chain and/or single joint/single plane, etc.

Additionally, these movements focus on an osteo-kinematic movement with little real world, functional application. While they serve the purpose of innervation to the point of increasing joint stability, they don’t go to the next level of functional performance.

Real world, functional osteo and arthrokinematics involve movement in multiple planes involving flexion/extension, abduction/adduction, internal/external rotation and compound multi joint integration.

The question then becomes, how do we safely and effectively train the mediolateral structures of the hip and knee for real world, functionally applicable outcomes? The recumbent lateral trainer modality provides a comprehensive solution on many fronts:

  • It accommodates training for all abilities at sub body weight
  • It features bidirectional abduction/adduction for reciprocal muscle group balance
  • It is a closed kinetic chain exercise (stabilized foot) and a compound exercise with flexion/extension at the ankle, knee, and hip
  • Natural, multiplane kinematics integrating flexion/extension, abduction/adduction and internal/external rotation of the acetabulofemoral joint
  • Provides superior med/min glute and TFL innervation and torque moment for improved hip and knee alignment
  • It is non-concussive so as not to exacerbate IT Band Syndrome (ITBS)
  • Improved eccentric deceleration and dynamic stabilization of the hip structure

 

Reference Point No. 3

Fraix, M. Role of the musculoskeletal system and the prevention of falls, Department of Neuromusculoskeletal Medicine/Osteopathic Manipulative Medicine, Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Pomona, CA,2012
Strength and Balance Control

In addition to vitamin D supplementation, evidence supports the use of exercise to reduce fall rates in older adults. A systematic review and meta-analysis by Sherrington et al15 that included 44 trials involving 9603 participants showed an overall reduction in the fall rate by 17% with the implementation of an exercise program. The study also demonstrated that exercise dose and balance training are important factors in determining the efficacy of an exercise program.

Exercise interventions lower fall rates among older adults only when at least 50 hours of training have been completed.16 Similarly, weight-bearing activities that are performed with minimal support, including walking with a narrow base of support or on a variety of terrains, improve balance and result in improved fall-related outcomes.17

A variety of exercise programs exist, including programs that target resistance and strength training (eg, physical therapy) and programs that incorporate coordinated movement of the body's center of gravity and limbs (eg, the Chinese martial art of tai chi).

Given the fact that exercise reduces falls in older adults,17 it is important for physicians to assess a patient's motor strength and coordination to institute an exercise program that incorporates both the appropriate amount and appropriate type of exercise. What is appropriate for one patient may be inappropriate or even harmful for another patient. For example, a walking program for an older adult at low risk for falls might improve his or her strength, endurance, and cardiovascular system function. However, for a frail older adult at high risk for falls, a walking program might increase his or her risk of falls and fall-related injuries. Table 1 defines levels of fall risk and shows the types of exercises that may be most appropriate for an older adult based on his or her risk level.

Reference Point No. 4

Falls and Their Prevention in Elderly People: What Does the Evidence Show?Laurence Z. Rubenstein, MD, MPHa,b,*,Karen R. Josephson, MPHbaDepartment of Medicine, David Geffen School of Medicine at UCLA, 10945 Le Conte Ave., Los Angeles, CA, 90095, USAbGeriatric Research Education & Clinical Center (GRECC), VA Sepu´lveda Ambulatory CareCenter & Nursing Home, 16111 Plummer Street, North Hills, CA 91343, USAFalls are a common and complex geriatric syndrome that cause consider- able mortality, morbidity, reduced functioning, and premature nursing home admissions. Falls have multiple precipitating causes and predisposing risk factors, which make their diagnosis, treatment, and prevention a difficult clinical challenge. A fall may be the first indicator of an acute problem (in- fection, postural hypotension, cardiac arrhythmia), may stem from a chronic disease (parkinsonism, dementia, diabetic neuropathy), or simply may be a marker for the progression of ‘‘normal’’ age-related changes in vision, gait, and strength. Moreover, most falls that are experienced by older per- sons have multifactorial and interacting predisposing and precipitating causes (eg, a trip over an electrical cord contributed to by a gait disorder and poor vision). Fig. 1 provides the complex relationship between selected risk factors, underlying causes, precipitating events, and falls.Identifying effective interventions to prevent falls and fall-related injuries among older adults is a major area of research and policy development in geriatrics. Several published clinical guidelines review the evidence for fall prevention strategies and provide recommendations for assessment and in- tervention. In the past few years there has been a major increase in the num- ber of randomized controlled trials that have evaluated various fall prevention interventions. Meta-analysis of these trials has provided more evidence on efficacy. These clinical guidelines and the extensive fall preven- tion literature provide much needed insight into the difficult clinical chal- lenge of fall prevention. This article provides a brief overview of the percentage of community-living persons with recurrent falls increased from 10% to 69% as the number of risk factors increased from one to four or more. Their identified risk factors included white race, a history of falls, ar- thritis, parkinsonism, difficulty rising, and poor tandem gait. In a study by Robbins and colleagues [15] that involved an institutionalized and outpa- tient population, many individual risk factors were related significantly to falls. Multivariate analysis simplified the model so that maximum predictive accuracy could be obtained using only three risk factors (ie, hip weakness assessed manually, unstable balance, and taking four or more prescribed medications) in a branching logic, algorithmic fashion. With this model the predicted 1-year risk for falling ranged from 12% for persons with none of the three risk factors to 100% for persons with all three risk factors. In summary, studies have shown that it is possible to identify persons who are at a substantially increased risk for sustaining a fall or fall-related injury by detecting the presence of risk factors. Many, if not all, of these risk factors are amenable to treatment or rehabilitative approaches to ameliorate them. Consequently, risk factor identification seems to be a promising first step in developing effective fall-prevention programs that are targeted to high-risk patients. To assist clinicians in the assessment of fall risk, evi- dence-based clinical practice guidelines on fall prevention and treatment were published by the American and British Geriatrics Societies [46]. Among other things, the guidelines recommend that a fall risk assessment be an integral part of primary health care for older persons, with the inten- sity of the assessment tailored to the target population (eg, low-risk versus high-risk individuals). Several published fall risk assessment tools are avail- able for quantifying fall risk for older persons at home and in institutional settings. An analytic review of these assessment tools recommended severalthat seem to be valid and potentially useful [47].Although the importance of fall risk factor identification is accepted gen- erally, the question of how best to modify these risk factors to prevent falls continues to be a challenge for clinicians and researchers.Prevention strategiesIn general, fall prevention interventions can be categorized into several broad categories: multidimensional fall risk assessment coupled with risk re- duction, exercise programs of various types, environmental assessment and modification, multifactorial interventions, and institutional interventions. Although the goal of preventing falls is common to each type of interven- tion, the approach taken by each is different.Multidimensional fall risk assessment and risk reductionThe objectives of the multidimensional fall risk assessment is to identify risk factors for future falls and to implement appropriate interventions to reduce fall risk. The multidimensional fall risk assessment can be compre- hensive or focused, depending on the target population. Comprehensive multidimensional fall risk assessment is most appropriate for high-risk indi- viduals (eg, those who have just fallen or have multiple risk factors for falls), whereas a focused assessment generally is more appropriate for individuals of average risk (eg, independent community-living elderly populations).Clinical guidelines [46] recommend that a comprehensive multidimen- sional fall risk assessment should include the following: a history of fall cir- cumstances and medical problems; review of medications; mobility assessment; an examination of vision, gait and balance, and lower extremity joint function; a basic neurologic examination, including muscle strength and mental status; and assessment of cardiovascular status. Other compo- nents of the fall risk assessment can include functional performance tests and an environmental assessment of the individual’s living location. Com- prehensive multidimensional fall risk assessment usually is performed in a clinical setting (eg, clinic, day hospital, nursing home), often by a multidis- ciplinary team. Following the assessment a detailed plan for therapy usually is developed and implemented.This model of multidimensional fall risk assessment and risk reduction has been used in successful fall prevention trials for older patients who did or did not have cognitive impairment who presented to an emergency department after a fall [48,49], and for residents of a long-term care facility who experienced a fall [50].Focused multidimensional fall risk assessment is used often to screen older populations to identify those who are appropriate for targeted inter- ventions (eg, exercise programs, assistive devices, comprehensive fall risk as- sessment). Typically, this model of risk assessment includes simple performance-based tests of gait, balance, mobility, or strength, such as the Timed Up-and-Go test [51], the Performance Oriented Mobility Index [52], and the one-leg standing balance test [53]. Evaluations of vision, cog- nition, orthostatic blood pressure, and a review of medications also are in- cluded often. Focused multidimensional fall risk assessment has been performed frequently by nurses or therapists in clinics and in the home.Exercise interventionsNumerous studies have shown that exercise can improve important fall risk factors, such as muscle weakness, poor balance, and gait impairment in healthy [54–56] and impaired older adults [57,58]. Consequently, exercise has become a widely studied fall prevention intervention. Different exercise models have been evaluated, including group [58–64] and individualized home programs [65–69], among healthy and impaired populations.Group exercise programs that are designed as fall prevention interven- tions typically are held two or three times per week for about an hour, and are supervised by a physical therapist or trained exercise instructor.
Most group programs have included a combination of exercises to improve flexibility, strength, and balance, and some level of aerobic conditioning. Progressive strength training generally focuses on lower and upper extremity large muscle groups, and may use body weight, ankle weights, elastic bands, or weight machines for resistance. Balance training often includes a range of static and dynamic exercises (eg, standing on one foot, tandem stand, ball games, movement to music) and functional activities (eg, reaching, bending, transferring). To improve aerobic conditioning, exercise programs have used whole body exercises, walking and stair climbing and stationary bicycles. Although performed in a group setting, exercises usually are individualized to the participant’s abilities.
Home exercise programs also are supervised by trained exercise profes- sionals, but participants perform the exercises alone in their homes. In most published studies, participants attended a series of group meetings to learn and practice the exercises, and then were instructed to perform the exercises at home [66–68]. In other studies, a physical therapist or nurse visited participants at home several times over the course of the intervention to provide instruction and motivation to perform the exercises [65,69]. In both models, the participant performed the exercises unsupervised and kept a diary. Home exercise programs typically include the same types of ex- ercises as do the group programs, only fewer and often at a lower intensity. Home exercise programs also incorporated a walking program frequently. Tai chi is another type of exercise that has been studied as a means of im- proving balance and reducing the risk for falling. Tai chi consists of a series of slow, rhythmic movements that require trunk rotation, dynamic weight shifting, and coordination between upper and lower extremity movements.
Tai chi has been studied as group [62–64] and home programs [67].

Environmental assessment and modification
Environmental assessment and modification is another promising fall prevention strategy, which is used as a means of identifying and removing potential hazards (eg, clutter, poor lighting, throw rugs) and for modifying the environment to improve mobility and safety (eg, installation of grab bars, raised toilet seats, lowered bed height). Several self-administered home safety checklists [70], which are designed for use by older people in their homes, assist in identifying important hazards and offer suggestions for improving safety. These checklists are most appropriate for use with av- erage risk and cognitively intact older adults. For higher-risk populations, several fall prevention interventions [71–73] have used trained professionals, such as nurses or occupational therapists, to perform home environmental assessments. An in-home assessment provides an opportunity for the health care professional to observe how an older person functions within the home, which may help to identify safety problems that may not be identified with a self-administered checklist or interview.

 

Reference Point No. 5

Department of Physical Therapy and Human Movement Sciences Northwestern University
Evanston, IL November 12, 2014

Abstract:

Gait Kinematics and Muscle Firing: Walking vs. Helix Recumbent Lateral Trainer

The purpose of this was study was to examine the relative benefits of two modalities used for cardiovascular training with respect to hip adduction, knee flexion, medial glute activation and hip flexion. Test subjects walked on a motorized commercial treadmill or used a Helix Recumbent Lateral Trainer HR3500.


Introduction:

The study was undertaken in order to better enable fitness participants to evaluate their choices regarding cardiovascular training, in particular with respect to improving lateral stability and reducing balance dysfunction and lateral falls. Falls result in approximately 9500 deaths in year in the United States alone1, with lateral falls accounting for the majority of hip fractures. 2

Hip Adduction
ng test subjects demonstrated 7.6 degrees at heel strike vs Helix Recumbent Lateral Trainer 0.0
(-.9/+.9)
Outcome: The Lateral Trainer does not cross mid-line.


Knee Flexion
Walking test subjects demonstrated 32.1 degrees’ load bearing, 64.2 degrees at 0 load with 0 muscle firing. Helix Lateral Trainer test subjects demonstrated 89.5-89-9 degrees with all four muscle quadrants firing through full cycle on lateral trainer.
Outcome: Lateral trainer offers a functional 90% knee flexion with muscles firing throughout that range.

Hip Abduction
Walking test subjects demonstrated 7.0 degrees with 0 muscle firing while walking. Helix Recumbent Lateral Trainer subjects demonstrated 25.4 degrees with all four-muscle quadrant firing.
Outcome: Medial Glute fires through the entire cycle on the lateral trainer.

Fig. 1 Glute Medial Activation seen on Walking Test Subjects

Fig. 2 Glute Medial Activation seen on Helix Lateral Recumbent Trainer Test Subjects

Hip Flexion

Walking test subjects demonstrated 22.6 degrees with muscles firing at heel strike. Helix Recumbent Lateral Trainer test subjects demonstrated 62.6 degrees with all four muscle quadrants firing through the full the concentric ROM.

Outcome: The Vastus Lateralis, Vastis Medialis, Glute Medial and Maximus all fire on the lateral trainer.

Balance Dysfunction, Lateral Stability, and Falls An impaired ability to control postural balance stability in the lateral plane of motion appears to be particularly relevant to the problem of falling among older people. Moreover, falls often involve lateral body motion, and hip fractures occur most frequently in association with lateral falls.

Summary: This unique movement effectively innervates the Glute Medial and quadriceps safely, which are critical for lateral stability and fall prevention. It is Closed Chain, Non- Concussive and Bi- Directional.

 

Reference Point No. 6

Lateral strength and stability are essential to proper biomechanics By Andy Baxter, MES, PRCS


Lateral strength and stability are essential to proper biomechanics for everyone, from the senior in functional decline to the elite athlete and everyone in between. The real world does not operate solely in a linear fashion, and even when it tries to it is dependent on lateral support!

People who cannot support their own body weight (full load bearing) on an upright machine will do one of two things; lean forward on to the machine and out of alignment or stop altogether. So they end up using the machine wrong, creating shear in the knee and deactivating the glutes, or not using it at all.

Bicycles, recumbent or upright, and recumbent steppers are antero/posto-linear movements that only recruit lateral musculature when “out of the saddle” on the upright bike. This is practically irrelevant as all of these other machines are not targeting the Spin Class crowd. This is important to note for the silver sneakers crowd, as the very machines that are designed to accommodate them aren’t directly addressing the system Directly affecting falls, fall prevention and the ability to walk with power and confidence – Lateral stability.

Treadmills and elliptical cross trainers account for many gym related injuries, mostly from falls getting on and off, but also from misuse and bad biomechanics.

Open chain, primary rotary “vanity “movements like the hip add/abduction machines are a serious black eye on the industry and have no place in a commercial gym, but they sell tickets cause women think
they will slim down their thighs. What they will do is place considerable torque on the small muscles and connective tissues of the hip joint as well as the joint itself, accelerating comorbidities of arthritis, bursitis and tendonitis. Rotary movements of that sort belong in PT with supervision, not at “insert big box gym here”.

The recumbent helix allows the user to work at any percentage of their body weight (partial load bearing) as their fitness dictates, all the while reinforcing proper alignment. It is a closed chain (foot is grounded) compound (displacing the load across two joint/muscle systems) movement that is also bidirectional for enhanced neuromuscular adaptation (neurogenesis). Because of these properties, this movement safely and effectively integrates the movement of the joint arthrokinematics (joint surface and connective tissue relationships) with the larger gross motor movement osteokinematics (large muscles of the leg and butt)

Of note, our study showed that ACL patients showed measurably greater medial glute firing, even while walking through the unloaded range of motion. The medial glute plays a significant role in gait integrity when the knee is unstable.

Additionally, lateral training is fun and dynamic and it keeps people’s interest. They feel a sense of accomplishment without being stressed and beat up, so adherence is high.

 

Reference point No. 7

Gait Kinematics and Muscle Firing Study.
Department of Physical Therapy and Human Movement Sciences, Northwestern University, 2014

Hip Abduction

Walking test subjects demonstrated 7.0 degrees with 0 muscle firing while walking. Helix Recumbent Lateral Trainer subjects demonstrated 25.4 degrees with all four-muscle quadrant firing.

Outcome: Medial Glute fires through the entire cycle on the lateral trainer.

Fig. 1 Glute Medial Activation seen on Walking Test Subjects

Fig. 2 Glute Medial Activation seen on Helix Lateral Recumbent Trainer Test Subjects

 

Reference point No. 8

What is the Gluteus Medius and Why is it so Important for my Running?

Injuries are common amongst runners, particularly as athletes increase speeds, distances or vary training programs

The Gluteus Medius is one of the most important, yet often forgotten muscles in preventing and rehabilitating running injuries both around the hip or further down the leg at the knee or ankle/foot. Adequate strength, activation and endurance of the Gluteus Medius muscle is required to allow optimization of biomechanics for walking, running and for reducing further injuries.

What Is The Gluteus Medius?

The Gluteus Medius is of three major gluteus muscles and originates on the outer surface of the ilium (pelvis) just below the iliac crest and converges as a large flattened tendon onto the lateral greater trochanter of the femur (thigh bone).

This allows the Gluteus Medius to act as a hip flexor and internal rotator (anterior) or a hip extender and external rotator (posterior) depending on what portion of the muscle is firing. When the whole muscle fires together it acts as well as a hip abductor (lifts the leg to the side) and pelvic stabilizer during weight bearing – especially running.

What Does That Mean For My Running?

In short, this means the Gluteus Medius helps to absorb ground reaction forces as the foot strikes the ground, stops an inward movement of the knee (adduction) and steadies the pelvis over the leg as you load the lower limb.

If this muscle is overloaded because it is weak or has been worked beyond its capacity, injury can occur within the Gluteus Medius muscle or it can allow load to be transmitted onto other structures, often due to a loss of good biomechanics.

Injuries Influenced By A Poorly Functioning or Overloaded Gluteus Medius

The injuries include, but are not limited to:

  • Gluteal Tendinopathy
  • Gluteal Muscle Strain or Tear
  • Patellofemoral Joint Pain Syndrome / Anterior Knee Pain
  • ITB Friction Syndrome
  • Achilles Tendinopathy
  • Hamstring Injuries
  • Hip and Knee Osteoarthritis
  • Piriformis Syndrome
  • Trochanteric Bursitis

Risk Factors for Gluteus Medius Overload

  • Female
  • Previous Injury to hip and its surrounding musculature
  • Sudden increase in training load – speed, distance, frequency
  • Change in running surfaces or running shoes
  • High impact sports or fast change of direction in sports
  • Repetitive loading in sports such as running
  • Poor static posture
  • Poor trunk and lumbar control

Rehabilitation and Prevention Exercises for Your Gluteus Medius Injury

Correct rehabilitation of your injury is essential for a successful return to sport with a minimal risk of re-injury.

Your physiotherapist will safely guide you through your rehabilitation program depending on the type and severity of injury, biomechanics, other preexisting injuries and the sport you participate in and will return back to.

Research shows that integration of trunk and lumbar stability exercises can further reduce loading onto and requirements of the Gluteus Medius. A progressive return to running and sport program will be developed as a part of your rehabilitation program.

If you have an injury it is crucial that you have a proper diagnosis and rehabilitation program from your physiotherapist but below you can find some exercises to help activate and strengthen your Gluteus Medius muscle and reduce your risk of future related running injuries.

Exercises & Videos to Help You Prevent Gluteus Medius Overload

I’d recommend the following exercises.

  1. Bridges with theraband
  2. Ball at the wall squat
  3. Crab walk (Video below)
  4. Monster walk
  5. References: Barton, C.J., Lack, S., Hemmings, S., Tufail, S. & Morrissey, D. (2015). The Best Practice Guide to Conservative Management of Patellofemoral Pain: incorporating level 1 evidence with expert clinical reasoning. British Journal of Sports Medicine, 49, 923- 934.
  6. Kim, D., Unger, J., Lanovaz, J. & Oates, A. (2016). The relationship of anticipatory gluteus medius activity to pelvic and knee stability in the transition to single-leg stance. American Academy of Physical Medicine and Rehabilitation, 8, 138-144.
  7. Semciw, A., Neate, R. & Pizzari, T. (2016). Running related gluteus medius function in health and injury: A systematic review with meta-analysis. Journal of Electromyography and Kinesiology, 30, 98-110.

 

References Point No. 9

Human Biomechanics and Physiology Laboratory Congdon School of Health
Highpoint University
High Point, North Carolina February 12, 2016
Comparative impact on Hip Flexion, Knee Rotation, and Hip Abduction-
Adduction
using Lateral Cardio Trainers James Smoliga, DVM, PhD

Abstract

The purpose of this study was to examine the relative impact on hip flexion, hip abduction/adduction and knee rotation using three commercially available lateral cardio trainers. The trainers used were the Octane Lateral X Elliptical, the Helix 3500 Lateral Trainer and the Helix Lateral Trainer 3-D.

Key Findings:

Calorie Expenditure: For a given perceived intensity, test subjects using the Helix Lateral Trainers burned 50-60 more calories per hour on average than test subjects using the Octane Lateral X Elliptical. This is notable given that heart rates and perceived intensity rates were the same.

Knee Flexion Range of Motion: The Knee flexion range of motion differed slightly on each machine, with the greatest range of motion seen on the Helix 3500, and the least on the Helix Lateral Trainer 3-D. Vertical range of motion tested similarly on all three machines.

Ankle Motion: Ankle dorsiflexion range of motion was greater on both the Helix 3500 Lateral Trainer and the Helix Lateral Trainer 3-D. The least amount of ankle dorsiflexion was observed on the Octane Lateral X Elliptical. Ankle eversion-inversion and rotation range of motion was greatest on the Helix Lateral Trainer 3-D.

Trunk Flexion: Test subjects using the Octane Lateral X Elliptical demonstrated the most trunk flexion/extension. The least amount of trunk bending was observed in the Helix Lateral Trainer 3-D.

Knee and Hip Abduction-Adduction: The Helix 3500 Lateral Trainer and the Octane Lateral X Elliptical demonstrated similar levels of knee and hip abduction/adduction. The Helix Lateral Trainer 3-D showed the least knee and hip abduction/adduction of the three pieces of equipment tested.

Hip Flexion/Extension: Hip flexion measurements were similar on all three machines evaluated.

Knee Rotation: The Helix 3500 Lateral Trainer produced the greatest knee rotation of the three machines, followed by the Octane Lateral X Elliptical and the Helix Lateral Trainer 3-D.

Conclusions:

Ease of use: Test subjects uniformly reported finding the motion of the Octane Lateral X Elliptical awkward in comparison to the motion of the Helix Lateral Trainers. Researchers posit that while the pelvis can be stabilized while using the Helix machines, it cannot with the Octane; instead, the Octane’s extremely wide foot platforms creates a large deviation from the center of the unit which discourages centering and forces side-to-side travel of the pelvis. Researchers further conjecture that this could be the reason that test subjects burned more calories using the Helix machines and fewer calories using the Octane machine despite working at the same perceived rate of exertion on each machine.

Bi-directionality: Researchers observed a great variety in degree of muscle activation and joint motion dependent upon which direction the machines were used by test subjects, noting that this was a significant benefit to all three of the machines with respect to versatility for the exerciser.

Joint function: Knee rotation is a key component to normal healthy joint function, but most rhythmic forms of cardio training (cycling, biking, rowing, etc.) do not provide much rotation. Each of the three machines in this study allowed for good knee rotation, with the Helix Lateral Trainer 3-D providing the best benefit.

Knee and hip abduction/adduction: The Helix Lateral Trainer 3-D demonstrated the least amount of abduction/adduction because its motion incorporates a forward and backward component that the other machines do not, thereby causing some of the ‘lateral load” to be dissipated to the front. The feet are still travelling cyclically, but the path is more three dimensional. As such, the knees are not bent to the side as much, and the hips are not forced apart to as a great a degree. Researchers believe that many users would find this motion more comfortable.

Author Information

James Smoliga, DMV, Ph.D.

Education:

2003 Cornell University, Doctor of Veterinary Medicine 2007 University of Pittsburgh, Ph.D., Sports Medicine

Career specialties:

James. Smogliam DVM, Ph.D. is the Associate Director of the High Point University Human Biomechanics and Physiology Laboratory. Prior to teaching in the DPT program, Dr. Smoglio taught undergraduate and graduate courses in human anatomy, physiology, animal physiology, exercise physiology and chronic disease. Additionally, he previously taught exercise physiology for primary care sports medicine fellows at Geisinger Medical Center in Danvil, PA. He is a peer reviewer for over 40 scientific journals.

Selected Publications :

  • Smoliga J.M., Weiss P., Rundell K.W. Exercise induced bronchoconstriction in adults: evidence-based diagnosis and management. BMJ (British Medical Journal). 352:h6951. PMID: 26762594.
  • Smoliga J.M., Mohseni Z.S., Berwager J.D., Hegedus E.J. Common causes of dyspnea in athletes – a practical approach for effective diagnosis and management. Breathe. 12(2):e22- 37. PMID: 27408644.
  • Smoliga J.M., Zavorsky G.S. “Tighter fit” theory – physiologists explain why “higher altitude” and jugular occlusion are unlikely to reduce risks for sports concussion and brain
  • injuries. Journal of Applied Physiology In Press. PMID: 27609202
  • Zavorsky G.S., Smoliga J.M., Risk of concussion for players in contact sports at “high” altitude vs. sea level. JAMA Neurology. In press. PMID: 27598557
  • Farina K.A., Wright A.A., Ford K.R., Wirfel L.A., Smoliga J.M. Physiological and biomechanical responses to running on a lower body positive pressure treadmill. Sports Medicine. In Press. PMID: 27380101.
  • Wright A.A., Taylor J.B., Ford K.R., Siska L., Smoliga J.M. Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis. British Journal of Sports Medicine. 49(23): 1517-1523, 2015. PMID: 26582192
  • Wright A.A., Hegedus E.J., Lenchik L., Kuhn K.J., Santiago L., Smoliga J.M. Diagnostic accuracy of various imaging modalities for suspected lower extremity stress fractures: a systematic review with evidence-based recommendations for clinical practice. American Journal of Sports Medicine. 44(1): 255-263, 2016. PMID: 25805712
  • Smoliga J.M., Wirfel L.A., Paul D., Doarnberger M., Ford K.R. In-shoe loading during unweighted running on a lower body positive pressure treadmill. Journal of Biomechanics, 48(10): 1950-1956, 2015. PMID: 25931271
  • Selected Resveratrol and Translational Medicine Publications:
  • Hausenblas H.A., Schoulda J.A., Smoliga J.M. Resveratrol treatment as an adjunct to pharmacological management in Type 2 diabetes mellitus – systematic review and meta- analysis. Molecular Nutrition and Food Research. 59(1), 2015. PMID: 25138371 Blanchard O.L. and Smoliga J.M. Translating dosages from animal models to human clinical

 

Reference Point No. 10

The Human Performance Research Lab The University of Tampa
Tampa, FL April 26, 2011

Comparative Heart Rate Reserve Attainment and Skeletal Muscle Activation: Helix Lateral Trainer vs. Precor EFX Elliptical Rider
Jacob M. Wilson, Ph.D., Lead Researcher

Abstract

The purpose of this study was to examine the effects of two competing cardiovascular training machines, the Helix Lateral Trainer and the Precor EFX Elliptical Rider, on heart rate attainment and skeletal muscle activation during comparable aerobic activity.

Introduction

Cardiovascular training, also known as aerobic or endurance exercise, is physical activity which increases the participant’s breathing and heart rate. Researcher Darren Warburton states that there is “irrefutable evidence of the effectiveness of regular physical activity in the primary and secondary prevention of several chronic diseases”1. Health benefits of cardiovascular training include, but are not limited to, weight regulation, the improvement of cardiovascular health, the lowering of blood pressure, the regulation of blood sugar, and the strengthening of the immune system2. Established guidelines, first released by the United State Surgeon General in 2008, recommend 150 minutes of cardiovascular activity per week for adults3. While jogging, walking and swimming are traditional examples of aerobic activity, cardiovascular training machines are popular alternatives in public gymnasiums and institutional settings as well as in private homes. Between 2006 and 2013, between 24.51 and 26.69 million Americans participated in some form of home gym exercise4 (e.g. see fig. 1).

Fig. 1. Americans 6 and up who participate in some form of home gym exercise (millions)

The study was undertaken to add to better enable fitness participants to make informed choices regarding their cardiovascular training. Although the recommendations are well-defined and the health benefits undeniable, many Americans cite lack of time as the primary reason for a failure to adhere to weekly cardiovascular activity guidelines. There are many cardiovascular modalities available to Americans, but with limited time for such training, it is desirable for participants to understand the relative effectiveness of the most popular cardiovascular trainers in order to maximize their results and realize optimal health benefits from their training.

Heart Rate Attainment

The heart rate level component of the study examined the time it took testing subjects to attain a steady heart rate reserve (HRR) of 65% of maximum. The maximum rate was calculated by subtracting the subject’s age from 220, with the corresponding figure equivalent to the maximum number of times per minute that the subject’s heart should beat during sustained cardiovascular training.

Muscles Monitored

Eight separate muscles and muscle groupings were monitored, including: the Vastus lateralis, Adductors, Gluteus maximus, Gluteus medius, Spinal erectors, Rectus abdominals, Hamstrings, and Obliques. Muscle activation was measured with a Delsys® fully wireless, trigon-electromyography system.

Goals, Methods and Materials

The primary objectives were to examine skeletal muscle activation of the outer thighs (vastus lateralis), inner thighs (adductors), gluteus maximus, gluteus medius, spinal erectors, rectus abdominals, and oblique muscles while test subjects performed cardiovascular activity at a level needed to obtain 65 % of the subject’s heart rate reserve. An HRR 65% of maximum corresponds to the rate at which exercisers expend the greatest number of fat calories relative to training intensity.

The equipment tested included the Helix 3000 Lateral Trainer by Helix (see Fig. 2) and the EFX Elliptical Rider by Precor. See Fig. 3.

Fig. 2. The Helix Lateral Trainer

Fig. 3 EFX Elliptical Rider by Precor

Fifteen subjects with a mean age of 20 years, and a mean body fat of 9% participated in the study. Prior to the experiment, subjects were familiarized with both machines, including watching instructional videos. After familiarization, subjects were then asked to randomly participate in five separate conditions on five separate occasions. Conditions one and two consisted of riding the elliptical or the Helix in a neutral position and then at maximal incline or the squat position in order to fully engage gluteal muscles.

In conditions three to five, subjects were asked to ride the Helix using the leg pump motion as defined by the manufacturer’s instructional video, starting with the motion with the right leg clockwise (emphasizing an outer thigh motion), or the left leg in a counter clockwise motion (emphasizing an inner thigh motion). Subjects then were asked to adopt the squatting motion defined by the manufacturer’s instructional video.

Targeted Heart Rate Reserve Results

Test subjects using the Helix Lateral Trainer were able to achieve designated HRR at a rate of 23% faster than test subjects using the elliptical.

Skeletal Muscle Activation Results

Test subjects using the Helix Lateral Trainer in what the manufacturer termed the ‘neutral’ position demonstrated increased muscle activity in five muscle groups as compared to test subjects using the Elliptical in a neutral position. See Table 1.

Table 1: Percentage of increased muscle activity: Elliptical vs Helix (neutral)


INSERT TABLE

Test subjects using the Elliptical in a neutral position demonstrated increased muscle activity in one muscle group as compared to test subjects using the Helix in a neutral position. See Table 2.

Table 2: Percentage of increased muscle activity: Elliptical vs. Helix (Neutral)

Test subjects using the Helix Lateral Trainer in what the manufacturer termed the ‘squat’ position demonstrated increased muscle activity in two muscle groups as compared to test subjects using the Elliptical in the fully inclined position, see Table 3.

Table 3: Percentage of increased muscle activity: Elliptical vs. Helix (squat)

Summary, Heart Rate Reserve Attainment

The study set out to measure the comparative cardiovascular benefit between two widely available cardiovascular trainers, focusing on the time research subjects took to achieve a target steady heart rate reserve (HRR) of 65%. Results found that the Helix Lateral Trainer users achieved an HRR of 65%, a full 23% faster than elliptical users, translating to more time spent expending fat calories in equivalently timed workouts.

Summary Muscle Activation Results:

Researchers also studied the comparative effectiveness on muscle activation during exertion for two widely available cardiovascular trainers.

Test subjects used the Elliptical Rider in a neutral position and the Helix Lateral Trainer in a neutral position. Researchers found that the Helix Lateral Trainer had superior results in 7 of 8 muscles tested. The Helix Lateral Trainer test subjects demonstrated greater electrical activity (a marker indicating muscle involvement) as follows: vastus lateralis 50% greater (see Table 4), the obliques 55% greater (see Table 5), and adductors 37% greater (see Table 6) compared to the Elliptical. Additional increased muscle activity was seen in the Helix Lateral Trainer test subjects for the spinal erectors (see Table 7), and the abdominals (see Table 8).

Table 4: Vastus Lateralis: Helix Lateral Trainer vs. Elliptical neutral

Table 5: Obliques: Helix Lateral Trainer vs. Elliptical neutral

Table 6: Adductors: Helix Lateral Trainer vs. Elliptical neutral

Table 7: Spinal Erectors: Helix Lateral Trainer vs. Elliptical neutral

Table 8: Spinal Erectors: Helix Lateral Trainer vs. Elliptical neutral

When comparing the Helix Lateral Trainer in a squatting position with the Elliptical Rider at a full incline, researchers noted 39% more activity in the gluteus maximus and 33% in the gluteus medeus with the Helix Lateral Trainer. See Table 9.

Table 9: Gluteus: Helix Lateral Trainer vs. Elliptical squat/full incline

Muscle activation in the Elliptical test subjects was found to be greater in the hamstrings than in the Helix Lateral Trainer when both machines were used in a neutral position. See Table 10.

Table 10. Hamstring: Helix Lateral Trainer vs. Elliptical neutral position

Conclusions:

The purpose of the study was to analyze the relative benefits of exercising on two widely available cardiovacular trainers. The Helix Lateral Trainer outperformed the Elliptical in nearly all tested categories and conditions. A notable benefit to the Helix Lateral Trainer was the test subjects’ speedier attainment of targeted ‘fat burning’ heartrates. It can be conferred that users who achieve targeted heart rates earlier will expend more calories during their workout activity, thus aiding in weight maintenance and control.

The Helix Lateral Trainer test subjects demonstrated markedly increased muscle activation in seven of the eight muscles tested in the study. Increased muscle activation confers beneficial results to exercisers via increased calorie burn and its subsequent aid in weight loss and maintenance. Additionally, regular use of cardiovascular trainers that better target and strengthen muscles can lead to desired benefits such as boosted metabolism and injury prevention. For example, the 33% increased activity in the Gluteus Medeus seen in test subjects using the Helix Lateral Trainer would, over time, serve to strengthen muscular support system for the knee and hip joints.

Researchers concluded that cardiovascular training on the Helix Lateral Trainer was more beneficial than cardiovascular training on the Precor EFX Elliptical Rider.

 

Reference Point No. 11

Gait Kinematics and Muscle Firing Study.
Department of Physical Therapy and Human Movement Sciences, Northwestern University, 2014

Hip Abduction

Walking test subjects demonstrated 7.0 degrees with 0 muscle firing while walking. Helix Recumbent Lateral Trainer subjects demonstrated 25.4 degrees with all four-muscle quadrant firing.

Outcome: Medial Glute fires through the entire cycle on the lateral trainer.

Fig. 1 Glute Medial Activation seen on Walking Test Subjects

Fig. 2 Glute Medial Activation seen on Helix Lateral Recumbent Trainer Test Subjects

 

Reference Point No. 12

ORIGINAL RESEARCH
COMPARISON OF TRUNK AND LOWER EXTREMITY MUSCLE ACTIVITY AMONG FOUR STATIONARY EQUIPMENT DEVICES: UPRIGHT BIKE, RECUMBENT
BIKE, TREADMILL, AND ELLIPTIGO®
Lucinda Bouillon, PT, PhD1 Ryan Baker, PTA, SPT1 Chris Gibson, PTA, SPT1 Andrew Kearney, PTA, SPT1
Tommy Busemeyer, PTA, SPT1

ABSTRACT

Background: Stationary equipment devices are often used to improve fitness. The ElliptiGO® was recently developed that blends the elements of an elliptical trainer and bicycle, allowing reciprocal lower limb pedaling in an upright position. However, it is unknown whether the muscle activity used for the ElliptiGO® is similar to walking or cycling. To date, there is no information com- paring muscle activity for exercise on the treadmill, stationary upright and recumbent bikes, and the ElliptiGO®.

Purpose/Hypothesis: The purpose of this study was to assess trunk and lower extremity muscle activity among treadmill walking, cycling (recumbent and upright) and the ElliptiGO® cycling. It was hypothesized that the ElliptiGO® and treadmill would elicit similar electromyographic muscle activity responses compared to the stationary bike and recumbent bike during an exercise session.

Study Design: Cohort, repeated measures

Methods: Twelve recreationally active volunteers participated in the study and were assigned a random order of exercise for each of the four devices (ElliptiGO®, stationary upright cycle ergometer, recumbent ergometer, and a treadmill). Two-dimensional video was used to monitor the start and stop of exercise and surface electromyography (SEMG) were used to assess muscle activity during two minutes of cycling or treadmill walking at 40-50% heart rate reserve (HRR). Eight muscles on the dominant limb were used for analysis: gluteus maxi- mus (Gmax), gluteus medius (Gmed), biceps femoris (BF), lateral head of the gastrocnemius (LG), tibialis anterior (TA), rectus femoris (RF). Two trunk muscles were assessed on the same side; lumbar erector spinae at L3-4 level (LES) and rectus abdominus (RA). Maximal voluntary isometric contractions (MVIC) were determined for each muscle and SEMG data were expressed as %MVIC in order to normal- ize outputs.

Results: The %MVIC for RF during ElliptiGO® cycling was higher than recumbent cycling. The LG muscle activity was highest during upright cycling. The TA was higher during walking compared to recumbent cycling and ElliptiGO® cycling. No differences were found among the the LES and remaining lower limb musculature across devices.

Conclusion: ElliptiGO® cycling was found to elicit sufficient muscle activity to provide a strengthening stimulus for the RF muscle. The LES, RA, Gmax, Gmed, and BF activity were similar across all devices and ranged from low to moderate strength levels of muscle activation. The information gained from this study may assist clinicians in developing low to moderate strengthening exercise protocols when using these four devices.

Level of evidence: 3

Keywords: Cycling, electromyography, elliptical, ergometers, lower extremity, muscle activity, treadmill

 

Reference Point No. 13

Comparative Heart Rate Reserve Attainment and Skeletal Muscle Activation
The Human Performance Lab, The University of Tampa, 2011

Fifteen subjects with a mean age of 20 years, and a mean body fat of 9% participated in the study. Prior to the experiment, subjects were familiarized with both machines, including watching instructional videos. After familiarization, subjects were then asked to randomly participate in five separate conditions on five separate occasions. Conditions one and two consisted of riding the elliptical or the Helix in a neutral position and then at maximal incline or the squat position in order to fully engage gluteal muscles.

In conditions three to five, subjects were asked to ride the Helix using the leg pump motion as defined by the manufacturer’s instructional video, starting with the motion with the right leg clockwise (emphasizing an outer thigh motion), or the left leg in a counter clockwise motion (emphasizing an inner thigh motion). Subjects then were asked to adopt the squatting motion defined by the manufacturer’s instructional video.

Targeted Heart Rate Reserve Results

Test subjects using the Helix Lateral Trainer were able to achieve designated HRR at a rate of 23% faster than test subjects using the elliptical.

Skeletal Muscle Activation Results

Test subjects using the Helix Lateral Trainer in what the manufacturer termed the ‘neutral’ position demonstrated increased muscle activity in five muscle groups as compared to test subjects using the Elliptical in a neutral position. See Table 1.

Table 10, Hamstring: Helix Lateral Trainer vs. Elliptical neutral position

Conclusions:

The purpose of the study was to analyze the relative benefits of exercising on two widely available cardiovacular trainers. The Helix Lateral Trainer outperformed the Elliptical in nearly all tested categories and conditions. A notable benefit to the Helix Lateral Trainer was the test subjects’ speedier attainment of targeted ‘fat burning’ heartrates. It can be conferred that users who achieve targeted heart rates earlier will expend more calories during their workout activity, thus aiding in weight maintenance and control.

The Helix Lateral Trainer test subjects demonstrated markedly increased muscle activation in seven of the eight muscles tested in the study. Increased muscle activation confers 

Reference Point No. 14

A study to evaluate cardiovascular responses by using treadmill and ergometer bicycle exercise in young adults.
Alok Kumar Yadav, Jayasheela. G. Bagi

Abstract:
BACKGROUND AND OBJECTIVE: Exercise is inevitable to keep good health status, advised for health promotion, diagnosis of diseases, and rehabilitation. Different types of exercise are performed as exercise tolerance, but tolerance is not same for every individual. Thus, the objective of this study is to evaluate the cardiovascular responses for three different intensities of exercise using treadmill and bicycle ergometer at fixed heart rate (HR) value in young healthy adults.

METHODS: After obtaining the ethical clearance from the Institutional Ethical Committee, a total of 130 participants were screened and 48 randomly selected male and female individuals with age group of 18-24 years and with normal body mass index. Selected participants are divided into three groups according to HR using WHO classification and Karvonen formula of exercise intensity. Sixteen individuals in each group start exercising for treadmill exercise at 3, 6, and 7.5 k/h, respectively, with zero inclination and for ergometer bicycle exercise at pedal frequency 50-60, 70-80, and 90-100 rpm, respectively, with 0 kg breaking resistance until calculated target HR is achieved. Cardiovascular parameters such as (systolic blood pressure [SBP], diastolic blood pressure [DBP], and rate pressure product [RPP]) pre- and post-exercise were recorded, and data are subjected to statistical analysis in both modes of exercise.

RESULTS: SBP and RPP are linearly increased with increasing intensity of exercise and more observed in ergometer bicycling than treadmill exercise. Postexercise mean DBP among the three intensities of exercise: in mild exercise, there was negligible change in case of treadmill exercise and a higher mean DBP was recorded in case of ergometer bicycle exercise; in moderate exercise, value was slightly lower in treadmill exercise and slightly higher in ergometer bicycle exercise, but in severe exercise, mean DBP decreased in both treadmill as well as in ergometer bicycle exercise.

CONCLUSION: Each mode of exercise has its own advantage and disadvantage depends on individual's physical condition and requirement.

 

Reference Point No. 15

The Recumbent Lateral Trainer:
Why it provides superior benefits to hip and knee structures across the spectrum of hip performance outcomes

By Andy Baxter, MES PRCS 8/11/1

In evaluating the full spectrum of hip performance outcomes, let us first identify the outermost extremes of that spectrum. At one end of the spectrum we have mediolateral protective stepping performance, hip abduction torque, and trunk mobility as it relates to fall prediction and prevention in the frail and elderly. At the other end of that spectrum we can measure overall joint structure stability and performance as it relates to torque and power (eccentric/amortization/concentric) in the elite athlete.

Addressing these outcomes, and all that lie between them, will almost invariably require a study of the specific musculature known as the hip abductors – Glute Medius, Glute Minimus and Tensor Fascia Latae (TFL). Secondary and tertiary effects of tight and/or weak hip abductors are malalignment of the knee and low back as they relate to the Iliotibial Band (ITB) origin and insertion.

There currently exist many exercises that attempt to address tight and/or weak hip abductors. Shortcomings of the current skew are myriad; side planks are isometric, side leg raises and clam shells are open chain and/or single joint/single plane, etc.

Additionally, these movements focus on an osteo-kinematic movement with little real world, functional application. While they serve the purpose of innervation to the point of increasing joint stability, they don’t go to the next level of functional performance.

Real world, functional osteo and arthrokinematics involve movement in multiple planes involving flexion/extension, abduction/adduction, internal/external rotation and compound multi joint integration.

The question then becomes, how do we safely and effectively train the mediolateral structures of the hip and knee for real world, functionally applicable outcomes? The recumbent lateral trainer modality provides a comprehensive solution on many fronts:

- It accommodates training for all abilities at sub body weight
- It features bidirectional abduction/adduction for reciprocal muscle group balance
- It is a closed kinetic chain exercise (stabilized foot) and a compound exercise with flexion/extension at the ankle, knee, and hip
- Natural, multiplane kinematics integrating flexion/extension, abduction/adduction and internal/external rotation of the acetabulofemoral joint
- Provides superior med/min glute and TFL innervation and torque moment for improved hip and knee alignment
- It is non-concussive so as not to exacerbate IT Band Syndrome (ITBS)
- Improved eccentric deceleration and dynamic stabilization of the hip structure

 

Reference Point No. 16

Gluteus Minimus and Gluteus Medius Muscle Activity during Common Rehabilitation Exercises in Healthy Postmenopausal Women

Published Journal of Orthopaedic & Sports Physical Therapy, 2017, Volume:47 Issue:12 Pages: 914-922 doi: 10.2519/jospt.2017.7229

Study Design
Controlled laboratory study, cross-sectional.

Background
The gluteus medius (GMed) and gluteus minimus (GMin) provide dynamic stability of the hip joint and pelvis. These muscles are susceptible to atrophy and injury in individuals during menopause, aging, and disease. Numerous studies have reported on the ability of exercises to elicit high levels of GMed activity; however, few studies have differentiated between the portions of the GMed, and none have examined the GMin.

Objectives
To quantity and rank the level of muscle activity of the 2 segments of the GMin (anterior and posterior fibers) and 3 segments of the GMed (anterior, middle, and posterior fibers) during 4 isometric and 3 dynamic exercises in a group of healthy, postmenopausal women.

Methods
Intramuscular electrodes were inserted into each segment of the GMed and GMin in 10 healthy, Postmenopausal women, Participants completed 7 gluteal rehabilitation exercises, and average normalized muscle activity was used to rank the exercises from highest to lowest.

Results
The isometric standing hip hitch with contralateral hip swing was the highest-ranked exercise for all muscle segments except the anterior GMin, where it was ranked second. The highest-ranked dynamic exercise for all muscle segments was the dip test.

Conclusion
The hip hitch and its variations maximally activate the GMed and GMin muscle segments, and may be useful in hip muscle rehabilitation in postmenopausal women. J Orthop Sports Phys Ther 2017;47(12):914-922. Epub 15 Oct 2017. doi:10.2519/jospt.2017.7229

 

Reference Point No. 17

Functional exercise after total hip replacement (FEATHER) a randomised control trial
1* 2 3 4 Brenda Monaghan , Tim Grant , Wayne Hing and Tara Cusack

Abstract

Background: Prolonged physical impairments in range of movement, postural stability and walking speed are commonly reported following total hip replacement (THR). It is unclear from the current body of evidence what kind of exercises should be performed to maximize patient function and quality of life.

Methods/design: This will be a single blind multi centre randomized control trial with two arms. Seventy subjects post primary total hip arthroplasty will be randomized into either an experimental group (n=35), or to a control group (n=35). The experimental group will attend a functional exercise class twice weekly for a six week period from week 12 to week 18 post surgery. The functional exercise group will follow a circuit based functional exercise class supervised by a chartered Physiotherapist. The control group will receive usual care. The principal investigator (BM) will perform blinded outcome assessments on all patients using validated measures for pain, stiffness, and function using the Western Ontario and Mc Master Universities Osteoarthritis index (WOMAC). This is the primary outcome measurement tool. Secondary outcome measurements include Quality of life (SF-36), 6 min walk test, Visual Analogue Scale, and the Berg Balance score. The WOMAC score will be collated on day five post surgery and repeated at week twelve and week eighteen. All other measurements will be taken at week 12 and repeated at week eighteen. In addition a blinded radiologist will measure gluteus medius cross sectional area using real time ultrasound for all subjects at week 12 and at week 18 to determine if the functional exercise programme has any effect on muscle size.

Discussion: This randomised controlled trial will add to the body of evidence on the relationship between muscle size, functional ability, balance, quality of life and time post surgery in patients following total hip arthroplasty. The CONSORT guidelines will be followed to throughout. Ethical approval has been gained from the Ethics committee Health Services Executive Dublin North East.

Trial registration: This trial is registered with ClinicalTrials.gov (a service of the United States National Institutes of Health) identifier NCT01683201

Keywords: Total hip replacement, Late stage exercise, Functional exercise, Physiotherapy Background
Total hip replacement (THR) is a very common surgical procedure carried out worldwide. Approximately 24,253 THR surgical procedures were performed in Canada in 2008/09 [1] with almost one million hip and knee repla- cements undertaken in the U.S in the same time-frame. [2] In England and Wales 53,462 hip replacements were undertaken in 2009 including both primary and revision

* Correspondence: Brenda.monaghan@hse.ie
Full list of author information is available at the end of the article 
joint procedures [3]. These figures have been projected to grow with the aging population and with the increased prevalence of arthritis in the elderly [4]. Improvements in prosthetic design and higher commu- nity expectations for quality of life have made THR more appropriate for both older and younger age groups resulting in an increased population and healthcare de- mand for surgery [5].

In recent years the shift towards reductions in the length of stay for patients following THR has caused a subsequent shift in rehabilitation services from ’in hos- pital’ to out patients [6]. Within the outpatient setting

© 2012 Monaghan et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Monaghan et al. BMC Musculoskeletal Disorders 2012, 13:237 http://www.biomedcentral.com/1471-2474/13/237

However a number of authors have reported functional limitations for patients post surgery. Pain, physical im- pairment, reduced range of motion and reduced muscle strength persisting for one year have been documented in subjects who had also received early stage physiother- apy [7]. It is currently unclear from the literature which therapeutic exercises performed over what period of time are either effective or necessary to improve muscle strength or ensure optimal return of patient function. Anecdotally therapeutic exercise programmes appear to be largely based on clinical experience and surgeon pre- ference [8]. Some evidence [9] has demonstrated that an eight week exercise programme with an emphasis on strengthening and stability resulted in a statistically sig- nificant improvement in all measurements of self per- ceived function and muscle strength in patients between four and twelve months post THR. It has been suggested in this study that patients should continue their func- tional strengthening exercise programme for at least one year and that this programme should be further pro- gressed as their function improved.

Another study [10] compared differences in the iso- metric hip strength of patients five months after THR with older adults without hip surgery and demonstrated lower peak torque in the hip flexors of the hip surgery group. Specific rehabilitation programmes are needed to address these strength deficits at this phase post surgery although few studies to date have evaluated this subject.

The gluteus medius muscle is critical to the provision of abduction force across the hip and the strength of the muscle is specifically relevant to the provision of stability in the hip joint [11]. Post operative function is deter- mined by regaining the optimal strength in this muscle and many rehabilitation programmes include strength- ening of gluteus medius. The strength of this muscle provides lateral stability to the trunk and pelvis and is essential during one legged stance and also during the stance phase of gait [12]. However there is a paucity of evidence in the literature examining specific changes in this muscle despite anecdotal evidence that reduced strength in this muscle is responsible for gait impair- ment and reduced balance [13].

Recognizing the difficulties in measuring rehabilitation of glutei dysfunction it has been suggested that future studies on the glutei muscles should evaluate each muscle in functional activities preferably using multiple parameters for example evaluation of muscle size to- gether with functional assessment [14]. Recently real time ultrasound imaging has been utilized as an accurate and reliable means of measuring muscle parameters in a non invasive manner [15,16]. Ultrasound imaging is a fast and inexpensive tool that produces excellent images of the musculoskeletal system without the need for radiation [17].

The primary aim of this research project is to evaluate the efficacy of a specific functional exercise programme to improve pain stiffness and physical function in patients between 12 and 18 weeks post THR when com- pared with a group following usual care. In addition this project aims to measure the effect of a functional exer- cise programme on the secondary outcomes of quality of life, balance, function and muscle size. Muscle size mea- sured by real-time ultrasound was selected as an add- itional secondary outcome in order to examine specific changes in the gluteus medius muscle.

In preparing this protocol a full systematic review and meta-analysis of previous work has been completed. This review found there was low grade evidence that late stage rehabilitation demonstrated significant improvement in gait speed indicating improved walking ability in patients post total hip arthroplasty and there was limited low grade evidence for improved hip abduction strength in patients following a programme which included low resistance strength training. However the full extent of the impact of late stage rehabilitation in patients post total hip arthro- plasty has not yet been established. These issues were considered in designing this randomized controlled trial.

Other preparatory work to prepare this protocol included preliminary clinical patient evaluation in a sin- gle elective orthopedic centre. A telephone questionnaire of 120 patients in 2009 at 12 weeks post surgery demon- strated approx 30 % of patients contacted reported per- sistent limping and gait abnormalities at 12 weeks. These patients were not previously referred to Physio- therapy. A second telephone survey evaluated ten cen- ters nationally which carry out elective hip arthroplasty and demonstrated a wide diversity of rehabilitation offered across the country and a paucity of evidence based practice guidelines for this client group.

The primary aim of this research project is to evaluate the efficacy of a specific functional exercise programme to improve pain, stiffness and physical function in patients between 12 and 18 weeks post total hip replace- ment when compared with a group following usual care. In addition this project aims to measure the effect of a functional exercise programme on the secondary out- comes of quality of life, balance, function and muscle size. Muscle size measured by Real time ultrasound was selected as an additional secondary outcome measuring specific changes in the gluteus medius muscle. There is a paucity of evidence in the literature examining specific changes in this specific muscle despite anecdotal evi- dence that reduced strength in this muscle is responsible for gait impairment and reduced balance.

Primaryhypotheses

A six week functional exercise programme from week 12 to week 18 in patients post total hip replacement will be more efficacious in improving pain, stiffness and func- tion than the usual care programme.

Monaghan et al. BMC Musculoskeletal Disorders 2012, 13:237 http://www.biomedcentral.com/1471-2474/13/237

Secondary hypotheses

A six week functional exercise programme from week 12 to week 18 in patients post total hip replacement will be more efficacious in improving balance, gait speed, qual- ity of life and muscle size than the usual care programme.

Methods/design

Trial design

This will be an assessor blinded two arm randomized controlled trial of a six week involving twelve func- tional exercise class interventions. Measurements will be taken at day five, week twelve and week eighteen for all subjects. Assessment of adherence to the treatment programme will be assessed with examination of exercise logs completed by clients at each attendance and signed off by the supervising therapist. The classes will be con- ducted at three sites, Navan, Cavan and Monaghan. The protocol will conform to CONSORT guidelines for reporting non- pharmalogical interventions and has been registered with clinical trials.gov prior to study commencement.

Participants

We will recruit participants at pre-assessment for pri- mary total hip replacement at Our Lady’s hospital, Navan which is the elective joint replacement for the Louth/ Meath and Cavan/Monaghan areas. To be eligible the following inclusion and exclusion criteria must be met.

Inclusion criteria

Patients 12 weeks post primary unilateral anterior approach THA for osteoarthritis. Age 50 years and above.

Able to read and understand instructions in English. Willing to attend classes twice weekly for 6 weeks Able to participate in an exercise programme without physical assistance.

Mobilizing independently 15m without crutches and/ or stick and passed by the referring Orthopaedic consult- ant as suitable for inclusion in the study at the routine six week post surgery appointment.

Exclusion criteria

Medically unstable.
Have central or peripheral nervous system deficits. Any underlying terminal disease. Suspicion of infection following joint replacement.

Procedure

Preliminary screening will be carried out at the pre- assessment clinic by the principal investigator (BM). Fol- lowing a standard interview process patients will be given a written description of the study and information with regard to the exercise class commitment involved. A screening record will be kept to document criteria eliminating those deemed to be ineligible. All patients will all be assessed using the WOMAC questionnaire on day 5 prior to discharge and they will be randomized to one of two treatment groups. The functional exercise intervention begins at week 12 and all patients will complete the Primary and Secondary outcome assess- ments at this point. All assessments are repeated for both groups at week 18. Patients allocated to the func- tional exercise class will attend a six week functional ex- ercise programme twice weekly from week 12 to week 18. The control group will receive the standard usual post surgery care as outlined in the patients’ information booklet given to all patients on admission. This care is given to all patients post surgery by the Physiotherapist working on the ward. This study is one comparing usual treatment with an intervention of functional exercise. All patients randomised to the usual care group will be offered the chance to attend the exercise group at week 18 post evaluation.

Ethical considerations

This study obtained ethical approval from the HSE Re- search Ethics Committee Dublin North East Area in De- cember 2011 for the clinical sites at Our Lady’s Hospital, Navan, Cavan General Hospital and Monaghan General Hospital.

Blinding

Both outcome assessors will be blind to group allocation and will not be involved in the interventions nor will they attend any of the functional exercise classes. The physiotherapists supervising the functional exercise classes are not blinded. The statistician will be blinded to group allocation prior to completion of the statistical analysis.

Randomisation and allocation concealment

Monaghan et al. BMC Musculoskeletal Disorders 2012, 13:237 http://www.biomedcentral.com/1471-2474/13/237

Following a standard interview at the pre assessment clinic, Patients will be given a written description of the study and information with regard to the exercise class commitment involved. They will also be given stamped addressed envelopes to post back written consent. Fol- lowing obtainment of written consent random allocation using sequentially numbered envelopes to both groups will be carried out by a third party Lara Bourton Cassidy (LBC) who is not involved in the study. The number se- quence will be generated using a computer generated random number table generated by Dr Tim Grant and communicated directly to LBC. Subjects will be ran- domly allocated either to a functional exercise class from week 12 post op to week 18 or to a control group receiv- ing usual post operative care. Allocation of patients to the treating therapists will be established by e mail con- tact from LBC to the Physiotherapist’s responsible for conducting the classes. These therapists have been iden- tified previously. Patients will be asked not to discuss their group allocation and all blinded outcome assess- ment examinations will take place in Our Lady’s Hos- pital, Navan.

Physiotherapists

Three experienced physiotherapists one at each site will be trained to supervise the functional exercise classes. Training will comprise a one hour practical workshop and all physiotherapists will be provided with a written illustrated manual of the training workshop.

Exercise interventions

This functional exercise class is designed to strengthen the hip muscles and incorporates exercises commonly used in clinical practice. It is based on previous work that shows that such an exercise programme improves pain and function [18]. Twelve exercises aimed to strengthen the quadriceps, hamstrings, and hip abductor muscles and improve functional balance will be taught to participants by the Physiotherapist. See Table 1. At the end of the exercise session the physiotherapist will monitor proper form and exercise intensity and will pro- gress the exercises as necessary. Each Physiotherapy ses- sion will be 30 minutes in length. Intensity will be determined by the participant’s ability to complete 10 repetitions for a given exercise.

Table 1 Functional Hip Exercise circuit

Follow-up period

The duration of this research project is eighteen weeks from the date of surgery. All patients will complete the WOMAC questionnaire on discharge from hospital at day 5 and all outcome measure- ments will be repeated at week 12 and again at week 18. The outcome measurement assessments at week 12 and at week 18 will take place in Our Lady’s Hospital in Navan.

Measurements

Baseline descriptive data will be obtained by question- naire and will include age, sex, weight, height, medica- tion use and previous health problems. A summary of all measurements is included in Table 2

Primary outcome measurements

Western Ontario and Mc master universities osteoarthritis index (WOMAC) likert version 3.1

This is a multidimensional, self administered disease specific standardized instrument which is proven to be reliable and valid within this client group [19]. The out- comes will be completed during face to face contact with the assessor (BM) in the Physiotherapy department prior to hospital discharge on day five and repeated at week 12 and week 20. The questionnaire consists of 24 ques- tions regarding pain (scored 0–20) stiffness (scored 0–8) and physical function (scored 0–68). For each division a score is calculated the range of scores is from 0–98 with higher scores indicating a lower health status. Minimal perceptible clinical improvement on the WOMAC ques- tionnaire has been established in the literature at −10.4 with the standard deviation of scores on the instrument at 13.6 [20].

Exercise

  • Sit to stand
  • Toe raises
  • Knee raises
  • Side and back leg raises Partial knee bends Single knee bends
  • One legged standing balance
  • Advanced one legged balance
  • Pelvic raising/lowering

Description and progression

Sit to stand exercise from chair. Hands used to guide only. Progress with increased repetitions and speed.

Stand straight feet flat on floor, Keep abdomen tight and hold one leg up as you raise on toes as high as possible. Back straight slowly lift one leg as high as you can and lower to floor raise opposite arms as knee is raised.
Slowly raise leg out to side and then return to start. Repeat with opposite side. Repeat exercise with leg into extension.

Stand on both legs. Keep abdomen tight lower towards floor by bending knees to approx 30 degrees. Straighten knees and repeat. Stand on one leg, grip floor with toes and slowly lower to approx 30 degrees progress with dumbbells.
Use two chairs transfer weight to operated leg and pick other leg up try to balance for 10 seconds. Progress with timed balance. As previous but also turn head from side to side.

Stand on operated leg. Stand unsupported not allowing pelvis to drop. Progress by slowly raising and lowering pelvis on the side of the bent knee. Monaghan et al. BMC Musculoskeletal Disorders 2012, 13:237 http://www.biomedcentral.com/1471-2474/13/237
Table 2 Summary of outcomes to be collected

Collection times in weeks
Day 5 Week 12 Week 18 Day 5 Week 12 Week 18
Day 5 Week 12 Week 15
Week 12 Week 18
Week 12 and Week 18
Week 12 and Week 18
Week 12 and Week 18
Day 5, Week 12, and Week 20
Primary Outcome Measurement Pain
Self reported Physical Function Self reported Stiffness

Real time ultrasound of the Gluteus Medius Muscle

6 Minute Walk Test Short Form SF-36 Berg Balance Score Visual Analogue Scale

Secondary outcome measurements

Real time ultrasound imaging of the gluteus medius muscles Real time ultrasound of the gluteus medius will establish the size of the muscle pre and post the func- tional exercise class. Measurement on day five is not possible due to wound dressing and patient positioning issues. Patients will be scanned by the radiologist at week 12 and the scan will be repeated at week 18. Intra therapy reliability testing will be carried out prior to scanning and the radiologist will be blinded to group al- location. Repeated measurement at week 18 will allow for comparison of both groups with and without inter- vention. Exploratory analysis on a subgroup of patients using real timed ultrasound to assess the size of gluteus medius in the non affected side will also carried out. This subgroup will be randomly selected from the main group following initial randomisation. It is planned to compare the size of the gluteus medius in the non affected side with the affected side at week 12 and again at week 18.

6 Minute walk test This is a reliable and valid test of physical function in this client group and has been shown to be responsive to detecting deterioration and improvement in the early post operative period [21]. It will be completed by the principal investigator (BM) who will remain blind to group allocation.

Short form SF-36 This is a well recognized and valid self reported questionnaire that measures health status and quality of life [22]. It will be completed in the pres- ence of the principal investigator who will remain blinded to group allocation.

Berg balance score This assessment scale of ability to maintain balance both statically and whilst performing various functional tasks will be completed by the blinded principal investigator (BM) at week 12 and repeated for all patients at week 18. It has been demonstrated to be valid and reliable in older adults [23].

Data Collection Instrument

Pain Subscale of the WOMAC osteoarthritis index 3.1 Likert Version
Physical Function subscale of the WOMAC osteoarthritis index 3.1 Likert Version Stiffness Function subscale of the WOMAC osteoarthritis index 3.1 Likert Version Cross sectional area measurement
Functional Performance
Self reported measurement of health Status and quality of life Functional balance assessment scale Average overall pain in past week 100mm VAS

Visual analogue scale This 100mm scale with descrip- tors at either end of the scale of “no pain”, and “worst possible pain” allows for self assessment of levels of pain at any specific time. It has been demonstrated to be reli- able in the osteoarthritic client group [24].

Sample size

The power calculations were based on the physical function subscale of the WOMAC questionnaire. The minimal clinical difference on the WOMAC question- naire has been established in the literature at −10.4 with the standard deviation of scores on the instrument at 13.6 [20]. The sample size was then calculated requiring a power of 80% in a two tailed test with a significance level of .05. The effect size was calculated at 10.4/13.6. It was .764 or a mod/large effect size. The sample size required was then calculated at 27 patients in each group or 54 in total. This would increase to 60 patients in total allowing for 10% attrition.

Consideration of the power calculations based on both the Berg balance score and the SF36 short form health survey, similar numbers are required. Using minimal de- tectable change scores and standard deviations from the literature [25] sample sizes at 80% power and .05 signifi- cance in a two tailed test were calculated at 70 subjects in total for the Berg Balance score and 54 subjects for the SF36 respectively. Therefore 70 subjects in total or 35 in each group would allow for 10% attrition for all outcome measurement tools.

Statistical analysis

Data analysis will be performed in consultation with Mr. Tim Grant in CSTARS. The primary conclusions of this project will be based on analyses conducted under the principal of intention to treat. All randomised patients will be analysed in the groups to which they are originally allocated to regardless of whether they actually received the intended treatment or not. Missing primary outcomes will be assumed to be missing at random and will not be considered in the primary analysis.

Monaghan et al. BMC Musculoskeletal Disorders 2012, 13:237 http://www.biomedcentral.com/1471-2474/13/237

Primary analysis of the effect of functional exercise will incorporate continuous variables which are expected to be normally distributed. These will be presented as mean and standard deviations and will be assessed using t tests at different time points i.e. at 12 weeks and again at 18 weeks. If the data is not normally distributed it is planned to use the non parametric Wilcox on signed ranks test.

A priori defined subgroup analysis

Exploratory analysis on a subgroup of patients using real timed ultrasound to assess the size of gluteus medius in the non affected side will be carried out. This subgroup will be randomly selected from the main group following initial randomisation. It is planned to compare the size of the glut medius in the non affected side with the affected side at week 12 and again at week 18. This data is expected to also to be normally distributed and will be assessed using t tests at the various time points. The results of any subgroup analyses will be reported and sub- mitted for publication soon after the primary publication.

2.5 Data set issues

The trial database will be frozen by the principal investi- gator (BM). The statistician (TG) will work on a copy of the trial database that has been downloaded to them by the principal investigator.

Any amendments to the data set will be documented.

The statistical software used for the analysis will de- pend on the preference of the statistician or person doing the statistical analysis based on what is widely used.

Timelines

This study has been funded by the Health Research Board and ethics approval has been obtained from the ethics board of the HSE Dublin North East branch in January 2012. Recruitment and training of Physiothera- pists will occur in October/November 2012 and the anticipated timelines for this project are as follows.

September 2012; Recruitment commences October/November; Physiotherapist training January 2013; Participants begin pre intervention testing 

January 2014; All participants completed intervention and post intervention follow up.

Discussion

This research project will focus on the effectiveness of a specific functional exercise programme to prevent re- sidual hip muscle weakness and subsequent disability following elective surgery and it also will incorporate the use of a real time ultrasound to measure the effective- ness of functional exercise on muscle atrophy in the short term. Specifically the patient group now requiring joint replacement in Ireland as in the rest of the devel- oped world comes from that demographic bulge in the population previously dubbed the ‘baby boomer’ gener- ation. Need for joint replacement surgery together with their increased expectation of quality of life and the eco- nomic reality of shorter inpatient length of stay will shape reformation of rehabilitation needs post total hip replacement for this group in the future.

This research project aims to assess the effect of a functional exercise programme in the THR patient group incorporating specific assessment of balance, quality of life and gluteus medius size using real time ultrasound as the secondary outcome measurements. This is very relevant to the specific patient population post total hip replacement. It is critical to the improve- ment of health and social gain in terms of improving post surgical functional ability and the subsequent ability of people following THR to contribute to society in a meaningful way.

Competing interests

The authors declare they have no competing issues. Authors’ contributions
All authors contributed to the development and writing of the protocol. All authors have been involved in the drafting and revision of this manuscript and have given their approval for the final version.

Acknowledgements

This work is supported by a grant from the HRB research fellowship for Healthcare professionals 2011.
The authors gratefully acknowledge funding support from the Irish Health Research Board research training fellowship for healthcare professionals 2011. Author details
Republic of Ireland. Centre for Support and Training in Analysis and Research (CSTAR), School of Public Health, Physiotherapy and Population Science, Woodview House, University College Dublin, Belfield, Dublin 4,
Ireland. Head of Department, Faculty of Health Sciences and Medecine,

Bond University, Robina, QLD 4229, Austalia. Physiotherapy and Population
Science, School of Public Health, University College Dublin, Belfield, Dublin 4, Ireland. Received: 27 September 2012 Accepted: 19 November 2012 Published: 28 November 2012 References
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2. AAOS 2010: American academy of Orthopaedic Surgeons (AAOS), Information about hip replacements 2002-2010. United Staes bone and joint inititive: The burden of Musculoskeletal Diseases in the United States. Rosemount

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Illinois. Secondth edition. 2010. http://www.aaos.org/wordhtml/research/ stats/hip_recent.htm.
3. National Joint registry for the United Kingdom: NJR Stats online. People building 2 Marylands Avenue, Hemel Hampstead, HPZ 4NW: National Joint registry; 2011. www.njrcentre.org.uk.
4. Westby MD, Kennedy D, Jones D, Jones A, Doyle-Waters MM, Backman C: Post acute Physiotherapy for primary total knee arthroplasty (Protocol). Cochrane Database Syst Rev 2008, (2):Art No:CD007099. doi:10.1002/ 14651858.CD007099.
5. March LM, Bagga H: Epidemiology of osteoarthritis in Australia. Med J Aust 2004, 180:S6–S10.
6. Roos EM: Effectiveness and practice variation of rehabilitation after joint replacement. Curr Opin Rheumatol 2003, 15:160–162.
7. Trudelle Jackson E, Emerson R, Smith S: Outcomes of total hip arthroplasty: a study of patients one year post surgery. J Orthop Sports Phys Ther 2002, 32:260–267.
8. Westby MD, Kennedy D, Jones D, Jones A, Doyle-Waters MM, Backman C: Post-acute physiotherapy for primary total knee arthroplasty (Protocol). Cochrane Database Syst Rev 2008, (2):CD007099. doi:10.1002/14651858. CD007099.
9. Trudelle-Jackson E: Effects of a late phase exercise programme after total hip arthroplasty a randomized controlled trial. Arch Phys Med Rehabil 2004, 85(7):1056–1062.
10. Frost KL, Bertocci GE, Wassinger CA: Isometric performance following total hip arthroplasty and rehabilitation. J Rehabil Res Dev 2006, 43:435–444.
11. Preininger B, Schmorl K, Von Roth P, Winkler T, Schlattmann P, Matziolis G, Perka C, Tohyz S: A formula to predict patients gluteus medius muscle volume from hip joint geometry. Man Ther 2011, 16:447–451.

12. Ogiwara S, Sugiura K: Determination of ten repetition maximum for gluteus medius muscle. J Phys Ther Sci 2001, 13:1–53.
13. Grimaldi A, Richardson C, Stanton W, Durbridge G, Donnelly W, Hides J: The association between degenerative hip joint pathology and size of the gluteus medius, gluteus minimus and piriformis muscles. Man Ther 2009, 14:605– 610.
14. Conneely M, O’Sullivan K: Gluteus maximus and gluteus medius in pelvic and hip stability isolation or synergistic activation. Physiotherapy Ireland 2008, 29:6–10.
15. Wallwork TL, Hides JA, Stanton WR: Intrarater and interrater reliability of assessment of lumbar multifidus muscle thickness using rehabilitative ultrasound imaging. J Orthop Sports Phys 2007, 37(10):608–612.
16. O’ Sullivan C, Bentman S, Bennett K, Stokes M: Rehabilitative ultrasound imaging of the lower trapezius muscle: technical description and reliability. J Orthop Sports Phys Ther 2007, 37:620–626.
17. Deyle GD: Musculoskeletal imaging in physical therapist practice. J Orthop Sports Phys Ther 2005, 35:708–721.
18. Trudelle-Jackson E, Smith S: Effects of a late phase exercise programme after total hip arthroplasty a randomized controlled trial. Arch Phys Med Rehabil 2004, 85(7):1056–1062.
19. Bellamy N, Buchanan W, Goldsmith CH, Campbell J, Stitt L: Validation study of WOMAC; a health status instrument for measuring clinically important patient relevant outcomes following total hip or knee arthroplasty in osteoarthritis. Journal of Orthopaedic Rheumatology 1988, 1:95–108.
20. Tubach F, Ravaud P, Baron G, Falissard B, Logeart L, Bellamy N, Bombardier C, Felson D, Hochberg M, Van der Heijde D, Dougados M: Evaluation of clinically relevent changes in patient reported outcomes in knee and hip osteoarthritis: the minimal clinically important improvement. Ann Rheum Dis 2005, 64:29–33.
21. Kennedy D, Stratford P, Wessel J, Gollish J, Penney D: Assessing stability and change of four performance measures: a longitudinal study evaluating outcome following total hip and knee arthroplasty. British Musculoskeletal Disorders 2005, 6:3.
22. Ware JE, Shelbourne CD: The MOS 36-item short-Form Health Survey (SF36), Conceptual framework and item selection. Medical Care 1992, 30:473– 483.
23. Berg KS, Wood D, Williams JL: The Balance scale: reliability assessment with elderly residents and patients with an acute stroke. Scand J Rehabil Med 1995, 27(1):27–36.
24. Bellamy N: Osteoarthritis clinical trials: candidate variables and clinimetric properties. J Rheumatol 1997, 24:768–778.
25. Steffen T, Seney M: Test retest reliability and minimal detectable change on balance and ambulation tests, the 36 item short form health survey and the unified Parkinson disease rating scale in people with Parkinsonism. Phys Ther 2008, 88:733–746.

 

Reference Point No. 18

Comparative Heart Rate Reserve Attainment and Skeletal Muscle Activation

The Human Performance Lab, The University of Tampa, 2011
see Vastus Lateralis Data page 8 and Adductors Data page 9

Test subjects used the Elliptical Rider in a neutral position and the Helix Lateral Trainer in a neutral position. Researchers found that the Helix Lateral Trainer had superior results in 7 of 8 muscles tested. The Helix Lateral Trainer test subjects demonstrated greater electrical activity (a marker indicating muscle involvement) as follows: vastus lateralis 50% greater (see Table 4), the obliques 55% greater (see Table 5), and adductors 37% greater (see Table 6) compared to the Elliptical. Additional increased muscle activity was seen in the Helix Lateral Trainer test subjects for the spinal erectors (see Table 7), and the abdominals (see Table 8).

Table 4: Vastus Lateralis: Helix Lateral Trainer vs. Elliptical neutral

 

Table 6: Adductors: Helix Lateral Trainer vs. Elliptical neutral

 

Reference Point No. 19

Muscle activity during leg strengthening exercise using free weights and elastic resistance: Effects of ballistic vs controlled contractions
Markus Due Jakobsen a,⇑, Emil Sundstrup a, Christoffer H. Andersen a,
Per Aagaard b, Lars L. Andersen a

The present study’s aim was to evaluate muscle activity during leg exercises using elastic vs. isoinertial resistance at different exertion and loading levels, respectively. Twenty-four women and eighteen men aged 26–67 years volunteered to participate in the experi- ment. Electromyographic (EMG) activity was recorded in nine muscles during a standardized forward lunge movement per- formed with dumbbells and elastic bands during (1) ballistic vs. controlled exertion, and (2) at low, medium and high loads (33%, 66% and 100% of 10 RM, respectively). The recorded EMG signals were normalized to MVC EMG. Knee joint angle was measured using electronic inclinometers. The following results were obtained. Loading intensity affected EMG amplitude in the order: low < medium < high loads (p < .001). Ballistic contractions always produced greater EMG activity than slow controlled contractions, and for most muscles ballistic contractions with medium load showed similar EMG amplitude as controlled contractions with high load. At flexed knee joint positions with elastic resistance, quadriceps and gluteus EMG amplitude during medium-load bal- listic contractions exceeded that recorded during high-load con- trolled contractions. Quadriceps and gluteus EMG amplitude increased at flexed knee positions. In contrast, hamstrings EMG amplitude remained constant throughout ROM during dumbbell lunge, but increased at more extended knee joint positions during lunges using elastic resistance.

Contraction time during low, medium, high and power loadings were 1324 ± 34, 1331 ± 35, 1319 ± 35 and 1069 ± 35 ms, respectively. Additionally, the ballistic loading displayed shorter (p < .001) contraction time than the low, medium and high loadings with controlled exertion.

3.4. Perceived loading

Irrespectively of loading modality, a significant effect of loading intensity on perceived loading (p < .001) was observed, increasing in the order 33% controlled <66% controlled <66% power <100% controlled (Table 2). Perceived loading was significantly higher (p < .001) during elastic lunges (4.4 ± 0.36) compared with dumbbell lunges (4.0 ± 0.34) (averaged across all loading).

 

Reference Point No. 20

Making Sense of Calorie-burning Claims.
By Robert A. Robergs, Ph.D., and Len Kravitz, Ph.D.

Introduction

If people answered honestly to the question, 'What are the reasons why you exercise?', a frequent answer would be to burn calories. In fact, according to U.S. Department of Health and Human Services (1992), 26% of U.S. adults between the age of 20 through 74 are overweight, which clearly demonstrates the impact of this national concern. When combined with the facts that reducing body fat can reverse several disease processes (eg. type II diabetes, heart disease, etc.), that exercise adds to total caloric expenditure, and that exercise also maximizes body fat loss and the maintenance or increase of muscle mass, participation in exercise is a very consequential and rewarding strategy to lose body fat and improve your health.

The suitability of exercise as a means to burn calories has been recognized by the fitness industry. There are many types of exercise modalities that are marketed with the claim of 'burning more calories,' and the consumer is left to wonder just what it is that determines the number of calories burned during exercise. This situation is the fundamental reason for writing this article.

You the fitness professional should be aware of what determines how many calories your body burns during exercise, why your body obeys certain rules that dictate the magnitude of caloric expenditure, and what are the best types of exercises that increase caloric expenditure. With this knowledge you can effectively educate your clients to more realistic goals that may be accomplished with your exercise prescription. In addition, you can better explain to your clients the truth about many of the advertising claims that suggest a particular exercise modality is best for caloric expenditure and weight loss.

We will begin with a brief discussion on the relationship between aerobic exercise, caloric expenditure, and exercise intensity. We will then present data from a laboratory case study we conducted to compare cardiorespiratory responses and caloric expenditure during cycle ergometry, arm ergometry, and combined leg and arm ergometry. The results presented will be combined with the published research on this topic to clearly illustrate the interrelation between exercise intensity, lower and upper body exercise, and caloric expenditure.

What determines caloric expenditure during exercise?

At rest, your body expends energy to maintain the functions of cells that are essential for life. The continual pumping of blood by the heart demands energy, as does the continual ventilation (movement of air into and out) of the lungs. In addition, maintaining a life supporting environment within and around cells requires a constant breakdown of certain energy releasing molecules. This energy is also used to form the molecules necessary for repairing cells, storing energy (glycogen and triglycerides), fighting infection, and processing nutrients obtained from digestion. These energy demanding functions combine to form the body's basal metabolic rate, which can vary from approximately 800 to 1500 Kcals depending upon body size and total caloric intake (ingested quantity of food).

Adenosine triphosphate (ATP) is the main molecule the body uses as a means to use chemical energy to perform cellular work. Exercise adds to the caloric expenditure of the body, as muscle contraction involves the need to repeatedly form and breakdown ATP. The energy released from the breakdown of ATP fuels the contraction of skeletal muscle, thereby adding to the energy demands of the body and raising caloric expenditure. Research has shown that during exercise the increase in caloric expenditure is almost entirely due to the contraction of skeletal muscle; the balance is due to an increase in the energy demands of the heart and the muscles used during ventilation.

How is caloric expenditure measured?

Caloric expenditure can be measured directly, which requires the measurement of the heat released by the body, or indirectly be measuring ventilation and the exchange of oxygen and carbon dioxide by the body. These methods are termed direct calorimetry and indirect calorimetry, respectively, and the research and validation of these methods date back to the late 1890's (Lusk, 1928). For numerous methodological reasons, the method of indirect calorimetry is the most suitable and accurate to evaluate caloric expenditure during exercise.

When a person expends calories, the body uses oxygen and produces carbon dioxide. Not all bodily reactions consume oxygen and produce carbon dioxide, but without the reactions that do, the remaining reactions of the cells would eventually stop, and the cells would die. This fact is important, as it means that quantifying the consumption of oxygen and production of carbon dioxide is an indirect means to measure the calories that are released and used by the reactions of the body. All that we need to know is the relationship between oxygen consumption and caloric expenditure. Fortunately, scientists who studied calorimetry during the first two decades of the 19th century determined this relationship for us (Lusk, 1928).

The number of calories released from the consumption of oxygen during cellular metabolism differs slightly when carbohydrate, fat, or protein are the nutrient source. However, as the body predominantly uses carbohydrate and fat as the nutrient sources, or "energy substrates," we only need to focus on these substrates. The energy released from carbohydrate and fat within the body approximates 4.0 and 9.0 Kcal/gm of substrate. Thus, fat is a more dense source of energy than carbohydrate. However, remember that we are not concerned with the amount of energy available from a given amount of energy substrate, but with how much energy is available relative to oxygen consumption. For pure carbohydrate and fat catabolism (breakdown), these caloric amounts are actually 5.05 and 4.73 Kcal/Liter O2, respectively. Therefore, the difference in caloric expenditure between pure carbohydrate and fat catabolism, of an average healthy person exercising for 30 min at a VO2 (oxygen consumption) of 1.5 L/min, would amount to
14.4 Kcals (227.25 Kcals carbohydrates to 212.85 Kcals fat). This is a small difference, but indicates that for accurate calculations of caloric expenditure during exercise, there is a need to know how much carbohydrate and fat are being used as energy substrates.

The contribution of carbohydrate and fat to energy metabolism (the process of chemical changes to provide energy) can be determined from the ratio between carbon dioxide production and oxygen consumption. This is referred to as the RER, or respiratory exchange ratio of carbon dioxide to oxygen consumption. The metabolic basis for this relationship lies in that there is greater carbon dioxide production from carbohydrate catabolism compared to fat catabolism.
Thus, the lower the carbon dioxide production relative to oxygen consumption, the greater the contribution of fat catabolism to caloric expenditure.

We are now armed with the academic knowledge needed to understand exercise intensity. In this article, our focus is exercise intensity and caloric expenditure. We will not elaborate on how one can maximize either carbohydrate or fat catabolism during exercise. We will save that topic for another article in another issue.

What are valid methods for estimating exercise intensity ?

From the information thus far presented, it should be clear that the best measure of the change in metabolism during exercise is oxygen consumption. As one completes the transition from rest to exercise, there is often an exponential increase to a plateau in oxygen consumption until a steady rate is attained, termed steady state. For low intensity exercise, steady state is attained in approximately 3 min. However, if the intensity is too high, or the duration of exercise at this intensity is too short, steady state is not attained. Research has shown that steady state VO2 increases in a linear manner with increases in the work or power performed during exercise (McArdle et al., 1991).

Much research has been completed using cycling as the exercise mode. This is because a measure of work and power is easily obtained from cycling using suitable stationary cycles that allow quantification of work and power. These special cycles are termed cycle ergometers, and ergometers such as these are also made for arm exercise, and are termed arm ergometers. The ability to quantify power or work while exercising is important, as it enables a scientifically valid way of changing the intensity of exercise, and therefore, to evaluate how the function of the body changes during known changes in intensity. It is because of this scientific precision that we used an arm and leg ergometer for the case study experiment presented in this article.

If we want to measure the change in physiological variables (such as heart rate, carbon dioxide production, ventilation, blood pressure, etc.) during exercise, a useful way to compare them to exercise intensity is to graph the response relative to oxygen consumption. This is especially important for exercises that do not have a means to quantify work or power, such as walking or running on level ground, aerobics, stair climbing, etc. Throughout a large portion of aerobic exercise, a linear relationship exists between heart rate intensity of the exercise and the oxygen consumption (and therefore caloric expenditure). Therefore if the heart rate is known, oxygen consumption can often be reasonably estimated. Although this technique is practical, other factors such as environmental temperature, body position, food intake, muscle groups exercised, and the nature of the exercise (continuous vs. stop and go) can all influence the heart rate. For instance, heart rates in aerobic dance appear to be higher than comparable oxygen consumption values on a treadmill due to the vigorous involvement of the arms. The rating of perceived exertion (or RPE) is also a measure of self perceived exertion during exercise which has also been shown to be a useful marker of exercise intensity.
The evaluation of exercise intensity by RPE is important in your classes, where often times there are no heart rate monitors, or gas analyzers and computers beside you and your students to monitor exercise exertion.

Will your fitness level effect the number of calories you burn?

Yes, as you do endurance training your body adapts in many physiological mechanisms. One positive adaptation is a lower submaximal heart rate intensity during your aerobic workouts at a given oxygen consumption. Fit individuals will often challenge themselves by exercising harder, elevating their heart rate intensity and thus burn more calories because they are also then elevating their submaximal oxygen consumption.

Can certain types of exercise burn more calories than others?

Based on the fundamental principles of indirect calorimetry, to burn more calories during exercise you need to increase oxygen consumption. The issue of exercise and caloric expenditure is as simple as that. Nevertheless, many people have been told, or developed an understanding that caloric expenditure can be different for certain types of exercise. You may recall certain advertising slogans that claim, "This exercise will burn more calories than running, or cycling alone," etc. The majority of these claims are based on how certain exercises use more muscle, and therefore will increase oxygen consumption and burn more calories. It sounds attractive doesn't it? If I use more muscle, I will use more oxygen and burn more calories! However, lets apply some straight forward scientific logic to the results of published research findings, and see how certain exercises stack up to the issue of caloric expenditure.

There is an increase in oxygen consumption when arm ergometry is added to cycle ergometry. This exercise combination increases the muscle mass exercised. This data appears to support the rationale that increasing muscle mass increases oxygen and energy expenditure. However, as they say in the classics, " not all is as it seems!"

In our single case study, the subject attained the highest or peak VO2 from cycling, and for any given submaximal oxygen consumption the heart rate response was highest for arm ergometry, and lowest for cycling alone. The higher heart rates also corresponded to higher perceptions of exertion (RPE) for a given oxygen consumption during arm and combined arm and leg ergometry. In other words, it is more difficult to exercise when arm exercise is combined with lower body exercise (Toner et al., 1990). Therefore, adding the arms to the exercise made the exercise feel harder due to increase in upper body muscle mass, but the actual oxygen consumption for a given heart rate was less than the legs only work.

A better comparison of the body's responses to different types of exercise occur when the exercises are compared at the same intensity. After all, it is obvious that adding arm ergometry will increase oxygen consumption, as it adds additional exercise, which increases intensity. In addition, we know that an increase in intensity will increase oxygen consumption and energy expenditure. However, if the addition of arm exercise makes the exercise too intense, then the completion of lower body exercise alone will enable exercise to be performed for longer at a given exercise intensity, and therefore burn more total calories (Loftin et al., 1988). For a given heart rate, there is a higher oxygen consumption during cycle ergometry, than for arm or combined arm and cycle ergometry.

Why is oxygen consumption and caloric expenditure lower during exercise involving the upper body?

Exercise involving the upper body musculature is generally complicated by the relatively small muscle mass. The smaller muscle mass is less effective than a large muscle mass in inducing the return of blood flow to the heart, reducing the volume of blood pumped by the heart each beat, and therefore causing an increased heart rate. In addition, for a given intensity, contraction of the upper body musculature provides greater resistance to blood flow than for lower body exercise, resulting in a greater increase in blood pressure. These factors result in a relatively lower maximal ability to consume oxygen during arm ergometry.

As exercise intensity increases, the body must attempt to provide increased blood flow to the contracting muscle. Normally for lower body exercise, this is tolerated. However, the addition of upper body exercise to lower body exercise can provide a demand that exceeds the body's ability to distribute and pump blood to the working muscle. In short, blood can't be pumped fast enough to adequately perfuse (spread through) both the lower body and upper body musculature. This reasoning explains the lower maximal oxygen consumption for combined arm and leg ergometry compared to leg ergometry alone, even though maximal heart rate is identical for the two tests. The extraction of oxygen multiplied by the blood flow to skeletal muscle is larger for leg exercise alone, than the combined oxygen extraction and blood flow to the upper body and leg muscles combined. However, for individuals who are genetically gifted with a large heart, large blood volume, and muscles that can use oxygen at higher rates, the cardiovascular limitations of combined upper and lower body exercise are less severe. This fact explains the known large values for VO2 max reported in the literature for elite cross-country skiers and rowers.

So, is lower body exercise better than combined upper/lower body exercise?
Better for what? The goal of this article was to explain the relationship between exercise and caloric expenditure during upper body, lower body and combined upper/lower body exercise using physiological research and a case study demonstration. If life-time commitment to physical activity for health-related fitness is the goal for yourself and your students, our recommendation is to choose an aerobic activity (lower body only or upper/lower body) that you enjoy and will be able to adhere to. A secondary goal of this article was to help you as professionals explain to your clients why certain advertising claims may be misleading or untrue. Hopefully we have provided the information for you to do that now. It should be mentioned that the long-term physiological benefits of regular upper/lower body exercise have not been fully elucidated in research findings. Therefore, it's not a matter of one type of exercise being better than another.

Rather, it is the clarification of the body's distinctive adaptations to the imposed demands of these different exercise regimes that's important.

Recommendations and Applications
From this article we would like to offer the following recommendations and applications:

1. Although equipment accessibility and availability is always a consideration, when helping clients to choose aerobic modalities attempt to find exercise activities that they enjoy and will want to continue, regardless of the lower body vs. upper/lower body issue.

2. Many individuals find upper/lower body exercise more challenging, thereby meeting an important criteria for their personal workout demands. The muscular fitness benefits of upper/lower body exercise have yet to be fully realized.

3. Because of the complex physiological demands of the body, at a given heart rate intensity, lower body only exercise will result in slightly greater caloric expenditure when compared to upper/lower body exercise.

4. When upper body exercise is combined with lower body exercise, the increased heart rate and RPE response does not necessarily reflect a significant increase in caloric expenditure.

5. With the number of well-equipped university, hospital and private sector physiology laboratories available throughout the nation, advertisers should be able to support their claims with valid, independent research. As health and fitness professionals, and potential owners of their products, you have every right to ask them to share this data with you.

References
Borg G.A.V. Psycholphysical bases of perceived exertion. Med. Sci. Sports Exerc. 14:377-381, 1982.
Lofton M., Bioleau, R.A., Massey, B.H., & Lohman, T.G. Effect of arm training on central and peripheral circulatory function. Med. Sci. Sports Exerc. 20:136-141, 1988.
Lusk, G. The elements of the science of nutrition. 4th ed, W.B. Saunders Company, Philadelphia, 1928.
McArdle, W.D., Katch, F.I., & Katch, V.L. Exercise physiology: Energy, nutrition, and human performance. 3rd ed, Lea & Febiger, Philadelphia, 1991.
Toner, M.M., Glickman, E.L., & McArdle, W.D. Cardiovascular adjustments to exercise distributed between the upper and lower body. Med. Sci. Sports. Exerc. 22:773-778, 1990.

U.S. Department of Health and Human Services. Health United States 1992 and Healthy People 2000 Review (DHHS [PHS] Publication No. 93-1232). Washington, DC: U.S. Government Printing Office, 1992.



Reference Point No. 21

Comparative Heart Rate Reserve Attainment and Skeletal Muscle Activation
The Human Performance Lab, The University of Tampa, 2011

Table 1: Percentage of increased muscle activity: Elliptical vs Helix (neutral)

Muscle Group Percentage of increased activation
Vastus Lateralis +50% Helix
Gluteus Maximus +39% Helix
Gluteus Medius +33% Helix
Obliques +55% Helix

Test subjects using the Elliptical in a neutral position demonstrated increased muscle activity in one muscle group as compared to test subjects using the Helix in a neutral position. See Table 2.

Table 2: Percentage of increased muscle activity: Elliptical vs. Helix (Neutral)

Muscle Group Percentage of increased activation
Hamstring +66% Elliptical

 

Reference Point No. 22

Human Biomechanics and Physiology Laboratory Congdon School of Health
Highpoint University
High Point, North Carolina February 12, 2016

Comparative impact on Hip Flexion, Knee Rotation, and Hip Abduction- Adduction using Lateral Cardio Trainers James Smoliga, DVM, PhD

Abstract

The purpose of this study was to examine the relative impact on hip flexion, hip abduction/adduction and knee rotation using three commercially available lateral cardio trainers. The trainers used were the Octane Lateral X Elliptical, the Helix 3500 Lateral Trainer and the Helix Lateral Trainer 3-D.

Key Findings:

Calorie Expenditure: For a given perceived intensity, test subjects using the Helix Lateral Trainers burned 50-60 more calories per hour on average than test subjects using the Octane Lateral X Elliptical. This is notable given that heart rates and perceived intensity rates were the same.

 

Reference Point No. 23

The Amount of Calories Muscles Burn
By Paige Waehner Medically reviewed by Richard N. Fogoros, MD

 

You've probably heard that muscle burns more calories than fat1 does—and that's true. Muscle is more metabolically active than fat. While it's not the miracle fat-burner that many might hope it to be, strengthening muscle can help you lose weight.

Calorie Burn per Pound of Muscle

There is a longstanding myth that says that if you put on 5 pounds of muscle (which is a challenge, even for young men), you could burn an extra 250 calories a day at rest (i.e., one pound of muscle burns 50 calories). The problem with these numbers is that there aren't any real studies to back them up.

Dr. Cedric X. Bryant, the American Council on Exercise's chief science officer, says that research suggests that a pound of muscle only burns about six to seven calories a day. Obviously, that's a big difference from 50. However, it is still three times more calories than are burned by a pound of fat.

The confusion exists because different studies use different ways to test metabolic changes after exercise. There are other mechanisms involved in metabolism that also affect how many calories you burn—sex, age, fitness level, activity level, and more.2

Because of that, there's still plenty of controversy about how much exercise really influences metabolism.

Just like target heart rate zones or the number of calories you burn exercising aren't exact, neither is this.

The Power of Lifting Weights

Given this information, you might wonder whether you should continue strength training if you're trying to lose weight. The short answer is yes. You may not burn an extra 250 calories a day by putting on muscle, but you are still changing your metabolism.

Strength training is important for losing fat and for keeping your body strong and healthy. In fact, maintaining your muscle mass as well as gaining more lean tissue is often what keeps people from gaining weight as they get older4. That's a powerful benefit. And there are others:

• High-intensity strength training can actually help you burn extra calories for hours after your workout—what's known as afterburn.5
• Strength training prevents the loss of lean body mass that happens from dieting and/or aging.6 Weight gain often happens as your metabolism slows over time.
• While strength training doesn't burn as many calories in one session as cardio exercise, it still contributes to your overall calorie expenditure.
• It changes your body composition, which helps shape your body and keep you healthy.
• It strengthens bones3 and connective tissue along with muscles.
• It improves coordination and balance and may help prevent injuries.
• Strength training is important for almost any fitness goal, whether you want to lose fat, gain muscle, or just get in better condition. Focusing on the process of getting your
body stronger and fitter is often more motivating than worrying about how many calories you're burning.

Add More Muscle

We all know muscle is more metabolically active than fat. Some experts say it is around 5-10 calories per pound per day while other experts, like Dr. Len Kravitz, estimate it's around 12- 15 calories per pound per day. Whether it's 10 calories or 15 calories, adding muscle can make a difference.

Maximize It:

• Train your muscles at least twice a week. If you're focusing on fitness and weight loss, try to get 2-3 sessions for each muscle group and make sure you take a day or two of rest between workouts to allow your muscles to recover.
• Challenge your muscles. Most people don't lift enough weight to overload their muscles, which is necessary for building lean muscle tissue. Choose a weight that you can ONLY lift for the desired number of reps.
• Use compound movements. The most effective strength moves involve multiple muscles and multiple joints. These compound movements (e.g., squats, lunges, pushups, etc.) allow you to lift more weight and burn more calories because you're using the large muscles of the body.
• Change your program. The body will always adapt to what you're doing but you can avoid that and continue progressing by changing different elements of your workouts.

 

 Reference Point No. 24

Comparative Heart Rate Reserve Attainment and Skeletal Muscle Activation
The Human Performance Lab, The University of Tampa, 2011

 Table 10, Hamstring: Helix Lateral Trainer vs. Elliptical neutral position

Conclusions:

The purpose of the study was to analyze the relative benefits of exercising on two widely available cardiovacular trainers. The Helix Lateral Trainer outperformed the Elliptical in nearly all tested categories and conditions. A notable benefit to the Helix Lateral Trainer was the test subjects’ speedier attainment of targeted ‘fat burning’ heartrates. It can be conferred that users who achieve targeted heart rates earlier will expend more calories during their workout activity, thus aiding in weight maintenance and control.

The Helix Lateral Trainer test subjects demonstrated markedly increased muscle activation in seven of the eight muscles tested in the study. Increased muscle activation confers beneficial results to exercisers via increased calorie burn and its subsequent aid in weight loss and maintenance. Additionally, regular use of cardiovascular trainers that better target and strengthen muscles can lead to desired benefits such as boosted metabolism and injury prevention. For example, the 33% increased activity in the Gluteus Medeus seen in test subjects using the Helix Lateral Trainer would, over time, serve to strengthen muscular support system for the knee and hip joints.

Researchers concluded that cardiovascular training on the Helix Lateral Trainer was more beneficial than cardiovascular training on the Precor EFX Elliptical Rider.

 

 Reference Point No. 25

Why You Should Add Lateral Exercises to Your Workouts

Side-to-side movement can help prevent injury *and* make you stronger.
By Julia Malacoff

If you're a runner or cyclist, you mostly move your body forward when you exercise. If you're a weightlifter or swimmer, you might occasionally move your body backward by doing reverse lunges or backstroke. But the reality is, the most popular activities people choose for getting fit don't generally require moving to the side. (That's part of why cross-training workouts are essential for runners.)

That doesn't make them less valuable, but it does mean you may want to put a little extra effort into moving your body in other directions. Ahead, fitness experts explain why, plus how to incorporate lateral exercises into your routine.

Why Lateral Movement Matters

So why are we making such a big deal about moving side-to-side? "It's typically not asked of us often," says Joe Holder, trainer and member of The Vitamin Shoppe Wellness Council. "We move front to back and rarely side to side because we like to lead with our eyes first." Plus, our environments are much more controlled (think sitting in front of a computer, sitting in a car, walking down the street) than they were in the past, when multi-plane motion was much more necessary, he says.

Okay, so maybe our ancestors were moving around in different directions more than we do, but is that really such a big deal? Well, kind of. Here's what lateral movement does for our bodies:

It can help prevent injury and may help even out imbalances. "Forward movements like running and biking use the same dominant muscles, stressing your hamstrings, calves, and quads," explains Tara Laferrara, a certified personal trainer, yoga teacher, founder of the TL Method, and co-owner
of Compass Fitness. "You stress the dominant muscle groups, causing them to become increasingly stronger as your smaller muscles stay the same." This can cause an imbalance, which can lead to injury. "Working the muscles on the inside and outside of your legs, for example, helps stabilize your hips and pelvis, keeping you injury-free," she adds. (See: How to Diagnose and Fix Some of Your Body Imbalances)

It can make you stronger. "Working smaller stabilizer muscles is just as important as working larger dominant muscles because it gets them ready for high performance," says Laferrara. "Firing up your inner thighs and glutes gets your hamstrings ready to deadlift 200 pounds." Talk about #goals.

Variety is a good thing. "It's fun to change things up from time to time," points out Joe Cannon, C.S.C.S., a personal trainer. "Doing different activities- like moving in different planes of motion-can reduce boredom and increase exercise adherence (which is a fancy way to say you're more likely to work out)."

How to Incorporate Lateral Exercises Into Your Routine

So lateral exercises are important. But how do you actually do them? "There are two ways to perform a lateral movement: abduction (moving a limb away from your body) and adduction (bringing that limb back in)," notes Laferrara. "These movements stabilize your joints and dominant muscles."
(Related: Weak Hip Abductors Can Be an Actual Pain In the Butt for Runners)

Laferrara says she includes lateral exercises in all parts of a workout (warm- up, workout, and cooldown) but she finds them especially important in the warm-up. "You are preparing your body for any movement that will occur in the workout," she points out. Even as a trail runner-which is primarily a forward movement-at one point you will have to jump to the side to avoid tripping over a rock or other obstacle. You HAVE to get your body ready for that."

Not sure where to start? Here are some ideas, courtesy of Holder. He recommends adding them into your regular workouts one to two times per week.

  • Side lunges: 3 sets of 12 reps per leg (BTW, here's why the side lunge is an essential part of every leg workout.)
  • Side shuffles: 3 sets of 20 yards per leg
  • Lateral bear crawls: 3 sets of 20 yards each way (See them in this superhero strength workout.)
  • Jumping jacks or star jumps: 3 sets of 30 seconds
  • Speed skaters: 3 sets of 10 reps per leg

 

Reference Point No. 26

Gait Kinematics and Muscle Firing Study.
Department of Physical Therapy and Human Movement Sciences, Northwestern University, 2014

Hip Flexion

Walking test subjects demonstrated 22.6 degrees with muscles firing at heel strike. Helix Recumbent Lateral Trainer test subjects demonstrated 62.6 degrees with all four muscle quadrants firing through the full the concentric ROM.

Outcome: The Vastus Lateralis, Vastis Medialis, Glute Medial and Maximus all fire on the lateral trainer.

Balance Dysfunction, Lateral Stability, and Falls An impaired ability to control postural balance stability in the lateral plane of motion appears to be particularly relevant to the problem of falling among older people. Moreover, falls often involve lateral body motion, and hip fractures occur most frequently in association with lateral falls.

Summary: This unique movement effectively innervates the Glute Medial and quadriceps safely, which are critical for lateral stability and fall prevention. It is Closed Chain, Non- Concussive and Bi- Directional.

 

Reference Point No. 27

Recumbent Lateral Training: A New Direction in Fitness

There is a certain percentage of the population who find traditional, weight- bearing fitness modalities, such as stair climbers or ellipticals, too intense on their bodies. People who have a hard time supporting their own bodyweight (full load bearing) on a traditional upright cardio machine will often display some common actions to compensate for this.

First, they may lean forward onto a machine, thereby putting themselves out of alignment. Second, they may use a piece of equipment incorrectly, creating shear in the knee and deactivating the glutes. Third, and maybe most common, they avoid exercising altogether.

These reasons illustrate the importance of clubs offering more recumbent equipment in their facilities to complement their upright counterparts. A cutting-edge form of recumbent modality is recumbent lateral stability training. Lateral strength and stability are essential to proper biomechanics for everyone, from seniors fighting functional decline to elite athletes and everyone in between.
Because recumbent lateral trainers activate the glutes, and because the glutes are one of the muscle groups most responsible for lateral stability, studies have shown seniors who use recumbent lateral trainers consistently can greatly reduce their risk of falling.

What this means is none of the exercise modalities typically prescribed to seniors do much to help lateral stability. Lateral stability and strength, and balance/proprioception, are the items with the most bearing on fall prevention.
Furthermore, people who compensate because they find upright full load bearing workouts challenging may have the opportunity to strengthen their stability muscles in a seated position, bringing confidence to their everyday lives and possibly to their upright workouts once again.

When choosing recumbent equipment for your facility, look for recumbent pieces with the following features:

• Bi-directional resistance, for more effective training than traditional recumbent cycles.
• Correct knee flexion and hip engagement.
• Engagement of gluteus medius, gluteus maximus, vastus lateralis, vastus medialis, and quadriceps, which results in a broad range of benefits — greater muscle activation and metabolic cost (compared to other recumbent exercise modalities), greater knee
stability, and greater power generation (for athletes).
For clubs that truly want to offer something for everyone of all ages, shapes and sizes, offering recumbent equipment is a must-have.

 

Reference Point No. 28

A LATERAL MOVE TO UP YOUR MOBILITY
By Patrick Netter, the Gear Guru®

We all know that 76 million Baby Boomers represent a generation that did not go quietly into middle age. And don’t tell them they’re now smack in the middle of their golden years!

While tens of millions have stayed more active and enjoyed improved quality of life in later years than previous generations, eventually the risk of falling becomes a fact of life. But, does it have to?

Loss of function, strength, flexibility, and lateral stability are going to happen at some point. Obviously, the longer one can maintain vigorous exercise and activity (assuming it’s “safe”) the longer one can put off functional decline.
That said, everyone will eventually experience some degree of functional decline. Even those who exercise regularly in later life will eventually experience diminished lateral stability, which includes reduced balance. They must train in a specific way to enhance it. Traditional cardio fitness products typically only train in the sagittal “front-to-back” plane. They do little to nothing for improving lateral stability. That’s a potentially major problem.

The more deconditioned people become, the more they rely on non- weight bearing recumbent cardio products. These do virtually nothing for improving balance or lateral stability. Even someone who commits to consistent recumbent-based training will continue losing lateral stability. One of the main reasons for this is that the lower body muscle group, responsible for creating lateral stability, are the glutes.

There is now a piece of cardio equipment that addresses these concerns and the science seems to back up claims made by the manufacturer.

Helix Company, who created the world’s first cardio machine-based lateral trainers, partnered with SciFit, a leading supplier of medical and PT-based fitness products. They’ve developed a machine they call a Recumbent Lateral Trainer, “RLT.”

Ok, here are the uber nerd aspects to all this: It’s taken from the technical explanation provided by researcher Andy Baxter, MES PRCS, in his summation of the Recumbent Lateral Trainer:

“Research indicates that these RLT’s offer several and specific benefits. First, the RLT is a closed chain (meaning the feet are grounded), compound (displacing the load across two joint/muscle systems) movement that is also bi-directional for enhanced neuro-muscular adaptation (neurogenesis). Because of these properties, this movement is designed to safely and effectively integrate the movement of the joint arthrokinematics (joint surface and connecting tissue relationships) with the larger gross motor movement osteokinematics (large muscles of the leg and butt).”

In addition to creating glute activation throughout the entire range of motion, the RLT has additional benefits. It creates no hip adduction and actually helps strengthen the hip joint because it creates activation of the muscles and connective tissues surrounding the hip joint. Conversely, regarding abduction, the RLT allows the hip joint to open externally improving ROM, with all four muscle quadrants of the quads firing AND the medial glute fires throughout the entire rotation on the RLT.

In only slightly more layperson-friendly terms, I am not aware of other traditional recumbent exercise modalities that create the multi-planar stimulus delivered by the Helix RLT. The RLT focuses on engaging the Glute Medius, Glute Maximus, Vatsus Lateralis, and all quadrants of the Quadriceps. This glute engagement helps create power and speed in elite athletes. For this and other populations, it also contributes to stabilizing the knees and improves lateral stability.
For the average gym member, I see it producing training of the lower body and greater metabolic cost than other recumbent modalities. The idea of course, is the more muscle groups engaged and activated will lead to greater metabolic value.
Helix will be debuting their Recumbent Lateral Trainers at IHRSA and I’ll further check out what sounds like a breakthrough way to train.