Part 1 of this multi-part posting on lumbar disc injury diagnosis and management discussed identification of the structural issues associated with the injury. Next post we’ll look at some of the finesse points that trainers and clinicians can address to improve long term function in the lumbar spine. Today we’ll look at the functional aspects.  How do we see a disc injury before it manifests as a fully blown sciatica/radiculopathy event or,…

What are the functional clues to impending disc injury?

Lab studies show that endrange loading of the lumbar discs into flexion in the presence of compression is the quickest way to cause a disc to herniate in the low back. More often than not in my experience, this represents the end result of long term habitual lumbar hinging, until the fateful day when the patient bent forward to pick up ___________(fill in the blank) and felt the searing pain in the butt and leg. Single injury events do occur, usually as a slip and fall onto the butt or as a poorly executed heavy lift. I can’t tell you how many initial onset histories in guys start with, “My first back injury occurred in high school in the weight room after football practice when me and 2 friends (always 2 friends, and poor grammar) decided to see who could back squat the most weight.” Often, they remember a ‘pop’, and back pain, with some sciatica later. Some researchers have said they can hear that ‘pop’ in the lab as the endplate fractures when they load the motion segments to failure in flexion/compression in pig spines. The research of spine biomechanist, Michael Adams, PhD suggests that that endplate failure is frequently the cause of the altered motion in the vertebral segment over time that results in disc degeneration.

If this patient walks into your clinic, studio or gym, that lumbar hinge is what you’re looking for. If they are acute with radicular symptoms and you try a multisegmental flexion assessment per SFMA, you’re a cruel bastard. The seated slump test from the previous post, and the quadruped sit back assessment as in the photos below from Stu McGill’s Low Back Disorders will yield your lumbar hinge under less provocative loading.

Start in quadruped

Look for the hinge as they sit back toward the heels.

Fix that hinge by quickly training them to hip hinge and box squat so that they don’t hurt getting up and down from the chair to the exam table. Video tutorials for these are available to subscribers of MyRehabExercise.com to send to their patients or clients. If you don’t feel comfortable in your clinic setting or your bodywork studio confidently instructing your patients or clients how to do this, I’ve uploaded these as free material on the FixYourOwnBack.com site. Use that as a resource for your patients or clients to learn more about their disc injury.

If you’re a trainer and your client has this history, put down your cell phone and stop texting while your client is squatting, rowing, deadlifting, etc and make sure that they aren’t hinging in the lumbar spine while performing those movements. If you’re doing Boot Camp types of movements like Burpees, Mountain Climbers and Squat Tosses with medicine balls, make sure they don’t hinge with these movements. (I think Boot Camp exercise vigilance might require a separate post now that I think of it). Trainers can help buttress the lumbar spine during squatting by cueing the client to use the lats by ‘bending the bar’  and cueing the glutes by pushing their knees in and having the client resist strongly by pushing the knees out. If this info is new to you, then you need Stu McGill’s other book, Ultimate Back Fitness and Performance. Seriously…go now and get it…we’ll wait until you get back!

The typical disc presentation is flexion-intolerant, but many of these folks also complain that extension hurts too when you stand them up and ask them to bend backwards. This is important to know because you need to repeat that extension in the prone position. You also need to repeat it several times and ask if the repetitions are less painful.

If they are, you’re on the right track and need to continue the extensions with McKenzie protocols. Does that mean you’re done with the rehab? NO!

The following quotes are from member feedback at FixYourOwnBack.com in the Discussion Forum:

“I now understand why 3 months of McKenzie exercises (post position) 8×10 reps a day prescribed by my last PT caused new pain and symptoms.”

“I have been taught to do the Dead Bug by four physical therapists over the past three and a half years. Doing it the way you explained in your video is a completely different experience and makes it a completely different exercise. Thank you for the in-depth explanation.”

I’ll also share a recent patient presentation too: 29 y.o. female 2nd year med student and former Division 1 soccer player presented with low back and leg pain 3 weeks after discharge from PT where she received McKenzie (MDT) therapy. Once her pain improved, she was discharged to normal ADLs. Her first rec league soccer match ended early with raging leg pain and weakness after a long cross field kick.

I’m a huge fan of MDT and use it daily in my own practice, and that approach did not fail with any of these cases. It did fall short of rehabilitating the injuries of these patients. To paraphrase the common question in all of these individuals:

Is There Life After McKenzie?

Full disclosure, I am not MDT certified but learned this approach in my DC training, through reading the literature concerning it and I employ it daily with my cervical and lumbar disc patients. The way I use MDT and frame it to my patients is as a first aid kit. I know of nothing else that allows a lumbar disc patient quicker self help pain relief for disc pain and sciatica. To my mind though, it only gets the patient to Square 1 of the rehab process.

Once the person is out of pain, that’s when the fun starts! I break out McGill’s rehab protocols, Janda’s Movement Pattern Assessments,  DNS assessment, SFMA algorithms, Liebenson’s Mag 7, etc and customize an exercise program for them that borrows from all of these schools of thought.  Once your toolbox is deep and you’re familiar with these methods they blend wonderfully for the lumbar disc patient. Despite all of these customizations though, probably 90% of these lumbar disc patients have a very similar take home plan.

1. Use McKenzie prone press up to control pain
2. Correct transitional movement flaws and posture faults to stop ‘picking the scab’
3. Stabilize the lumbar spine by building endurance in sagittal and frontal planes/incorporating proper breathing stereotype
4. Correct mobility deficits that likely exist in the T-spine and hips, possibly ankle
5. Build strength
6. Build agility
7. Build power
8. Address sport specific issues pertaining to the lumbar disc

Does Everyone Need An Individual Assessment?

Wouldn’t that be nice? While I would love to see everyone receive an excellent functional assessment,  but so many folks are suffering from lumbar disc injury and it is responsible for such a drain on public health that I think we need to address this from a public health perspective.  We need  low cost ways to get most of the people suffering from disc injury educated about what not to do, what they should do more of, and how to incorporate exercise into their self treatment without hurting themselves. Once folks get feeling better, they will need guidance and excellent exercise instruction. Are you qualified? If not, why not? And that leads us to another important question:

What Will You Do In Your Next Career When Your Patients Find Out That They Feel Better After Working Out Than After Leaving Your Office?

Those of you who are savvy to Functional Rehab and who are members of MyRehabExercise.com, know that all of those approaches above are already available to you on that website to prescribe those tutorials by sending your patients an email link to their customized prescription.  However, what if you’re a bodyworker, or massage therapist and you don’t feel comfortable taking your relaxed, naked patients through rehab exercise instruction after a massage? I just released another site to help those folks distinguish your services by including exercise. Refer your clients and patients to FixYourOwnBack.com where they can get free education and for much less than they would pay for an office call, they can get the exercise plan above laid out for them as video tutorials. Next post, I’ll cover deeper functional approaches to managing the lumbar disc patient by decoupling the hip movement from spine movement, and improving mobility in key areas. Cheers!

Can you recognize a disc patient when they walk into your office? The reason I ask is because a sizable number of the chiro students that come through my office find it difficult. The MDs that I see in the office don’t seem to know it when they see it…or even when they have it! It was also enlightening a year ago while working with Dr. Craig Liebenson to see the DC/PT crowd in the 80+ audience struggle with a disc presentation.

I’ve wondered about why this seems to be obtuse to many clinicians and I think that it is ironically due at least inpart, to the way we ingest the literature regarding back pain. An artifact of the RCTs on back pain is that clinicians are trained to diagnose disc injury only in the presence of frank neurological signs. After all MRIs frequently demonstrate disc pathology in the asymptomatic population and that’s the only way we can be sure the disc is injured, right?  Recently, one of the world’s best known, and most published spine researchers was rumored to have said (paraphrasing) “Randomized Controlled Trials (RCTs) on back pain should be banned because they’re so f@#$ed up“‘. What on earth did this researcher mean? RCTs are the gold standard of evidence-based practice! In the post-modern, evidence-based world, shouldn’t we be on bended knee to the “evidence”?  As a clinician who has taken part in some of those major clinical trials I would say yes…but…

Let’s review the definition of evidence based practice as defined by Joel Sackett. It is defined as practice based on the following 3 components:

1. The best available current scientific evidence.
2. The clinical expertise of the provider.
3. Patient choice in their care.

Here is a quote from Sackett that I think is germane to this blogpost and speaks directly to the 3rd point above and to the insecurities of many who are afraid of EBP:

“Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.”

RCTs are limited by the questions they ask and by the populations they ask them of. For instance, some cynically note that specific exercise has not been shown to be beneficial for back pain. The problem is that historically, the cohort in LBP studies has mostly been heterogeneous and doesn’t account for either what type of exercise is prescribed, or what type of subgroup of back pain is receiving the prescription.   Jeff Hebert et al, described these subgroups nicely along with effective treatment modalities for the subgroups in this paper.

I feel another misinterpretation of the literature is regarding the diagnosis of disc injury and radicular presentation (sciatica). Many clinicians are trained to only make the diagnosis of disc injury if neurological symptoms are present (numbness, tingling, pain, motor weakness in a dermatomal distribution). It used to be that we’d rely on MRI to make the diagnosis but now know that many asymptomatic people have disc pathology on MRI.  However, a functional approach takes account for a continuum of an injury. I feel that only calling a disc injury a disc injury when one has neurological signs and symptoms is like ignoring the smell of smoke before the fire over takes you. I also feel that failure to identify disc injury prior to neurological deficit has a major effect on the public health and on cost of health care.  Reflecting back to point 2 above, the clinical expertise of the provider, I’d like to take an opportunity to describe how I address disc patients now after treating them daily in clinical practice for 10 years.

So how do we detect a disc injury before it causes neurological signs?  By assimilating multiple clues from the patient’s history, physical exam and neuro exam as well as any imaging findings.

History

Family history is very important here as Videman and Battie’s research suggests that a genetic component is at play here, and seems to involve some polymorphisms that result in weaker collagen formation and subsequent disc degeneration (may account for 30-70%!). Also important are the activities of daily living that worsen pain. The hallmarks that I’ve seen are:

• Pain in transition for sitting to standing
• Pain when rolling over in bed
• Pain getting in and out of cars
• Pain putting on shoes/socks

This video shows a quick correction of these movement patterns so that a disc patient can quickly be taught how to stop hurting themselves. It is part of the free educational video area of FixYourOwnBack.com.

Examination

In the functional rehab world, it is currently fashionable to poo-poo structural issues in diagnosis and management of patients. My opinion is that this represents an adolescent trend in healthcare. We have errantly over-relied on structural cause for pain and dysfunction for far too long. While the research of folks like Ron Melzack,  Lorrimer Moseley and David Butler has rightly brought our attention to the ‘Neuromatrix of Pain’, I fear that we may be throwing the baby out with the bath as we rush to disregard structural pathology.  In an interview I did with Michael Adams, he had the following quote re: research on disc injury:

“Most people producing the research concerning back pain don’t talk about disk injury. It’s almost a shock to find someone take a breath and actually talk about disc injury.”

To bring the discussion back to the exam of the back pain patient, the current evidence suggests a cluster of orthopedic tests is best to help identify lumbar disc injury and whether or not that disc injury compromises a nerve root. Below is a video I did putting these 2 tests together in the way that I perform them in clinic for expediency and accuracy. Additionally, I add a functional test for lumbar extension borrowed from the McKenzie folks to help identify quickly how to treat the patient both in the clinic and with home exercise.

Quick overview of the 3 tests :

• Slump tells you it’s a mechanically compromised disc
• SLR tells you if the compromised disc is affecting a nerve root
• McKenzie prone press up (Sphinx in yoga) shows the way for treatment

• Multisegmental movement offers clues but poorly tolerated in disc pt
• McGill’s quad sit back shows the hinge
• Squat/rise shows contributing global movement pattern
• Hip flexor endurance test
• Leg raise per FMS

For those interested in seeing the combination of structural and functional approaches as it applies to disc injury, please visit FixYourOwnBack.com. There you will find an organized, self-help exercise program based on the outline modelled here. Arranged in an innovative, interactive chapter book format, users can work at their own pace to address the mobility, stability, integration, strength, agility and power components of complete rehab of the lumbar disc injury.

This April, the Royal College of Chiropractic Sports Sciences is hosting the Sports Chiropractic for Ultimate Performance symposium in Vancouver, BC.  On April 27-29, 2012  join Dr. Tom Hyde (founder of FAKTR) Dr. Jeff Spencer (DC for Lance Armstrong and the Discovery and US Postal cycling teams) and several others as spring arrives in Vancouver! For more info check out the links below.

 For More info and Registration Click Here

Click here for registration and speaker details

Tom Hyde, DC

Jeff Spencer, DC

Don Aspegren, DC

Jack Taunton, DC

Terry Weyman, DC

Greg Bay, PT

Michael Adams, PhD.

In the world of spine research, few have contributed as much as Dr. Michael Adams.  In his work as a clinical professor of biomechanics at the University of Bristol in the U.K., he and his research colleagues have helped to further our understanding of the cause of one of the most common maladies affecting humans…back pain.  His watershed research 20 years ago helped us understand the diurnal phenomenon in lumbar discs which results in markedly increased risk of disc injury in the first hour after arising due to increased hydrostatic pressure.  Over the past 30 years, his area of focus in his dozens of research projects have moved from pain of vertebral endplate origin, to pain of nucleus pulposus origin, to his most recent interest in pain of annulus fibrosus origin.

Mr. Adams’ recent opinion paper on future strategies for treatment of back pain of annular origin raises some interesting questions that touch on some hot topics in the world of rehab.  He notes the similarity of the annular tissue to tendon tissue and wonders whether clinicians should consider loading the annulus strategically during specific phases of rehab to improve outcomes.  Given that some of that loading might be arguably be into flexion, I wanted to talk with Mr. Adams about how we might explore these loading vectors safely to avoid risk of re-injury to patients.  I also wanted to get his opinion on what the research says about the wisdom of loading the flexed spine with exercise in the un-injured spine.

Quick bullet points in this interview include

• Disc injuries take a long time to heal and may never heal to ‘original factory specifications’
• Endrange loading of the lumbar spine injures discs
• Loading of discs into flexion, but not to endrange, AND WITH CAREFUL ASSESSMENT AND MONITORING may help improve health of a disc during late phase of remodelling
• Tendons may represent the closest other body tissue that we have some understanding of the effect of loading on during healing
• We still haven’t figured out many things about tendonopathy
• We still need to define what constitutes ‘loading’ during flexion of the spine and what safe frequency of loading might be
• Sit ups and crunches at the right time, at the right frequency, and in the right volume, MAY theoretically help to improve the health of discs

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Click on the arrow below to hear the interview with Michael Adams, PhD.

Michael Adams, PhD Interview with Phillip Snell, DC 12-7-2011 Play Now | Play in Popup | Download

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Click here to see Dr. Adams' excellent text

Adams MA, Stefanakis M, Dolan P. Healing of a painful intervertebral disc should not be confused with reversing disc degeneration: implications for physical therapies for discogenic back pain. Clin Biomech (Bristol, Avon). 2010 Dec;25(10):961-71. Epub 2010 Aug 23.

Theraband use for RNT in First Position of DNS

As I write this from 30,000 feet on my way home from a recent course in Dynamic Neuromuscular Stabilization (DNS), I hope to provide some personal perspective and something of an overview of Pavel Kolar’s program with this post.  My understanding is based on my experience of only 2 courses over the past 2 years, but I hope that it might offer a bit of help to those clinicians, trainers and bodyworkers who are considering ponying up the time, money and commitment to immersing themselves in this physical medicine approach.  Below, you can also check out some other perspectives from folks that have been doing this a bit longer.  At the end of the post you can find videos from Ken Crenshaw, ATC of the Arizona Diamondbacks; Sue Falsone, PT of the LA Dodgers and Drs. Mike Rintala and Brett Lemire who have been using the DNS approach at the highest levels of pro and amateur sports.

“As to methods there may be a million and then some, but principles are few. The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble.”                           -Ralph Waldo Emerson

The DNS approach is principle-focused, and thus allows for jazz-like riffs in the assessment and treatment of patients and clients.  However, a solid understanding of the basics of human movement and assessment is a prerequisite to the course, and many will find that this material is like a post-grad diplomate for the FMS/SFMA protocols.   For the official specs on DNS, check out the excellent Powerpoint presentations at the DNS website, www.RehabPS.com.  The following are my own gleanings and represent the ‘bullet points’ that really stuck out for me after the 4 day course.

Principle 1- Proper orientation and function of the diaphragm is key to elegant movement.

Principle 2- In a healthy, developing central nervous system (CNS), proper diaphragm orientation and function are innate.

Principle 3- In a healthy, developing CNS, acquisition of motor programs occurs in a predictable, observable manner in the infant.

Principle 4- In adults, poor musculoskeletal function often starts when diaphragmatic breathing and stabilization is lost.

Principle 5- Improved musculoskeletal function can be re-acquired by returning to developmental stages of movement and re-grooving balanced movement in the presence of proper diaphragmatic breathing and stabilization.

DNS uses the clinical audit process (CAP) in application. In these methods, the patient is first assessed, a treatment is applied and the effect is then reassessed to determine short term effect of treatment.  Studies have shown that long term prognosis in musculoskeletal conditions improves by 3 fold when within treatment benefit is noted.  Much of the DNS assessment is on breathing patterns and postural stabilization using the diaphragm.  Those breathing patterns are corrected by the clinician, often in positions that mimic developmental infant postures and movements.  This process was built on the work of former Prague School of Rehabilitation head, Vaclav Vojta.

Vojta’s work with children suffering from cerebral palsy (CP) showed improvement in function of CP kids when this type of developmental approach was used.  This is where one of the more controversial aspects of DNS starts to enter the picture.  Vojta theorized that during development of motor programs, the infant’s observed progression from supine to sidelying to prone to sitting to kneeling to more advanced vertical postures resulted in areas of high sensory input corresponding to the weightbearing structures during that period of development.  Vojta felt that these high sensory areas persist into adulthood and he coined the term ‘reflex points’ to describe them.  In the adult, these areas of the body, like the anterior lower ribs, ASIS, medial knee and elbow, palm and medial calcaneus, theorietically can be used to access more primitive movement stereotypes that are innate to the human.  Manual pressure to these points, again, theoretically, can ‘re-boot’ the more balanced respiratory and stabilization functions of the diaphragm and motor system, allowing for a better cache memory of movement that is balanced.  Building on that temporary improvement with personalized exercise is the next step to restoring function to the musculoskeletal system.

In my own opinion, the evidence for these reflex points and reflex locomotion is tenuous at best.  I’m happy to see that the DNS approach, while informed by the possibility of these special points, does not rely on them for application.  In the training of the reflex points in the course, students are taught what anticipated movements might occur with stimulation of reflex points, and then they practice on each other.  As a result, these “reflex movements” are highly suggestible, and I suspect that much of what is observed in the seminar environs is not truly reflex, but the wishes of the participants to experience the phenomenon.  I have only the reports of trusted colleagues that this reflex movement occurs in a predictable manner in the naive patient.  I very much try to educate patients about the origins of their dysfunction so that they are empowered to help themselves without need for treatment.  Quietly waiting over a patient, while pressing specific reflex points, without telling the patient what you’re doing and why seems awkward to me.  Telling them, however, removes the naivete. The real ‘magic’ IMHO, is in the anticipated movement patterns.

To my mind, the beauty of the DNS approach is in refining our understanding of ideal, anticipated movement patterns that occur with basic human movement stereotypes like rolling over, squatting, kneeling, stepping, etc.  When adequate deep stabilization of the spine occurs, these pure movement patterns occur spontaneously in the infant.  If spine stabilization is hampered in development or later in life in the adult, then aberrant motor programs become ingrained.  These aberrant patterns of movement result in joint de-centration, with resultant negative effects on the joints, attached soft tissues and performance.  Overuse syndromes, pain and suboptimal performance of movement in athletics are the results.  The good news…Kolar has shown us how to intervene clinically by teaching the patient/client how to better stabilize the spine and then re-groove the ideal movement stereotype.

The clinician or trainer leads the patient into the ideal movement and weightbearing, and then can reinforce proper movement using reactive neuromuscular training (RNT) strategies.  The challenge is in finding exactly when in the movement pattern that the individual loses stabilization, de-centrates and thus needs help.  Practitioners require a refined ability to assess the nuances of movement quality.  Prescribed DNS exercises are highly individualized to the patient/client, and rely heavily on internal cuing.  That is, the patient/client is taught to feel the loss of integrity in the movement, correct it by stabilizing better and then continuing the movement with different weightbearing and force vectors that mimic the developmental movement stereotypes.

To those who are fond of algorithms and ‘low cortical output’ (read mindless) practice, DNS will disappoint you.  This is a systems approach to the human body and requires you to be ‘on’ to apply it effectively.  Like much of the modern functional approach in physical medicine, initial focus is on an individual assessment of the patient/client.  This assessment frequently starts with territory that has for many of us been considered to be ancillary at best.  DNS places great emphasis on the diaphragm and its role in not only respiration but also on stabilization of the core to create a fixed point (punctum fixum) for the hips and shoulders to plug into to generate movement.

I have already seen benefit using these methods on those patients (including myself) that I have not quite been able to rehab completely using the other paradigms like FMS/SFMA, McKenzie, McGill, etc.  My next personal challenge will be in how to represent this material well in the exercise roster at MyRehabExercise.com to help clinicians and trainers more easily teach these strategies to their patients and clients.  So far, the DNS approach has been tangentially represented at MyRehabExercise in some of the Dead Bug exercise progressions, Baby Get Up from Craig Liebenson, DC and perhaps even in the Turkish get up break downs in the rehab setting.  Look for more refinement of the exercises on MyRehabExercise in the future to include more detailed DNS based methods.

 Find out how to become a member of MyRehabExercise.com

Dead Bug progressions video viewable by members of MyRehabExercise.com

Wall Bug progressions video viewable by members of MyRehabExercise.com

Baby Get Up progressions video viewable by members of MyRehabExercise.com

Membership to MyRehabExercise.com is only $9.99 per month and allows access to an extensive library of functional rehab exercise video tutorials to help with patient and client rehab exercise training.  Trial the site for only $1 for 30 days with no obligation.

Click here to learn more about MyRehabExercise.com

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Below, Ken Crenshaw, ATC, lead trainer for the Arizona Diamondbacks discusses the role of DNS in the management of pro baseball players.

Sue Falsone, PT is the first female head of athletic training in any of the 4 major league sports in the US.  She was recently hired by the LA Dodgers to help oversee the care of those players.  Here, she discusses the role of DNS in the athletes she helps to treat in her work as head PT for Athlete’s Performance International.

Dr. Mike Rintala and Dr. Brett Lemire were ‘early adopters’ of the DNS program and incorporated it into clinical practice starting 10 years ago.  Dr. Rintala discusses the effect of DNS in working with pro and amateur athletes including PGA Tour pros.  Dr. Lemire discusses the effect of DNS in a standard DC practice.

Pavel Kolar, PT, PhD founder of DNS

Happy Thanksgiving all!  Here in the US, today is a holiday set aside to gather with family and reflect on the things that we have to be thankful for.  I feel truly thankful this year for not only my own family, but also for the professional family that I’ve been fortunate enough to be adopted into this past year.  I want to thank you folks for playing together on Facebook and in the blogosphere and especially for spending time together at continuing education weekends.  This past few weeks have been quite active in that regard with back-to-back long weekends on a cranial download of Fasical Manipulation and Dynamic Neuromuscular Stabilization (DNS) coursework.

Click to learn more about DNS and for schedule of upcoming classes

For those who haven’t yet been exposed to the DNS material, it is the latest in the evolution of the Prague School of Physical Medicine and is the brainchild of Professor Pavel Kolar.  Dr. Kolar is the current head of the school which is housed at the Motol University Hospital in Prague, Czech Republic.  Past heads of the school have included Vaclav Vojta, Karel Lewitt, and Vlad Janda.  Kolar’s work has been greatly influenced by Vojta’s work with children with cerebral palsy (CP) which started back in the 1950′s.  Vojta’s observed that the innate developmental movement patterns of infants are not only predictable in their ontogeny, but that those predictable patterns are disturbed at a very early age in CP kids.  To an astute observer, those flawed patterns offer an opportunity to diagnose CP at an earlier age, and then to intervene for those kids’ benefit.  Vojta found that grooving more normal motor programs in those children helped them achieve higher levels of function.

Members of my "rehab" family, clockwise from left, Patrick Ward, Josh Funk, Darcy Norman, Craig Liebenson, Jeff Cubos.

Pavel Kolar’s work was also informed by his athletic experience as an Olympic gymnast for the Czech Republic.  Kolar wondered whether children with CP might not be the only benefactors of Vojta’s ideas.  He began to note that the commonly presenting pain syndromes in adults were coupled to poor movement patterns that mirrored the faulty movement patterns observed in CP kids.  When he began to apply the same exercise strategies in these adults, their pain syndromes improved.  Given his athletic background, Kolar started applying the DNS principles with athletes for performance improvement and once again found success.  Today, high performance athletes are beating a path to Prague and to those practitioners worldwide who are well versed in these techniques.

This past weekend, one of the larger courses in the US was held at Athlete’s Performance International in Phoenix, AZ and included classes in the A, B, C and Advanced levels of training.  The roughly 80 total participants were treated to grand rounds with professional athletes and world record holders.  The attendees included physical therapists, chiropractors, MDs, athletic trainers, personal trainers and bodyworkers.  One of the most satisfying aspects of this DNS community is the ‘cross-pollination’ between the healthcare disciplines that occurs at these events.  I was privileged to be able to interview a few of the instructors and attendees before I left Phoenix and those interviews will be posted in this and the next entry here.  To learn more about the DNS program, go to www.RehabPS.com and register for their limited seating courses to be on the cutting edge of the new Rehab Renaissance.

Alena Kobesova, MD is a familiar face to US DNS attendees as she works as a lead instructor for the Prague School, but also functions eloquently as Pavel Kolar’s translator.  Here, Dr. Kobesova speaks about the DNS perspective on the diaphragm’s role in respiration and stabilization.

Dr. Craig Liebenson has played a pivotal role in the last 20 years in gaining a US audience for the work of the Prague School.  He has hosted Vladimir Janda and Dr. Kolar many times, and was the main organizer for this event in Phoenix at API.  Here he discusses open chain vs. closed chain exercises in the DNS program.

Clare Frank, DPT is one of the primary DNS instructors in the US programs and was co-author of Assessment and Treatment of Muscle Imbalances: the Janda Approach.  Here she discusses the misconceptions of many about the importance of reflex points and reflex locomotion in the DNS system and also explains the influence of Janda’s work on the DNS point of view.

Charlie Weingroff's Training=Rehab, Rehab=Training is a must-have for trainers and rehab professionals

Charlie Weingroff, DPT is a Renaissance Man!  After 12 years in the NBA as the head strength and conditioning coach for the Philadelphia 76ers, he added the doctorate  to his PT degree and went to work as lead PT and trainer for the US Marine Corps Special Operations.  Charlie’s work is highly influenced by his involvement with FMS, DNS and recently RKC.  He has been pivotal in arguing for the inclusion of qualified personal trainers in the rehab continuum and his DVDs, Training = Rehab, Rehab = Training help show trainers how to integrate with rehab clinicians like physical therapists, chiropractors and medical physicians.  Plainly put, if you’re a personal trainer, and you don’t have these DVDs, you’re behind the curve.  Get them and take your seat at the table with those of us who are part of the Rehab Renaissance and let’s make a difference in public health!  To help foster that movement, Charlie has also been very helpful in providing direction and guidance on MyRehabExercise.com.  This library of functional corrective exercise videos is only $9.99 per month and will help clinicians and trainers teach excellent rehab exercises to patients and clients.  Trial it for only $1 for 30 days, no contract or obligation.  Check out the information video to the right of the page here.

Exciting new things are now on Dr. Weingroff’s horizon and he took a moment from his busy schedule to chat about some of the buzz topics in the literature and the blogosphere recently.

Things we covered in the interview include:

• Is there a place in the rehab or training program for crunches and other loaded spine flexion exercise?
• Is ISCRS the definitive, multi-disciplinary community of rehab and fitness professionals?
• How does Dynamic Neuromuscular Stabilization influence the TGU, powerlifting, etc.?
• Why should you be keeping your chin tucked if you’re lifting heavy?
• How does Joint by Joint Expanded view elbow pain?
• Recent conversation between Charlie and Pavel Tsatsouline of RKC.

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To listen to the interview or to download the podcast, click on the Arrow below

Charlie Weingroff, DPT interview Play Now | Play in Popup | Download

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If you’d like to catch more from Dr. Weingroff, check out this link to a webinar at StrengthCoach.com.  StrengthCoach.com is a great resource of training info like this and you can once again get CE credits for listening to this broadcasts.

For those of you interested in joining a community of rehab/performance oriented professionals such as chiropractors, physical therapists, personal trainers, athletic trainers and body workers, join the International Society of Clinical Rehabilitation Specialists (ISCRS).

And as a parting shot, here’s Charlie under the bar…love the massive vertical leap at the end.  Thanks again Charlie!!

Knee pain is the most common pain reported in runners and no one has contributed more to our understanding of this pathology than Irene Davis.  I’m a huge fan of researchers that really sink their teeth into a topic and doggedly work to methodically shed more and more light on the subject.  Dr. Davis is one of those rare individuals.  Working out of the Gait Lab at the University of Delaware, Davis started exploring the biomechanics of the knee in the mid-90s, and has a formidable list of publications that numbers well over 40.  Recently, she moved on to the Spaulding National Running Center at Harvard University.

Irene Davis, PT, PhD

One of the common observations of several studies on patellofemoral pain (PFP) has been that weakness of the hip abductors and external rotators is correlated with, and also predicts PFP.  The solution to the problem then seems to be very straightforward…strengthen the muscles that are weak in controlling the valgus knee during gait and all will be splendid.  Indeed, were the findings in some studies, but others were less promising.  What could be the missing variables?

Are running injuries hardware related?...

...or software related?

Last year, an elegant study co-authored by Davis indicated that perhaps the solution is as much related to software as it is to hardware.  Brian Noehren, et al, demonstrated one of the most impressive effects on chronic anterior knee pain in runners ever published.  And they did it using gait re-training without strength training.  They took a small cohort (n=10) of runners (at least 6 mi/week, avg of 16 mi) who had at least 4/10 pain in the anterior knee with running.  The average chronicity was 75 months!!  They did a gait analysis as well as single leg squat, and measured kinematics including contralateral pelvic drop, peak hip adduction and internal rotation.  They also measured vertical impact forces.

Intervention was verbal coaching while running in 8, 30 minute sessions on a force plate treadmill and with live gait analysis.  As the runners implemented the coaching cues, they got real-time feedback via the gait analysis software which showed a representation of their peak hip adduction.  After 2 weeks, pain was reduced by 86%.  On follow up one month later, ALL WERE RUNNING PAINFREE!  For more details, here’s a link to that study.

Here are the 3 verbal cues the coaches used to help the runners change their gait:

1. Contract the gluteal muscles (or as I tell my patients, pretend you are pinching a coin between you butt cheeks. Don’t crush it, but don’t drop itj!)
2. Run with the knee pointing straight ahead.
3. Keep the pelvis level (or as I tell my patients, don’t run like a supermodel!)

Click here for registration information!

Dr. Irene Davis’ Bio:

Dr. Stu McGill and Dr. Phillip Snell

Spine researcher Stuart McGill, PhD, was kind enough to spend some time answering some questions I had about recent developments in the spine literature and popular culture. We discussed a recent article in Strength and Conditioning Journal by noted blogger and trainer, Bret Contreras and co-author Brad Schoenfeld entitled To Crunch or Not to Crunch: An Evidence-Based Examination of Spinal Flexion Exercises, Their Potential Risks, and Their Applicability to Program Design.  This article was picked up by Gretchen Reynolds in the Health section of the New York Times.  Contreras and Schoenfeld contend that some loaded flexion of the lumbar spine, in a well chosen population is not only OK, but also, perhaps even health promoting.  Dr. McGill weighs in on this topic with his understanding of the literature and his experience working with elite athletes.  For those interested in learning more about Dr. McGill’s approach, check out his DVDs and books at BackFitPro.com.

Osteopath, Dr. Eyal Lederman authored a rather provocatively titled paper in Journal of Bodywork and Movement Therapy entitled The Fall of the Postural-Structural-Biomechanical Model in April 2011.  In that issue, several multidisciplinary luminaries responded to Dr. Lederman’s contention that a more encompassing clinical model was needed in management of musculoskeletal pain.  We  discussed some of the tenets of his Process Approach model, noting the similarities to Gordon Waddell’s Biopsychosocial Model.

Corrective exercises from Dr. McGill are located on MyRehabExercise.com as well as corrections from the FMS/SFMA work, Craig Liebenson, Robin McKenzie, Vlad Janda, Eric Cressey, the kettlebell community and many more.  These videos are thorough tutorials, in patient/client friendly verbiage for clinicians, bodyworkers, trainers and coaches to use to help simplify patient education.  Trial the site for $1 for 30 days.  If you like it, it’s only $9.99 per month!

Great for abs, still bad for backs.

Click on the arrow below to play.  Feel free to share by download or linking!  Articles we mentioned are linked below.  Enjoy!

Stu McGill Takes on Crunches...Again Play Now | Play in Popup | Download

*Catch Dr. Stuart McGill in person in LA October 15-16, 2011 when he’s hosted by Clare Frank, DPT and Cynergy Education Group.  This 2 day workshop will cover Ultimate Back Fitness and Performance.

* Link to Videman’s paper, Challenging the Cumulative Injury Model: Positive Effects of Greater Body Mass on Disc Degeneration.

* Link to Hebert et al’s paper, Clinical Predictions for Success of Interventions for Managing Low Back Pain.

Some recent Facebook posts I made need a little bit more fleshing out.  I was upset because I had a patient show up 9 months after I rehabbed her lumbar disc injury.  She had re-injured her back while performing seated machine crunches on a machine like the one below, while UNDER THE SUPERVISION OF A TRAINER IN A ‘BIG BOX’ GYM!  Several folks responded to that thread so I thought we’d explore the topic more.

Ab crunches are not for breakfast anymore!

Recently, some prominent trainers in the blogosphere have begun to question the “no crunch” literature of Stuart McGill and others.  While I too think there is more room for us to explore limited unloaded flexion of the lumbar spine (like in Charlie Weingroff’s ‘Core Pendulum Theory’), I think the polarized environment in which this discussion often takes place really makes for a worse world for patients and clients.  Young trainers can get caught up in the polarization, become adherents of an influential fitness guru, and lose site of the importance of screening clients well for personal goals and injury history.  The resultant adherence to dogma on the training room floor leads to injured clients.  When trainers injure patients, both patients and clinicians lose respect for trainers.  Then clinicians are less likely to respect trainers and send their patients into those trainers’ gyms.   This re-creates the old turf war environment where trainers think clinicians are too cautious and want to steal their clients, and clinicians are afraid to let their patients work with trainers.  This represents several steps backwards.  In the post-FMS world, we have Gray Cook to thank for providing an effective communication model, a sort of rehab Esperanto (look it up) that allows clinicians and trainers to liase.  That handshake from rehab to training is WAY important and we need that model filled with understanding and respect.

So, let me make it clear…WE CLINICIANS NEED TRAINERS ON OUR TEAM TO HELP SEGUE PATIENTS TO SELF CARE!  In the competitive environment of personal training, an excellent way for you trainers to bring clients to your door is to bone up on the literature surrounding rehab, then market to chiropractors, physical therapists and medical doctors in their community, showcasing your chops to manage their patients.  In fact, just get good at avoiding injury to the most common painful tissue in back pain, the lumbar disc, and you can plan on lots of work.  Any clinician worth their salt will give you audience if you send a letter explaining your understanding of the pathobiomechanics of disc injury in the lumbar spine.  Those that don’t see the value in your services don’t matter.  Move on until you find the heads up clinicians that want your help as much as I do.  Many reading this are already savvy to much of this material.  For those who aren’t,  I will suggest a must-do list of education to get you prepped for your pitch.  Those that already know this stuff, forward this post on to the newbies so we can up everyone’s game.  There are way too many people in pain out there and we need to work together folks.

THE NEW TRAINER’S GUIDE TO NEW CLIENTS

1.  Read Stu McGill’s book, Ultimate Back Fitness and Performance-The go-to manual for managing the spine on the training room floor.

2.  Go get certified in FMS, here’s the calendar-Gray Cook has changed the landscape of training and rehab by providing an accessible model of assessment and corrective exercise that trainers and clinicians can both use.

3.  Subscribe to StrengthCoach.com-Mike Boyle took his vast coaching experience, added that of the brightest minds in training and coaching, and created an incredible resource that is right on the cutting edge.

4.  Subscribe to SportsRehabExpert.com-Joe Heiler, PT tweaked the StrengthCoach format and focused on the rehab end of things. This site is a crazy value and helps you learn the ins and outs of functional rehab so you can liase with the clinicians.  Clinician that aren’t frequenting this site are falling behind the curve.  Members to MyRehabExercise.com should ALL be using Joe’s site to stay current on the literature in functional correctives.

5. Get Charlie Weingroff’s Training=Rehab, Rehab=Training DVDs.-Charlie Weingroff, DPT scares me.  Not only because he can squat 800 lbs, but because he’s one of the brightest folks in rehab and has the chops to crossover between elite coaching, physical therapy, and chiropractic.  He also knows WAY too much about professional wrestling and fantasy football.

6.  Get Craig Liebenson’s new Functional Performance Training DVDs (more on that in an upcoming post)-Craig Liebenson, DC is my ‘Sensei’…there, I’ve said it.  Craig’s work in functional rehab has influenced my work going all the way back to my first year in chiro college.  While his Rehabilitation of the Spine textbook is enough to keep you occupied for a year, his release of  3 new DVDs on Core Stability, Functional Training, and Flexibility will be what all of us are talking about in the next year.

7.  RSS Jeff Cubos’ blog-Jeff Cubos, DC knows more than you do.  He knows more than most of us do.  I have never seen a more voracious appetite for learning, in a more humble individual. Jeff truly loves to share his knowledge and does so on his blog, JeffCubos.com.  His participation on the recent Muscle Imbalances Revealed-Upper Body, hints at great things to come in the future.

8.  And I humbly suggest you subscribe to MyRehabExercise.com just over on the right of this page.  I’ve put together a roster of corrective exercise video tutorials for you to share with your clients and patients so that they can “balance their chassis” before you start loading it up with a bunch of weight and intensity.  Those videos are from multiple sources (FMS, kettlebell community, McGill, Liebenson, Cressey, McKenzie and many more) but are conveniently located in one place so you don’t have to send patients and clients all over the web looking for rehab examples.  The price is right too, at less than $10 per month.  Heck, if that’s too much, send 10 of your colleagues to MyRehabExercise.com and you can get the service for free for a year!

Consider this approach as well.  In my clinic, I encourage my patients to invite their trainers in to my office during their treatments if they are comfortable with this.  I’ll then allow the trainer to stay for an afternoon and observe treatment for other patients that are okay with it.  Trainers, see if the clinicians you refer to would be copacetic with this arrangement.  Clinicians, offer this opportunity to local trainers.

Now, back to the topic of post-graduate education for trainers…one of the best places

Clare Frank, DPT

you can go to start your information gathering is Stuart McGill’s work.  And if you ever get a chance to see Stu in person, jump at it!  It just so happens that Clare Frank, et al at Cynergy Education Group are hosting Dr. McGill in LA on Oct. 15-16.  Here’s the link to that gathering, but get to it because there aren’t many seats left.

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Stu McGill in LA Oct 15-16-Building the Ultimate Back: From Rehab to Performance 

Professor Stuart McGill

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My personal journey with Dr. McGill began about 10 years ago.  A nasty twisting injury to my thoracolumbar junction that occurred in my 20′s when I was a kayak guide, re-emerged after a crappy lifting episode.  I found that more and more frequently, my back would seize with less and less provocation.  I figured the world had little use for a chiropractor with a gimpy back so it was time for this chiropractic physician to heal himself.  Sure, I had had my fill of old-school chiropractic treatment for this issue including manipulation, soft tissue therapies and lots of passive modalities.  However, like so many other people’s experience with that limited toolbox, my benefit was only transient.  At about that time I was introduced to Stuart McGill’s books and started to read his work suspecting intuitively that that approach of spinal stabilization was going to be my best solution.  It did help me tremendously and it also transformed my practice as I shared this approach with my patient base.

I put together my first tutorial videos for McGill’s correctives about 5 years ago to help my own patients learn these exercises.  Much to my surprise, clinicians, trainers, bodyworkers, yoga and Pilates instructors and the lay public started using my site and Dr. McGill’s exercises with excellent results.  That experience formed the base for the current MyRehabExercise.com.  Now, in addition to Stu’s exercises, we also have FMS correctives, material from Craig Liebenson, MacKenzie, the kettlebell community.  We’ve even got functional rehab from Eric Cressey, Dan John and folks many of us have crossed in the blogosphere.  All of these exercises are patient-friendly tutorials, and are aimed at helping patients and clients not only learn how to do the exercise, but also to learn a bit more about their conditions.  Those interested in trialing the videos for use with their own patients and clients can follow the links over on the right side of the page here.

 Learn More About MyRehabExercise.com