A recent paper from the Mayo Clinic in Rochester, MN (Yuan et al, 2013) appeared in the American Journal of Sports Medicine which brought to light that screening the hip range of motion (ROM) in young athletes might be worthwhile to identify problems that might be in that athlete’s future. Yuan, et al found that a simple modified flexion/adduction/internal rotation (FADIR) impingement test in asymptomatic athletes was able to pick up early stages of cam type of femoracetabular impingement (FAI). Specifically, they assessed 226 athletes for internal rotation deficits by flexing the supine athlete’s hip to 90 degrees, and then applying adduction and internal rotation. They also received the impingement test which was essentially the same test with hip flexion performed to endrange. 19 of those athletes (8%) demonstrated IR <10 degrees and 34 of 38 hips in those athletes demonstrated <10 degrees IR-ROM. Only 18 of those hips had pain with the impingement test. Of those with positive findings, 13 chose to participate in the study. A control group of 13 was chosen from normals from the the original N=226 cohort and both groups received Xray, MRI, and a subsequent manual exam.
- Mean alpha angle on MRI was 44.3 in the control group and 58.1 in the study group.
- 86% of those asymptomatic hips with clinical signs in the study group demonstrated abnormal findings on plain film Xray.
- >2/3 of the study group had MRI demonstrated pathology vs. 1/3 of the study group. The more accurate MRA assessment was not ok’d by IRB for pediatric population.
Yuan BJ, Bartelt RB, Levy BA, Bond JR, Trousdale RT, Sierra RJ. Decreased Range of Motion Is Associated With Structural Hip Deformity in Asymptomatic Adolescent Athletes. Am J Sports Med. 2013 May 22.
Philippon MJ, Yen YM, Briggs KK, Kuppersmith DA, Maxwell RB. Early outcomes after hip arthroscopy for femoroacetabular impingement in the athletic adolescent patient: a preliminary report. J Pediatr Orthop. 2008 Oct-Nov;28(7):705-10.
Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA. Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum two-year follow-up. J Bone Joint Surg Br. 2009 Jan;91(1):16-23.
Andjelković Z, Mladenović D. Measuring the osteochondral connection of the femoral head and neck in patients with impingement femoroacetabular by determining the angle of 2alpha in lateral and anteroposterior hip radiographic images. Vojnosanit Pregl. 2013 Mar;70(3):259-66.
Hartofilakidis G, Bardakos NV, Babis GC, Georgiades G. An examination of the association between different morphotypes of femoroacetabular impingement in asymptomatic subjects and the development of osteoarthritis of the hip. J Bone Joint Surg Br. 2011 May;93(5):580-6.
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Elbow Treatment 1.0
Lateral elbow pain (lateral epicondylitis, AKA tennis elbow, radial nerve entrapment syndromes) is a frequent presentation in our clinic March-May as folks who started a weight routine for a New Year’s resolution begin to ‘crash and burn’ as poor form leads to tissue failure in the extensor tendons for the wrist. Nirschl described a surgical technique in the 1970s which was highly effective at relieving this condition. Common current wisdom is that the putative cause of pain is related to the commonly observed granulation tissue associated with the ‘mobile wad of 3′ extensor tendons. Co-morbidity we frequently see in clinic may include entrapment neuropathies and Miller and Reinus, in 2010 provided a nice review of those. While this is interesting from a structural perspective and helps to inform manual therapies addressing this condition, it is not the thrust of this article. Let’s examine lateral elbow pain from a functional point of view.
Elbow Treatment 2.0
Borrowing a page from the Joint by Joint approach, the elbow is a hinge joint somewhat analogous to the knee. The literature suggests that many of the maladies of the knee can be addressed by working on strength and mobility around the hip. Similarly with the elbow, we see a stable joint complex surrounded by comparatively more mobile shoulder and wrist joints. Consistent with Joint by Joint, poor mobility in the inherently mobile joint structures will lead to the body “asking for” more mobility in a stable joint complex, in this case the elbow. Often using this approach and working through shoulder mobility and stability we can have a great impact on the long-term function of the elbow. In the last several years this approach has been quite useful in reducing treatment time and improving outcomes in this condition in our clinic. Typically we would focus on improving scapular mobility often using Stecco’s manual therapies to assure appropriate scapular retraction and protraction. Upper thoracic joint mobilization or manipulation was also quite helpful in improving overall shoulder mechanics by improving mobility in the scapular thoracic articulation and in the thoracic spine in order to spare the glenohumeral articulation. A patient in our clinic today provided an excellent example of an even more modern approach integrating DNS principles with the joint by joint and manual therapy methodology.
Elbow Treatment 3.0
SR, a 35-year-old public safety officer, presented with left lateral elbow pain which began insidiously over the past several weeks. Eight weeks before he had started a self-improvement project involving weightlifting using a four day split. Prior to that it had been several years since he had engaged in regular weightlifting. Significant prior history included several incidents of shoulder injury and near dislocations on the affected side. Painful ADLs included reaching for the milk in the back of the refrigerator, lifting a coffee cup, opening a heavy door or gripping the handlebars of his mountain bike. In the gym, patient found benchpress, and overhead pushing and pulling exercises to be provocative.
In standing, left arm was inwardly rotated and the humerus was palpated in an anteriorly displaced position in the glenoid. Shoulder abduction, external rotation and extension were painlessly limited in active range of motion. Palpation over the left lateral epicondyle of the humerus, passive left wrist flexion, resisted left wrist extension, and strong handshake all produced pain at CC. Strong handshake produced 6/10 severe pain. Intra-abdominal pressure (IAP) assessment revealed rib flare, apical breathing pattern and poor ability to pressurize the thoraco-pelvic canister. Spinal segmental extension restrictions were noted in the thoracic spine. ULNNTs were negative and Spurling’s suggested no radicular involvement.
A structural diagnosis of lateral epicondylitis was rendered with functional contributors including:
- poor IAP/respiratory pattern per DNS protocols,
- poor shoulder mobility leading to overuse of the stability-loving joint complex per Joint by Joint approach.
We decided to begin with DNS-informed protocols first to see if patient would be able to correct most of his own condition utilizing functional corrective exercise. We decided that afterward we would address joint and myofascial components as deemed necessary.
Patient was instructed in diaphragmatic breathing while maintaining rib tuck position and long spine. That pattern formed the basis for all subsequent exercises. We then trialed dead bug, wall bug and foam roll progressions and the latter 2 were within patient’s functional pain free range. In short as Dr. Craig Liebenson would put it, they were the most difficult exercises the patient could perform excellently. To see Dr. Liebenson apply this approach you can check out this video. To assist with thoracic extension while providing a closed chain weight-bearing position for the affected joint complexes patient was coached in modified Sphinx exercise. Before manual therapy was applied, a mid-treatment audit was performed as a handshake test. With firm grip patient smiled widely and noted that he only had 1/10 severe pain in the lateral elbow. Objectively, the strength of the grip was quite a bit more robust.
Subscribers to MyRehabExercise.com may view the above videos by clicking on the images.
Manual therapy included prone manipulation of the T4 segment into extension as well as prone combo manipulations of the upper ribs. Glenohumeral rotation mobilizations were provided in internal and external vectors through abduction and flexion ranges of motion to aid in joint capsule mobility. Graston technique was provided using gua sha type rapid stroke movements proximal to distal to improve blood flow and oxygenation of the extensor muscles. This concluded the treatment portion of the first encounter. Total amount of contact time for this established patient with new presentation was 30 minutes. A posttreatment audit was performed as strong handshake and patient had 0/10 severe pain in the lateral elbow and his grip strength was markedly improved. He received emailed exercise prescription follow-up of all of these exercises from MyRehabExercise.com. He was scheduled for a return visit in one week which will likely consist of manual therapies per Stecco protocols to improve scapulothoracic mobility and joint centration of the glenohumeral articulation. typical follow-up exercise at that time will likely be closed chain DNS exercises such as Tripod Sit and Bear Crawling and Therabar Eccentrics.
Previous blog posts here outlined the rationale for addressing the deep spine stabilization system and respiratory pattern in this case. Below is the graphic that shows how those dominoes stack up.
According to DNS theory, the hypertonic upper trapezius represents an adaptational motor program for shoulder stabilization. In the absence of an adequate punctum fixum with a well functioning deep spine stabilization system, lower trapezius and serratus anterior are unable to stabilize the scapula against the chest wall. The upper trapezius is then placed into a primary role to stabilize the shoulder girdle by “plugging it in” to the cervicothoracic area. The resultant alteration in biomechanics pitches scapula upwards and forwards in the shortening of the pectoralis minor and internal rotators. The hypertonicty in these muscles in turn de-centrates the humeral head in the glenoid. While the clinician and manual therapist can positively impact the course of care with manual method alone, adding this kind of foundational corrective exercise dramatically decreases the treatment time and improves the overall musculoskeletal health of the patient. Much of this exercise work can also be provided by a heads up personal trainer who has learned these techniques, but the trainer should have a DC or PT help on the pain management end. Better yet, those trainers who are familiar with DNS assessment techniques for their work, can help avoid having their clients on the disabled list where they can’t train at all.
I will try to follow up with this patient on the blog in future posts. In the meantime, consider MyRehabExercise.com for excellent patient/client oriented videos for the correctives shown above as well as many more to help with your functional exercise instruction. Click on the link below to learn more!
Nirschl RP, Pettrone FA. Tennis elbow. The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979 Sep;61(6A):832-9. PubMed PMID: 479229.
Miller TT, Reinus WR. Nerve entrapment syndromes of the elbow, forearm, and wrist. AJR Am J Roentgenol. 2010 Sep;195(3):585-94. doi: 10.2214/AJR.10.4817. Review. PubMed PMID: 20729434.
Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010 Feb;40(2):42-51. doi: 10.2519/jospt.2010.3337. Review. PubMed PMID: 20118526.
Strunce JB, Walker MJ, Boyles RE, Young BA. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. J Man Manip Ther. 2009;17(4):230-6. PubMed PMID: 20140154; PubMed Central PMCID: PMC2813499.
In recent conversations with students in my office and with colleagues curious to learn more about how Dynamic Neuromuscular Stabilization (DNS) works “on the ground” in practice, I have attempted to bring together an overview that can be readily understood for these folks. Full disclosure…at this point (2-17-2013) I have completed DNS training through the “C” level of clinical practice and “Sport” courses 1 &2. This level of training does not qualify me to be an instructor in the DNS system, so all of my musings here should be taken with a grain of salt and are trumped by those who have received those more advanced qualifications. Therefore, think of this post as my own personal musings as I attempt to integrate the work into my sports-injury/rehab-focused practice of chiropractic and take what you will from it. The graphic below was my attempt to explain the flow of common musculoskeletal injury and dysfunction through the DNS lens. Below that, we’ll examine each of these points so that we can see how this pattern recurs with our patients. In future posts, we may refer back to this post to help frame specific Case Studies.
1. Apical Respiration-When Stress Somatisizes
One of the primary tenets of DNS is the importance of breathing stereotype. The effects of inefficient respiration carry over to other disciplines of health care such as cardiology (1,2,3), gastroenterology (4), pain management (5) and psychology (6) as well. In the DNS model, breathing patterns that are high in the chest, rapid and shallow (apical) can result in altered position of the diaphragm. (7)
2. Disruption of Native Spine Stabilization Strategies
Using the muscles of the ‘deep core’ (multifidii, transversus abdominis, pelvic floor and diaphragm), spine stabilization can occur via improved intra-abdominal pressurization. (8,9) This video by Gray Cook, PT speaks to this topic from a tangential viewpoint.
3. Adaptation of High Threshold Stabilization Strategies
When optimum stabilization strategies are not available, phasic muscles typically used for prime movement are used to both move and to provide alternate stabilization strategies. These strategies for movement often result in joint de-centration which leads to less-than-optimal performance. If loads are too high, too intense, or too frequent joint degeneration and tissue failure may be the result. Charlie Weingroff, DPT speaks to this below.
4. Structural Adaptations of Myofascial Elements
Langevin and other researchers have shown that the fascial remodeling occurs in those with chronic low back pain (CLBP) and that the lumbodorsal fascia of those with CLBP is 25% thicker than in controls. (10,11) The presence of ’tunnel syndromes’ involving superficial neurology has been well described. (12) Janda’s Crossed Syndromes spoke to inhibition of agonists in the presence of shortening of antagonists. This pattern was later updated by Gray Cook and Mike Boyle and is now referred to as the Joint by Joint Approach. As synergistic muscles are re-tasked to shoulder the load left by inhibited muscles, remodeling of the muscle can change its texture, pliability and result in fascial remodeling in the involved muscles. This may also result in superficial entrapment of local superficial nerves and result in local neuralgia in the absence of joint or muscle injury. This point in the process is where manual therapy has the most direct impact and allows bodyworkers an in-road on understanding and treating patients using a functional approach.
5. Tissue Failure/Degeneration and Diminished Performance
Langevin also theorized in her paper on thoracolumbar fascia,
“Possible explanations for reduced thoracolumbar fascia shear strain during passive trunk flexion in LBP include abnormal patterns of trunk muscle activity and/or intrinsic connective tissue pathology.” (13)
In the DNS model, we may see common injuries develop around the hip, knee, shoulder and elbow in response to the aberrant loading of those joints in these scenarios. Rather than structure-focused treatments to address the site of pain, practitioners assess movement and stabilization strategies and address those non-painful dysfunctions to effect long lasting beneficial changes. Similarly, in the FMS model, we screen for asymmetrical movement patterns and correct the non-painful dysfunction. These last 2 areas we will save for further explorations with case studies to demonstrate the clinical applications of the combined structural-functional methods. We will also show those corrective exercise interventions featured on MyRehabExercise.com.
- Anderson DE, et al. Regular slow-breathing exercise effects on blood pressure and breathing patterns at rest. Journal of Human Hypertension. In press. Accessed Nov. 9, 2010.
- Gavish B. Device-guided breathing in the home setting: Technology, performance and clinical outcomes. Biological Psychology. 2010;84:150.
- Schein MH, et al. Treating hypertension in type II diabetic patients with device-guided breathing: A randomized controlled trial. Journal of Human Hypertension. 2009;23:325.
- Bryan T. Green, MD; William A. Broughton, MD; J. Barry O’Connor, MD, MS(Epid). Marked Improvement in Nocturnal Gastroesophageal Reflux in a Large Cohort of Patients With Obstructive Sleep Apnea Treated With Continuous Positive Airway Pressure. Arch Intern Med. 2003;163(1):41-45. doi:10.1001/archinte.163.1.41.
- Busch V, Magerl W, Kern U, Haas J, Hajak G, Eichhammer P. The effect of deep and slow breathing on pain perception, autonomic activity, and mood processing–an experimental study. Pain Med. 2012 Feb;13(2):215-28.
- Alicia E. Meuret, David Rosenfield, Anke Seidel, Lavanya Bhaskara, and Stefan G. Hofmann. Respiratory and Cognitive Mediators of Treatment Change in Panic Disorder: Evidence for Intervention Specificity. J Consult Clin Psychol. 2010 October ; 78(5): 691–704.
- Kolar P, Sulc J, Kyncl M, Sanda J, Cakrt O, Andel R, Kumagai K, Kobesova A. Postural function of the diaphragm in persons with and without chronic low back pain. J Orthop Sports Phys Ther 2012;42(4):352-362.
- Hodges PW, Eriksson AE, Shirley D, Gandevia SC. Intra-abdominal pressure increases stiffness of the lumbar spine. J Biomech. 2005;38:1873-1880.
- Hodges PW, Cresswell AG, Daggfeldt K, Thor- stensson A. In vivo measurement of the effect of intra-abdominal pressure on the human spine. J Biomech. 2001;34:347-353.
- Langevin HM, Sherman KJ. Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Med Hypotheses 2007;68(1):74–80.
- Langevin HM, Stevens-Tuttle D, Fox JR, Badger GJ, Bouffard NA, Krag MH, Wu J, Henry SM. Ultrasound evidence of altered lumbar connective tissue structure in human subjects with chronic low back pain. BMC Musculoskelet Disord. 2009 Dec 3;10:151.
- Pecina MM, Krmpotic-Nemanic J, Markiewitz AD. Tunnel Syndromes: Peripheral Nerve Compression Syndromes. CRC Press, 2001.
- Langevin et al. Reduced thoracolumbar fascia shear strain in human chronic low back pain. BMC Musculoskeletal Disorders 2011, 12:203
On Jan 10-13 I had the pleasure of attending the DNS-Sport 1&2 courses in LA at Chris Powers’ Movement Performance Institute and given that many have contacted me about the content of the course, thought I should put together a review. My exposure to DNS to date has been through the clinical track of DNS A,B and C certifications (C cert pending) over the past 3 years and may continue with D level in the next year.
I will say that I entered this Sport course with some reticence as I was not sure whether adding more DNS material in my toolbox was going to help much. The primary tools I was looking for, corrective exercises to share with patients, seemed to be an afterthought in my previous courses. My specific points that I was personally concerned about with my prior DNS classes were:
- Too much focus on internal cueing strategies vs external cueing strategies
- Too little focus on corrective exercises to share with patients to reduce need for care
- Prevalence of so-called Vojta ‘reflex stimulation points’ in the course matter
- Poor organization of material and course notes
- Too much focus on pediatrics
So How Were the DNS “Sport” Courses Different?
I was stoked to find that the “Sport” courses had left out pediatrics, reflex locomotion material and internal cueing focus had been de-emphasized! Finally too, exercise strategies we can share with our patients and clients were the focus! I was very excited about this turn of direction in the DNS course work but heard from some of my strength and conditioning (S&C) colleagues that they were concerned about the persistent clinical focus of the course and the hands-on cueing demonstrated. Grand Rounds focused on injured athletes, but instructor Petra Valouchova studiously avoided rendering a diagnosis or focusing on tissue injury. Instead the focus was on movement assessment and correction, these are tenets that are the bailiwick of both the S&C world and in the clinical rehab world thanks to the FMS/SFMA paradigm shift provided by Gray Cook. Statutes and scope of practice restrictions in much of the world prevent trainers and S&C folks from manual contact with their clients, but the roughly 50% population of S&C folks in the room, they saw that this material was easily verbalized to potential clients.
When I came back home to Portland, the only regret I had was that the incredible group of S&C folks that I share patients and clients with did not yet have this material under their belts. While the FMS/SFMA palette gives clinicians and trainers a common language to speak and hand off to each other with, the DNS material has not reached that level of common usage yet. The courses I attended provide that common map from which we can use our respective fields of experience to orienteer.
What’s in a Name?
I think that perhaps the “Sport” designation was a misnomer that grew out of earlier conversations about how to create a template that clinicians and trainers can work from together. I propose that these “Sport” courses are a MUCH better introduction to motor pattern ontogeny and to achievement of proper joint centration to set the stage for performance than are the clinical A, B, C, D level courses. As a result, I think the current Sport courses should carry a name that better reflects their content…something like
- DNS 1-Introduction of Developmental Motor Patterns,
- DNS 2-Application of Functional Joint Centration to Reduce Injury.
- The true “Sport” course, which has yet to be developed, would focus on use of these principles to bring optimal performance to athletics. I’m thinking of a name like DNS 3-Optimizing Performance with DNS Principles. Those venues would be in gyms and weightrooms and Grand Rounds would not be injured athletes, but would instead feature promising athletes at different developmental levels who want to run faster, jump higher, throw farther. I could see those courses using items like Omegawave over subsequent days and OptiGait and slow motion video capture to see pre and post DNS interventions in the healthy athlete. Further coursework could focus on sport specifics…Track and field, Cycling, Tennis, etc. See..now I’m excited!
DNS Sport At Present
For now, the course content of the DNS-Sport classes is as follow:
DNS Sport 1 and 2 are an introduction to ontogenic motor patterns.
Course 1-Focuses on development of deep spine stabilization system via diaphragm/pelvic floor and TA
Course 2-Focuses on joint centration of limbs on the deep spine stabe system. Course 2 also teaches assessment and correction of common motor pattern faults that can lead to injury. Here I’m talking about the chronically tight hip flexors and traps that defy daily stretching techniques. We all see these in clinical practice and might even know them as Upper Cross and Lower Cross through the Janda perspective. However, many of us with manual toolboxes ‘face palm’ daily about the recurrent tightness in those muscles that doesn’t respond to stretching, ART, Graston, foam rolling, lacrosse balls, etc. DNS offers a window to effectively treating these hypertonic muscles by improving intrinsic spine stabilization to take to adaptive stabilization roles these types of muscles off of the table. Phasic muscles return to their movement roles and very quickly decrease hypertonicity when the stabe system is returned.
So, should you, as a trainer or clinician, cough up the $$ to bring this understanding to your patient/client population? IMHO, the answer is an enthusiastic YES!!! Moreover, I think the current DNS-Sport 1&2 courses embody best way to gain access to this material in an organized, well-presented manner…even if the courses are named wrong In the future, that Performance course I wished for above , will be presented and you will want to have the understanding represented in the current Sport courses. If you want opinions of others that attended the Sport courses, check out the videos below.
Finally for my colleagues in Prague, I would also offer constructive criticism that the courses would be improved by offering a repository of videos to course attendees which offer review of the movement patterns. Perhaps the excellent library that Mike Rintala, DC and Dave Sabo are cranking out can be used! I can imagine a password protected site where attendees could see instructors demonstrating and covering the essential points of prone and supine movements on video for their own review. I could also see benefit in another service for attendees consisting of PDFs of specific exercises that are covered in these courses. These PDFs could contain photos and key points and work as handouts to help the patients and clients do their home exercises. Just a thought!
In my clinical practice of chiropractic, I mostly manage pain and the majority of that pain is back pain. In school, we docs are taught that back pain from discs represents perhaps 10-15% of all cases of back pain. However, other research points out that when back pain becomes severe enough to prompt a person to seek care, roughly 50% of that back pain is related to the lumbar disc. If you know what to look for, you can pick up that irritated disc on clinical exam well before the disc injury becomes significant enough to cause neurological symptoms.
My practice has been informed by the works of my mentor, Craig Liebenson, and thus by Vlad Janda, Pavel Kolar, Karel Lewitt and Stu McGill. Gray Cook came along and turned the rehab and personal training world on it’s ear by suggesting that rather than battling over turf, trainers and rehab professionals should work to liase and thus improve patient and client outcomes. I’ve been fortunate in my practice to work hand in hand locally with some cracker jack trainers like Chris Bathke, Tony Gracia and powerlifter and coach Chris Duffin. Here’s what guys like this know that many of us in the rehab world are missing. The magic is in the movement, not in the therapy.
Most back pain significant enough to prompt a person to seek treatment is flexion-intolerant. Much of that pain will ultimately progress to become discogenic if it isn’t already. In the clinical world, we can apply the McKenzie derangement model, some steam and cream, some rubby-dubby and some poppy-cracky to that back all day long and walk on water. “Thank you doctor for helping me get out of pain!!!” Then, when the pain professional cuts the patient loose and says to go back to the job/game/whatever, the patient re-injures themselves, that patient is back in the pain management racket. When the patient says “What can I do to improve my FUNCTION?”, that’s when the pain pros get vague. “Well, maybe you can come in on a regular basis so that we can keep you ‘in-line’ and that might help”. Coincidentally, that’s what the pain pro learned from the MBA in the practice management seminar over the weekend. Luckily most DCs don’t use the type of $$$-first, patient-second tactics identified below. If you’re a patient and you get this kind of treatment, laugh at the “doctor” and walk out of the room…please!
So in the context of the flexion intolerant back, here’s what the personal trainer knows that too few DCs and PTs know…That client’s back hurts because their squat and deadlift pattern sucks! Shout it out trainers! Your squat and deadlift sucks! Fix that crap and your back will get better. The way I explain it to patients, the simplest way of understanding the flexion intolerant, discogenic back is to realize that they have an inappropriate hinge in their lumbar spine and it should instead be in their hip joint. I love it when I see those patients that come back after several years for the odd computer-neck and note that their back pain got WAY better when the found this great trainer who taught them how to squat. I always get those trainers’ cards and keep them on hand so that I have a pool of references when patients want help in the gym.
Now, here’s the dark side…don’t be the trainer checking your email while your client cranks out 3 sets of 10 “bicycling”, performing spine flexing/compressing “core work” because some ACE article said it provided the “highest EMG activity of any ab exercise” (while loading the spine in flexion). Never mind that while you were friending Joe Dowdell on Facebook, your client was gassing in the captain’s chair demonstrating hip and lumbar movement dissociation and flexing that lumbar spine under a compressive load and inching closer to my office. Don’t be the gal wondering if “those are real” on the woman across the gym while your client drops below their functional squat range under load and flexes their lumbar spine. Instead, catch that crappy squat and deepen their functional range with Stu McGill’s cues to “bend the bar” and “spread the floor with your feet”.
Recently Charlie Weingroff had an interesting post on the flexion intolerant back through a McKenzie and an SFMA lens. As I read I remembered Stu McGill’s admonition to us years before when managing a compromised back…Job 1. Correct the poor movement pattern. Fix that crappy squat. Pick up your purse without a lumbar hinge. Move the hip with the spine stabilized. Roll over in bed with the abs braced. Perhaps as Mike Boyle suggests, shift that client to a split squat or Bulgarians rather than a heavy back squat to spare the spine.
A few months ago I put together my clinical approach to the flexion intolerant back in a self-help education and exercise focused website called FixYourOwnBack.com. I encourage those with flexion intolerant backs to:
- Correct the lumbar hinge and restore the hip hinge
- Use McKenzie-influenced extension patterns as “First Aid” to help with the back and leg pain.
- Use McGill’s Big 3 and the DNS influenced Sternal Crunch and Diaphragmatic Breathing from Craig Liebenson to stabilize the spine
- Use the FMS-influenced correctives to address common hip and T-spine mobility deficits
- Integrate the stable spine with the mobile hips using more FMS-based correctives
- Build strength, agility, power using kettlebell-focused basic movement patterns with low tech, low cost, low objection exercises like TGUs, swings, front squats, etc.
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I’m still rolling with the excellent presentations I was witness to in Seattle at the Perform Better 1 Day Event on April 21, 2012!! Sadly, when I searched my calendar for the upcoming 3-Day evenets I found that I was already booked on the dates of the Providence, Chicago and Long Beach summits. What are the odds!? The rest of you should be at one of those though. Here is my take on the event that weekend that featured some real heavy hitters…
As fate would have it, Mike Boyle who was on the agenda, was tied up with spring training in his new job with the Red Sox. While I was disappointed to not meet Mike, the guy who pinch hit for him wasn’t half bad either! Gray Cook stepped in to join Charlie Weingroff, Rachel and Alwyn Cosgrove for one of the most enjoyable, well organized and knowledge filled continuing ed events I’ve attended in many years. The format was an hour of didactic from each presenter, lunch, and then the afternoon was 30-40 minutes rotating between 4 hands-on stations hosted by each presenter. In contrast to the typical neck and back numbing sit-fest that usually is present in a weekend CEU event, this one even managed to allow participants to get a bit of a workout in.
Rachel led off with an excellent presentation that chronicled her work with training over the years and her eventual focus on training women and fat loss clients. Participants got a good dose of the psychology that is inherent in managing these clients and keeping them motivated for results. In the afternoon, she led attendees through thoughtful exercise progressions from corrective to high performance and did a masterful job matching the training strategies to FMS scores on the FMS screen. I appreciated the low tech/low space approach of using kettlebells, furniture sliders, resistance bands and TRX suspension trainers to go through some very creative approaches to managing some challenging functional limitations. Keep your eye out for these correctives in the member’s area for MyRehabExercise.com in the future!
Charlie is perhaps the only guy on the speaking circuit who can address 200 people in an 8000 square foot hall without really needing a mic! He brought his obvious passion to breaking down some of the DNS material into the training environment with Understanding Joint Centration. He continually brought the listeners around to the feedforward process of centering of joints to allow for green light from the cortex for optimal and painfree performance. In the afternoon, he navigated that territory using TGU positions, allowing us to feel the difference in loading capacity in centrated vs. un-centrated positions. The sled pulls were especially entertaining in seeing the impact of pulling both with and without shoulder and neck packed positions with several volunteers really getting an excellent take home lesson! I particularly liked the simple, elegant demo of toe touching with and without the neck packing. It went like this…
Position yourself with your back to the wall and a foot or so away from the wall. Pack the neck by performing a chin retraction and keeping the neck in neutral, i.e. don’t tip your head down. Bend forward and touch the toes, and wiggle your feet to position yourself where you are simultaneously touching the toes while barely touching your butt to the wall. Return to upright postion and repeat but this time arch your neck up and look at the ceiling. Put your butt against the wall and then try to touch the toes again. Can you feel how much more restricted your toe touch is? Imagine the implications as you try to deadlift and reduce your ability to toe touch. In our challenged patients and clients, this could result in a rounding of the lumbar spine as they try to get to the bar!
Gray was his usual entertaining self as he doled out detail after detail from his voracious reading habit. He made a case for the need for a checklist in our approach to assessment and a standardized system such as the FMS so that we can track changes in our patients and clients.I appreciated the sharing of Ed Thomas’s slides showing the evidence of dysfunctional movement in Americans in the 1950′s whereas 50 years prior movement pattern trends in physical education were much better. The example of the military rifleman shooting from a deep squat position in the 40′s and the need to change that training as the recruits showing up for training in later years steadily lost the ability to deeply squat.
Gray is also a thoroughly quotable figure. Below are a few of the gems that issued forth over the weekend:
- ”You will not hear me tell a pt to engage the glutes. I’ll put them in a position where they can’t engage their quads and back and ask them to move.”
- ”We teach squatting in reverse in the gym…by putting the weight up high and move under it. Babies start on the ground and move their own weight up.”
- “People are not a bag of parts, they’re a bag of patterns”
- “That functional movement pattern your client/patient is looking for is not missing, it’s on their hard drive, but they’re having difficulty locating it.”
- “We’re all in the wrong business because the mark up on duck calls is like 7000%.” (Author’s note: OK, OK, this was later over dinner after enjoying the local ‘cider’)
Alwyn was very entertaining too but as a clinician, I must admit I was not excited for his talk on Cutting Edge Fitness Business Principles. However, I wound up taking a single pearl home that I think may ultimately be an excellent adjunct to the FixYourOwnBack site that I’m currently re-tooling. More on that later… Honestly, Alwyn’s gym, Results Fitness offers a fabulous training model for group training environment which captures a lot of the fun energy people seem to like in the Crossfit model, but offering sustainable movement exercise that challenges multiple energy systems while focusing on complex functional movements.
Later, he put us through a challenging 27 minute workout that hit all the basic high points: static mobility, dynamic mobility, strength, speed, power, reaction time and agility along with a nice metabolic challenge as a cherry on the top! Nice way to end the day! You can see an example of the gym flow at Results Fitness at this video below.
As it turned out, the day wasn’t over for me, and I had the opportunity to join Charlie, Gray, and Tim Vagen for dinner. As Charlie was co-presenting the following day nearby at Joel Jamieson’s gym along with Patrick Ward, those 2 joined us along with Sounders strength coach David Tenney. Rumours on the grapevine suggest that that event was recorded and will show up as a DVD in the near future so keep your eyes out! Great meal, great company and a fabulous event. I can’t thank the Perform Better folks too much for putting together a great event, and heartily encourage readers to get out to one of these gatherings in the near future. For a schedule of upcoming Perform Better events, click here!
This is the third installment of our series on the ‘care and feeding’ of the injured lumbar disc. In Part 1 we discussed the structural pathology (the broken stuff) and in Part 2 we started a discussion of the functional pathology (why stuff broke). Today, we’ll continue the functional discussion assuming you’ve done some pre-reading or have an understanding of the Joint By Joint Approach. If you don’t, follow the link and brush up. Also, these approaches and the exercises associated with each stage of the rehab process are represented in the library of detailed functional rehab exercise here at MyRehabExercise.com. You can’t use them to help teach your patients and clients unless you’re a member. Membership is inexpensive ($9.99/mo), 30 day trial for $1 and you can discontinue service anytime. Follow the links to the right to sign up.
If you don’t have an office set up to instruct your clients or patients in rehab exercise, or if you just don’t feel comfortable customizing the exercise Rx yet for disc injury, check out FixYourOwnBack.com. There, you can just refer your patients or clients with disc injury, disc bulge, herniation, sciatica and for $9.99/mo they can receive the self-help education and rehab Rx that is being discussed in this blog series re: management of the lumbar disc injury.
The Plan–”Plan the work, then work The Plan”
Once we have an injured lumbar disc, The Plan (as it’s referred to on FixYourOwnBack.com) is as follows:
- Stop faulty movements and postures that “pull the scab off” of the healing disc
- Learn disc “First Aid” using McKenzie methods to assist in healing and control pain
- Use McGill’s Big 3 and DNS methods to stabilize the lumbar spine
- Improve mobility in the T-spine and hips to spare the spine
- Use FMS-based corrections to integrate stability and mobility achieved in #3 and 4 above into long term sustainable movement patterns
- Improve strength in the muscles necessary to perform #5 above
- Improve agility in those sustainable movement patterns to help with resilience when life throws a curve
- Incorporate sport specific skills to help manage disc injury and recurrence
The Stiff Upper Back
The Creaky Hips
As the shortened flexors’ insertion onto the lesser trochanter persists, the femur shifts anteriorly in the acetabulum. When that individual squats deeply, the acetabular labrum gets munched and sometimes the repetitive loading of this imbalanced hip into deep flexion can result in bony changes now referred to as femoral acetabular impingement (FAI). For more info on FAI, check out this link to Craig Liebenson’s blog. Learning how to test for this is helpful, as an Xray can point to whether that patient should be in an orthopedist’s office. However, all anterior hip pain is NOT FAI, and the condition starts as a soft tissue issue. Catching it early in the progression means you can head off not only a hip replacement years later but also the well-meaning FAI surgery!
Charles Scott Sherrington’s Law of Reciprocal Innervation won him a Nobel Prize in 1932 for describing the neurological relationships between agonist and antagonist muscle groups. Stated simply, when a muscle contracts, its antagonist on the other side of the joint is reflexively relaxed to allow joint movement to occur. Several decades later, Czech neurologist Vladimir Janda coined a corollary to Sherrington’s Law which states that when a muscle’s resting length has been shortened, it’s antagonist will be reflexively inhibited. Around the hip joint, the tight hip flexors inhibit the large muscles of the buttock…the glute max and the glute med. This condition in the hips has been referred to in Janda circles as part of the Lower Cross Syndrome, and years later by Stu McGill as ‘gluteal amnesia’.
- In single leg stance, pull one knee to the chest and release.
- Observe for failure in ability to maintain >90 degrees of hip flexion for 15 sec.
- Is there cramping in the TFL?
- Observe for posterior lean, rounding in the spine or lateral tilt of the pelvis
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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.
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.
- Use McKenzie prone press up to control pain
- Correct transitional movement flaws and posture faults to stop ‘picking the scab’
- Stabilize the lumbar spine by building endurance in sagittal and frontal planes/incorporating proper breathing stereotype
- Correct mobility deficits that likely exist in the T-spine and hips, possibly ankle
- Build strength
- Build agility
- Build power
- 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!