Embracing Complexity: The Mountain Stream Metaphor

• "For every complex problem there is an answer that is clear, simple, and wrong" -H.L. Menken

Keeping “it” simple is important at times.  It prevents us from becoming overwhelmed, clarifies concepts, aids in general understanding, and directs the focus towards a single goal.  Most importantly, keeping it simple is necessary when communicating new topics or concepts to others.  However, the problem occurs when keeping it simple is used a substitute for understanding the complexity.When we oversimplify complexity it increases the chances of a blunder occurring.  Assumptions, cognitive biases, and ignorance all become more prevalent when we start to overlook the dynamic and intricate patterns of problems, situations, and systems.  This can be seen in everything from politics to healthcare.  Even everyday discussions are often plagued with people over simplifying a topic to support their perspective (whether they know it or not).Thus, to avoid these cognitive traps and mental errors it is important to embrace complexity and attempt to identify and study it, not to ignore or eliminate it.One way to understand complexity is through the Dynamic Systems Theory.  More specifically, I have found the following metaphor from Esther Thelen to be an interesting  thought experiment.  She invites you to become aware of the ever-changing complexity of something as “simple” as a mountain stream.

The Mountain Stream Metaphor

“The metaphor is of a fast-moving mountain stream. At some places, the water flows smoothly in small ripples. Nearby may be a small whirlpool or a large turbulent eddy. Still other places may show waves or spray. These patterns persist hour after hour and even day after day, but after a storm or a long dry spell, new patterns may appear. Where do they come from? Why do they persist and why do they change?No one would assign any geological plan or grand hydraulic design to the patterns in a mountain stream. Rather, the regularities patently emerge from multiple factors: The rate of flow of the water downstream, the configuration of the stream bed, the current weather conditions that determine evaporation rate and rainfall, and the important quality of water molecules under particular constraints to self-organize into different patterns of flow. But what we see in the here-and-now is just part of the picture. The particular patterns evident are also produced by unseen constraints, acting over many different scales of time. The geological history of the mountains determined the incline of the stream bed and the erosion of the rocks. The long-range climate of the region led to particular vegetation on the mountain and the consequent patterns of water absorption and runoff. The climate during the past year or two affected the snow on the mountain and the rate of melting. The configuration of the mountain just upstream influenced the flow rate downstream. And so on. Moreover, we can see the relative importance of these constraints in maintaining a stable pattern. If a small rock falls into a pool, nothing may change. As falling rocks get larger and larger, at some point, the stream may split into two, or create a new, faster channel. What endures and what changes?”

A Movement Assessment Example

Let’s take the example of someone who can’t touch their toes.It may be useful to give this person a specific, simple exercise (ex. KB ASLR) and education (ex. thought viruses) to help cause an immediate shift in their movement pattern - kind of like a rain storm quickly altering the way the stream runs.  The benefit of this approach is that it offers control and predictability, which are two main factors when working with stressed and painful systems.  However, as many of us have experienced in the clinic, these quick changes are usually temporary and are neither complete nor permanent fixes in themselves.  The rain storm passes and the stream returns to it’s former pattern.  To truly affect the path of the stream it’s important to direct some attention to the entire mountain system.In the example of someone who can’t touch her  toes it is important to acknowledge the mountainous (sorry, couldn’t resist) complexity of “why”... Maybe she can’t touch her toes because she has a stiffer body that lays down more collagen - her parents can’t touch her toes and their parents’ parents couldn’t touch their toes (epigenetics?).  Maybe her allostatic load is too high because she’s overstressed from her job or relationships.  Maybe she’s not motivated.  Maybe she has a psychological issue - depression, anxiety, history of trauma, etc.  Maybe it’s behavioral.  Maybe she grew up in a very sedentary lifestyle and prefered to read or play video games for the first 26 years of her life.  Maybe she was taught to lift weights or perform athletic techniques improperly and hammered those patterns into her body over many years.  Maybe she believes that rounding her back or lengthening her hamstring is dangerous.  Maybe she has a cold (neuro-immune connection).  Maybe her microbiome is a mess.  Maybe she doesn’t sleep well and has a circadian mismatch.  Maybe it’s her vestibular system, stomatognathic system, or vision.  Maybe it’s neurodynamics.  Maybe it’s her respiration.  Maybe it’s an osseous abnormality.  Maybe she can’t IR her femur because of her pelvis position.  Maybe a joint is tight in her cervical spine that decentrates the rest of the body.  Maybe it’s a forefoot varus.  Maybe it’s her posterior hip capsule.  Maybe her paraspinals are unable to eccentrically control the movement.  Maybe it’s her core. Or maybe it’s one of the other many things that could prevent any human from touching their toes.It’s important to acknowledge the intricate, evolving interaction of these variables, which then becomes another variable in and of itself.  It’s the perspective of “the whole is greater than the sum of its parts”. Once all this is considered it will be easier to determine which variables can act as a control parameter to cause the desired phase shift of the system. In other words, maybe for the aforementioned patient a neurodynamic exercise would provide an adequate stimulus to shift her system into a place where she can perform a full, pain free toe touch.  Or maybe it will require a combination of stimuli such as a core strengthening program, improved sleep hygiene, and graded exposure.  Or maybe...The success does not lie in the intervention, but how the system responds as a whole.This complexity is why one exercise, manual technique, or communication style will work well with one patient, but have no effect on another “similar” patient.  Or why someone may not do well with physical therapy, but feels better after going to a dietician or getting a new job.Some people may be able to alter their stream easily with a simple passing weather pattern, while others will need a long-term tectonic shift.  The art is finding where the change needs to come from.Simple will work at times, but it is not a solution for all.  The human species is far too complex to be simple.

Bottom Line

It’s great to keep it simple on some levels.  But don’t make the blunder of convincing yourself that it is simple.  Instead, embrace the complexity.  How do you do this?Dig deeper.  Try to gain a better understanding.   Always look to learn more.   Learn to enjoy the state of not knowing - curiosity.  Find the quality.  Never be satisfied.  Always ask why.  Then ask why several more times.  And dedicate yourself to the lifelong effort of finding the elusive truth.Again, to reiterate, this isn't to say simple is bad. It's just that oftentimes I find the beauty of simplicity comes from understanding its complexity.

• “A philosopher is a person who knows less and less about more and more, until he knows nothing about everything.” -John Ziman

Thelen, E. and Smith, L. B. 2007. Dynamic Systems Theories. Handbook of Child Psychology. I:6.-- The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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An Open Letter to Crossfit: The 2 Mistakes (Part I)

As many physical therapists have probably noticed, there is an increase in the amount of Crossfit athletes showing up in our clinics.  This isn’t because it injures everyone.  It’s because it’s becoming very popular and people love it.We see the same thing happen during ski season and marathon season.  It’s not necessarily the activity, it’s the increase in participation.However, that’s not to say that it’s only an increase in participation that leads to a higher incidence of injuries.  There are many other variables involved.  Some of which can be improved upon to decrease the risk of injury.I’ve noticed a few trends in my experience with Crossfit athletes.  The crossfitters that tend to get hurt are the ones that seem to make the same 2 Mistakes:

1) Constantly Training to (and Past) Failure

2) Not Training Unilaterally Enough.

I think if Crossfit could improve on these 2 mistakes they would see a lot less people getting injured.

A Disclaimer

I have nothing against crossfit and don’t think it is ruining our species like some of my peers.  In fact, I think Crossfit is great.  Some of you might agree and some of you might be angry just by reading the word crossfit.  But let me explain why I think it’s good.Crossfit changes peoples lives.  This is often an exact quote from many of my crossfit patients.  I’ve had many patients who have lost tons of weight and become motivated to stay active because of Crossfit.  This leads to changes in other parts of their lifestyle and improves their overall quality of life .  Where personal trainers, spin classes, running, and traditional weightlifting have failed, Crossfit has succeeded.  In a time where obesity and sedentary lifestyles are an epidemic, anything that gets people moving should be viewed favorably.  I’d much rather have our population suffer with the occasional sore shoulder rather than die early from heart disease.Crossfit has popularized strength training.  Too many people go on crazy diets, perform too much aerobic activity, or follow DVD fads to lose weight and get a metabolic burn.  Crossfit has helped shift the emphasis to being strong.  And strength is one of the best modalities for improving function, decreasing injuries, reducing morbidity, and decreases mortality (1-11).Crossfit focuses on movements.  Isolated muscle strengthening and machine based workouts are better than nothing, but they are vastly inferior when compared to multi-joint based movements.  Crossfit has brought functional global movement exercises such as power lifts, olympic lifts, and kettlebells back to the mainstream (12-13, 22).One last disclaimer is that I know not all “Boxes” are the same.  Not all coaches are the same.  And not all athletes are the same.  Like every other activity or profession, there is a continuum of competence among crossfit gyms and coaches. I know there are a ton of very knowledgeable and talented Crossfit coaches out there already doing all the right things.  Also, these mistakes are not just made by Crossfit coaches.  There are many trainers, strength & conditioning coaches, physical therapists, and chiro’s making the same mistakes.  The goal of this article is simply to bring awareness and offer solutions for 2 common mistakes that seem to happen often (not to attack crossfit as a whole).

Mistake #1 = Constantly Training to (and Past) Failure

I understand it’s important to test your limits every once in a while.  And I know that when you’re in a competition or going for a PR many of the rules go out the window.  But that doesn’t mean you should train like this every time.As fatigue sets in, good biomechanics, technique, and form start to fail.  Everyone that has worked out to failure knows this and has felt this.  Even if you haven’t experienced a fatigued state, there is more than just empirical evidence to support this hypothesis.  Research has shown that mechanics and proper form go out the window in a fatigued state (14-18).This is not only bad for performance, but more importantly, it is bad for your health.  The more you continue to train in a fatigued state, the greater your risk for injury.  This injury can either be an acute one or a chronic one.Acute injuries are fairly easy to comprehend.  Acute injuries occur instantaneously when the external load is greater than the tissues accepting it.  It’s a cause and effect event.Some examples of the acute injuries:  A tired and sloppy deadlift with a rounded back on the 10th rep could damage your lumbar spine.  A tired and sloppy snatch with forward shoulders and poor T-spine extension could lead to a labral tear.  A tired and sloppy box jump with a knee caved in could lead to an ACL tear.  In other words, it puts you at risk for an accident that occurs in a split second, but takes months to recover from.Chronic injuries are a little more complicated and have to do with compensations and movement patterns.Movement patterns are the stored neurological “program” that resides in the brain.  This “program” is what your nervous system fires out to make the right muscles fire at the right time to achieve the desired result.  Performing exercises with poor form and inefficient muscle activation can teach your brain poor movement patterns.  In other words, it can set in bad habits.A long winded example might help.  Lets take my favorite exercise done to failure - deadlifting.  When you finish out those last 5 deadlifts with a rounded back because you were too tired to use the right muscles, your brain stores a new motor pattern.  Now your brain has a new easier way to deadlift.  Why lift with muscles when you can just lean on passive tissues like ligaments, joint capsules, and lumbar disks?  In other words, your brain decides it’s better to save energy and rely on tissues that don’t require energy to get the job done (passive tissues).  It decides lifting with a rounded back is a good idea.  Stupid brain.  You might be able to lift more weight (temporarily), but it will be at a cost to your spine.  Overtime, this stress to your back accumulates and can lead to a slew of injuries (paraspinal strain, disk herniation, neurodynamic problems, SIJ strain, etc.).So is it really worth it to sacrifice your movement to push it to the limit at every workout?  Do you really need to do over 40 reps of every exercise on each set?  What if you did more sets instead of more reps? Wouldn’t it be better to stop the set once technique starts to waver?  What if you let people “ladder” down throughout the WOD instead of compensating through?  Why not perform AMPRAP (As Many Perfect Reps As Possible) instead of just AMRAP?

A Suggestion

Better programming and an emphasis on improving technique as well as strength is something that many Crossfitters could benefit from.Crossfit coaches can improve in this realm by emphasizing technique over numbers or metabolic expenditure.  Assessing for poor technique and over-fatigue significantly decreases the risk of injury and will improve performance in the long run (you can’t make gains if you keep having to take time off because you’re injured).  Coaches need to help athletes become aware of when their form goes bad and stop them from grooving bad movement patterns with compensatory muscle activity.  And the WODs they develop can be programmed to avoid unnecessary fatigue and sloppy form on complex movements.However, it’s important to understand that assessing for over-fatigue and poor technique is not just the coaches responsibility.  The athletes need to be EDUCATED that when they can’t maintain form they are at a greater risk for injury and they need to stop.  I think this is one of the biggest mistakes most crossfitters make.  Many of them don’t understand this concept; they don’t understand the dangerous effects of not listening to your body and training with poor technique.  Others are simply not aware of their poor form.  Either way, this mistake needs to be addressed to decrease the risk of injury.A warrior mentality often exists with Crossfitters.  However, this mentality should adopt the idiom - live to fight another day.

Click Here for Part II

References

Strength is a Good Thing1) Preethi Srikanthan, Arun S. Karlamangla. “Muscle Mass Index as a Predictor of Longevity in Older-Adults.” The American Journal of Medicine (2014) 2) Lauersen JB, Bertelsen DM, Andersen LB.  The effectiveness of exercise interventions to prevent sports injuries: a systematic reviewand meta-analysis of randomised controlled trials.  Br J Sports Med. (2014) Jun;48(11):871-7.3) Harridge, Stephen D.r., Ann Kryger, and Anders Stensgaard. "Knee Extensor Strength, Activation, and Size in Very Elderly People following Strength Training." Muscle & Nerve 22.7 (1999): 831-39.4) Suetta, C., S. P. Magnusson, N. Beyer, and M. Kjaer. "Effect of Strength Training on Muscle Function in Elderly Hospitalized Patients."Scandinavian Journal of Medicine & Science in Sports 17.5 (2007)5) Askling, C., J. Karlsson, and A. Thorstensson. "Hamstring Injury Occurrence in Elite Soccer Players after Preseason Strength Training with Eccentric Overload." Scandinavian Journal of Medicine and Science in Sports 13.4 (2003): 244-506) Nadler, Scott F., Gerard A. Malanga, Melissa Deprince, Todd P. Stitik, and Joseph H. Feinberg. "The Relationship Between Lower Extremity Injury, Low Back Pain, and Hip Muscle Strength in Male and Female Collegiate Athletes." Clinical Journal of Sport Medicine 10.2 (2000): 89-97.7) Peate, Wf, Gerry Bates, Karen Lunda, Smitha Francis, and Kristen Bellamy. "Core Strength: A New Model for Injury Prediction and Prevention."Journal of Occupational Medicine and Toxicology 2.1 (2007)8) Orchard, J., J. Marsden, S. Lord, and D. Garlick. "Preseason Hamstring Muscle Weakness Associated with Hamstring Muscle Injury in Australian Footballers." The American Journal of Sports Medicine25.1 (1997): 81-859) Jankowski, C.m. "The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial."Yearbook of Sports Medicine 2012 (2012): 65-66.10) Willson JD, Dougherty CP, Ireland ML, et al. “Core stability and its relationship to lower extremity function and injury.  J Am Acad Orthop Surg. (2005) Sep;13(5):316-25.11) Hewett TE, Lindenfeld TN, Riccobene JV, et al. “The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study.” Am J Sports Med. (1999) Nov-Dec;27(6):699-706.Movement Based Exercise vs. Isolated Exercise12) Gentil, Paulo, Saulo Rodrigo Sampaio Soares, Maria Claúdia Pereira, et al. "Effect of Adding Single-joint Exercises to a Multi-joint Exercise Resistance-training Program on Strength and Hypertrophy in Untrained Subjects." Applied Physiology, Nutrition, and Metabolism 38.3 (2013): 341-4413) Gottschall, Jinger S., Jackie Mills, and Bryce Hastings. "Integration Core Exercises Elicit Greater Muscle Activation Than Isolation Exercises."Journal of Strength and Conditioning Research 27.3 (2013): 590-96Exercising in Fatigued State14) Cortes, Nelson, Eric Greska, Roger Kollock, Jatin Ambegaonkar, and James A. Onate. "Changes in Lower Extremity Biomechanics Due to a Short-Term Fatigue Protocol." Journal of Athletic Training 48.3 (2013): 306-13.15) Santamaria, Luke J., and Kate E. Webster. "The Effect of Fatigue on Lower-Limb Biomechanics During Single-Limb Landings: A Systematic Review." Journal of Orthopaedic & Sports Physical Therapy 40.8 (2010): 464-73.16) Barnett S Frank, Christine M Gilsdorf, Benjamin M Goerger, et al.  “Neuromuscular fatigue alters postural control and sagittal plane hip biomechanics in active females with anterior cruciate ligament reconstruction.” Sports Health (2014) Jul;6(4):301-817) Quammen D, Cortes N, Van Lunen BL, et al. “Two different fatigue protocols and lower extremity motion patterns during a stop-jump task.” J Athl Train. (2012) Jan-Feb;47(1):32-41.18) Pau M, Ibba G, Attene G. “Fatigue-induced balance impairment in young soccer players.” J Athl Train. (2014) Jul-Aug;49(4):454-61.Imbalances Are Bad19) Knapik, J. J., C. L. Bauman, B. H. Jones, J. Mca. Harris, and L. Vaughan. "Preseason Strength and Flexibility Imbalances Associated with Athletic Injuries in Female Collegiate Athletes." The American Journal of Sports Medicine 19.1 (1991): 76-8120) Baumhauer, J. F., D. M. Alosa, P. A. F. H. Renstrom, S. Trevino, and B. Beynnon. "A Prospective Study of Ankle Injury Risk Factors." The American Journal of Sports Medicine 23.5 (1995): 564-70.21) Common Sense & Conventional Wisdom (>6 million years BC)Motor Learning22) Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.23) Schmidt, Richard A., and Craig A. Wrisberg. Motor Learning and Performance: A Problem-based Learning Approach. Champaign,IL: Human Kinetics, 2004.24) Williams, L. R., McEwan, E. A., Watkins, C. D., Gillespie, L., & Boyd, H. (1979). Motor learning and performance and physical fatigue and the specificity principle. Canadian Journal of Applied Sport Sciences, 4, 302-308.

“The body does not have the capacity to learn movement patterns when highly stressed/fatigued. This factor is not related to the specificity of training principle associated with overload adaptation in energy systems. The specificity principle of physiological adaptation does not apply to motor learning. To learn skilled movement patterns that are to be executed under fatigued conditions, that learning has to occur in non-fatigued states” — Williams 1979

 --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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The Deep Squat (Part 2 - In the Clinic, In the Gym, How to Train it)

Part I went over the benefits and disadvantages of the deep squat.  In Part II, I will describe how I approach the squat in different settings and how I train it.  Contrary to Part I, which was a collection of the current research and physiological facts about the squat, Part II is mostly empirical evidence and professional opinion.

In the Clinic

Is the Deep Squat a Physical Therapy Intervention?

As movement therapists, should we have people deep squatting as an exercise?The answer is that it all depends on your priorities and the patient's limitations.If someone is in physical therapy for pain, they will likely have many other impairments and dysfunctions that need to be corrected first.  The deep squat might be pretty far down the line for them.  Why?The deep squat is a high level, complicated movement.  It has many parts coming together for a complex movement pattern.  Most patients I see are not ready to perform this movement as an exercise.  They need a lot work on the "parts" just to get to be able to perform a clean unloaded deep squat.  As a result, you may need to master more primitive movement patterns before you attempt the deep squat.

Which Patients Should Deep Squat?

Squat On

Don't get me wrong.  I'm not saying that the Deep Squat doesn't belong in rehab.  In fact, I think there are many patients that can benefit from this exercise while in physical therapy.If the deep squat correlates with their injury, impairments, movement deficits, goals, and lifestyle, then the deep squat should be a focus.  For example, if someone comes in with lateral knee pain, weak quads, and needs to squat down to play with their kids, then the deep squat might be a great exercise (eventually).  If someone comes in with weak glutes, valgus moment at the knee, and likes to play squash, then the deep squat might be a great exercise to work on.

Think Twice Before Deep Squatting

More times than not, the patient is so far away from a deep squat that it would take longer than the average bout of physical therapy to get them to where they need to be.  For example, if someone comes in with back pain and can't touch their toes, brace their abdominals, or hip hinge, then the deep squat is not a priority.If someone has a structural pathology that cannot be changed (eg hip OA, bone spurs, meniscus pathology), then the deep squat may never be part of their program.  For example, if someone comes in with chronic knee pain, meniscus pathology, and a hip impingement, then the deep squat is not a good exercise for them.Now I'm not saying that these patients should never squat.  Many of these patients can eventually learn to squat.  But when they walk into the clinic, there are usually many other variables that need to be addressed first.Keep in mind that as physical therapists our goal is to decrease the patient's pain and help them move better; not to force the most complicated movement pattern on them to perfection.

In the Gym

It's not much different in the gym than in the clinic; priorities and limitations are still the name of the game.

Not Everyone Wants to Deep Squat

Some people may not be in the best position to deep squat and would need a lot of work to gain this ability.  Plus, you have to respect the fact that some people have different priorities.  Some people don't want to spend the necessary time to improve their movement patterns.  Some just want to get their heart rate up and sweat.  Forcing the deep squat on someone who won't put in the work to improve their movement quality is dangerous.

Building a Better Athlete

However, if your client is in the gym because they want to get stronger, move better, and improve performance, then the deep squat needs to be a goal and trained consistently.  The abundance of benefits from the deep squat are just too good to pass up.  Simply put, if you're not squatting, you are missing out on some major strength, stability, and mobility gains.Not only does it generate strength and mobility, but many consider the squat as one of the most important strength and conditioning movements (others: push, pull, hinge, loaded carry).  Missing out on one of the most fundamental exercises is a recipe for disaster and will handicap anyone's athletic development.From a movement pattern perspective, the deep squat has a big carry-over to many other movements.  Much like how a solid deadlift sets a great foundation for kettlebells and horizontal force development, the deep squat sets a great foundation for the olympic lifts and vertical force development.Going beyond the weight room, the squat also prepares athletes for what Charlie Weingroff has termed "level changing".  The ability to vertically change your center of mass (COM) in relation to gravity is what the squat is all about.  Athletes are forced to do this over and over in their sports.  The defensive end has to go from low to high and explode off the blocks, the squash player has to go from high to low to get to that drop shot, the basketball player has to from low to high when attempting to block a shot.  If the athlete is inefficient and doesn't have adequate vertical real estate to perform these movements, they'll have to compensate and waste valuable energy.

Prerequisite to Train the Squat

Mobility

There are many prerequisites before someone can begin to work on the deep squat.  The most important prerequisite is to have adequate mobility to achieve the bottom position without compensations.For some, this may take a long time to correct before they can start to deep squat.  Others may only need a few weeks to clean up some restricted areas.  A big part of this is going to depend on their genetics, development, history, and whether it's more of a structural adaptation or a neurological phenomenon.The 4 main areas you need to focus on are

1. Ankle Mobility
2. Knee Mobility (rarely needs work)
3. Hip Mobility
4. Thoracic Mobility

As always, there are many different ways to achieve the same result.  First assess and find the specific local impairment.  Then use whatever you're good at to help the patient achieve the necessary mobility to squat cleanly.

Training the Squat

One of the best things I've learned from Gray Cook is the importance of movement patterns.  It's often not a strength or mobility issue; it's a neurological movement pattern issue.With that in mind, you want to start training the movement patterns in the right level of challenge.  If it's too difficult, they won't be able to adapt to the movement.  If it's too easy, they won't be challenged enough to improve the pattern.As a PT, I sometimes see people that need to start from ground the ground up, literally...from the ground.  Below is a progression I often use with people.  The prerequisite before each exercise is proficiency in the one before it.  However, this isn't set in stone, it's just an example.  The progression should vary per individual, but the concepts should remain the same (unloaded before loaded, assisted before unassisted, etc.)Another important part of training the squat is to make sure you have clean movement before you add a load.  If you load up a compensated pattern, you will be reinforcing that faulty movement pattern.  You will be "saving" the compensation.  And this "saved" movement pattern can come out at a time when it can seriously damage the athlete.  This is one of the reasons why many need to "maintain the squat, train the deadlift" (another Gray Cookism).So if the movement pattern needs work, don't load it up.  But once they've got the movement pattern down, feel free to load it up with the goblet squat, front squat, and/or back squat.

Quadruped Rocking

https://www.youtube.com/watch?v=Zd4io3ltqu0Quadruped rocking is a great place to start for 2 reasons.One, it provides a movement that unloads spine, hip, knee, and ankle joint.  It also allows the patient to "grease the groove" of lumbar/hip dissociation.  Thus, it can be a great starting point to train neutral spine.Two, as Stuart McGill has pointed out, this quadruped position can provide an appropriate assessment to determine squat stance.

TRX Deep Squat

https://www.youtube.com/watch?v=LAExqeGDHOoThe TRX deep squat allows patients to use their upper extremities to partially unload the movement.  Plus, it provides the necessary support to prevent compensatory motion.  If someone can't fully resolve their ankle DF or hip flexion, the TRX can allow them to work around this impairment by shifting the COM posteriorly.

Heels Elevated Squat (COM/BOS Modification)

https://www.youtube.com/watch?v=VKFpyqq_0N4This progresses from the TRX by removing the UE support and loading the movement pattern.  However, the elevated heels does not only mean that you have adjusted for ankle mobility deficits.  There's much more biomechanically going on (e.g. joint alignment, anterior chain stability requirements, posterior chain mobility requirements, etc).This exercise provides is a posterior shift of the COM in relation to the base of support (BOS).  Modifying the COM/BOS orientation causes a cascade of changes that alters the global movement pattern, not just the ankles.

Progressive Box Squats

https://www.youtube.com/watch?v=hn2GFBfqldIThe Box Squat is one of the more common squat variations I use to train the squat pattern.  It allows beginners and those with non-optimal mobility to squat without having to control their COM in the difficult transition phase (eccentric to concentric).  It is also a great way to teach the squat from the bottom up.

Goblet Squat

https://www.youtube.com/watch?v=ZnG3Z7ZgpzsThe Goblet Squat is my favorite squat exercise; both for movement pattern work and for loading.  Adding a load into the system helps to create more tension in the body, which can aid in stabilization.  The act of holding the weight anterior of your COM allows for ease with posterior weight shift during the squat.  And the proper Goblet Squat form ensures that there will be no valgus collapse because your elbows will be in the way.

Front Squat

The Front Squat and Back Squat are exercises for intermediate/advanced strength and performance training.  These are highly technical lifts that require a great deal of strength, mobility, and skill.Specifically, the front squat requires a great deal of ankle dorsiflexion to perform without compensations.  But it is a great way to start loading up the squat that doesn't involve too much trunk flexion.

Back Squat

The deep back squat is difficult to perform well.  I see many people hacking this one up at the gym by performing some weird type of box squat romanian deadlift hybrid where they end up lifting most of the weight with their back.  This occurs either because of poor technique, impaired ankle mobility, and/or the inability to get into their hips.  Regardless, if someone's back is sore after they back squat, you may want to consider regressing them to the front squat or goblet squat.For more information on the front and back squat, check the references below.

Bottom Line

In the end, it's just important to realize that everyone is different.  No one will have the exact same squat.  Some will easily be able to drop all the way down, some will only make it to a little below parallel.  Some people may need a lot of mobility work, some may need a lot of stability work.  And everyone will have different kinematic motion.  Therefore, everyone will require a different training progression, different cues, and different "parts" work.For some, it is not a realistic goal or one worth chasing.  For others, it's a great opportunity to improve movement and performance.The key is to respect people's individuality, don't force it, and respect that it may take a long time for the tissues to adapt to the specific demands of a deep squat.

Dig Deeper

Kjaer, M. "Role of Extracellular Matrix in Adaptation of Tendon and Skeletal Muscle to Mechanical Loading." Physiological Reviews 84.2 (2004): 649-98

HENNING, C. E., M. A. LYNCH, and K. R. GLICK, Jr. An in vivo strain gage study of elongation of the anterior cruciate ligament. Am. J. Sports Med. 13:22-26, 1985.

Klein K. The deep squat exercise as utilized in weight training for athletes and its effects on the ligaments of the knee. J Assoc Phys Ment Rehabil 15: 6–11, 1961

Escamilla RF. Knee biomechanics of the dynamic squat exercise. Med Sci Sports Exerc 33: 127–141, 2001.

Meyers E. Effect of selected exercise variables on ligament stability and flexibility of the knee. Res Q 42: 411–422, 1971.

Chandler T, Wilson G, and Stone M. The effect of the squat exercise on knee stability. Med Sci Sports Exerc 21: 299–303, 1989.

Bloomquist, K., H. Langberg, S. Karlsen, S. Madsgaard, M. Boesen, and T. Raastad. “Effect of Range of Motion in Heavy Load Squatting on Muscle and Tendon Adaptations.” European Journal of Applied Physiology 113.8 (2013): 2133-142.

Hartmann, Hagen, Klaus Wirth, and Markus Klusemann. “Analysis of the Load on the Knee Joint and Vertebral Column with Changes in Squatting Depth and Weight Load.” Sports Medicine 43.10 (2013): 993-1008.

Caterisano A, Moss RF, Pellinger TK, Woodruff K, Lewis VC, Booth W, Khadra T. The effect of back squat depth on the EMG activity of 4 superficial hip and thigh muscles. J Strength Cond Res. 2002 Aug;16(3):428-32.

Steiner M, Grana W, Chilag K, and Schelberg-Karnes E. The effect of exercise on anterior-posterior knee laxity. Am J Sports Med 14: 24–29, 1986.

Esformes, Joseph I., and Theodoros M. Bampouras. “Effect of Back Squat Depth on Lower-Body Postactivation Potentiation.” Journal of Strength and Conditioning Research 27.11 (2013): 2997-3000.

Salem, George J. et al.  Patellofemoral joint kinetics during squatting in collegiate women athletes.  Clinical Biomechanics 16:424-430, 2001.

Bryanton, Megan A., Michael D. Kennedy, Jason P. Carey, and Loren Z.f. Chiu. “Effect of Squat Depth and Barbell Load on Relative Muscular Effort in Squatting.” Journal of Strength and Conditioning Research26.10 (2012): 2820-828.

Schoenfeld BJ. Squatting kinematics and kinetics and their application to exercise performance. J Strength Cond Res 24: 3497–3506, 2010

Escamilla, RF, Fleisig, GS, Zheng, N, Lander, JE, Barrentine, SW, Andrews, JR, Bergemann, BW, and Moorman, CT. Effects of technique variations on knee biomechanics during the squat and leg press. Med Sci Sports Exerc 33: 1552–1566, 2001a.

Walter, Chip. Last Ape Standing: The Seven-million Year Story of How and Why We Survived. New York: Walker &, 2013

Lieberman, Daniel. The Story of the Human Body: Evolution, Health, and Disease. New York: Pantheon, 2013. Print

Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.Eric Cressey - (Here & Here)Mike Robertson's Squat Tutorials (Here and Here)StrongFirst (Here & Here)Dan John (Here)T-Nation - Squat Articles (many great articles here)Westside Barbell - Squat ArticlesDeepSquater ArticlesBret Contreras (Here)Squat vs. Hip Hinge   --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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Everything is Moving Proximally

In the past 10-20 years there has been a trend towards stabilizing the proximal joint.  Everything seems to be going more and more proximally.  And this is a good thing!  It is providing us with better outcomes and quicker pain free rehabilitation.If you look at the knee joint you can see the progress.  We've gone from isolated patella mobs and VMO strengthening to hip strengthening.  And now we are going even further up the chain and looking at lumbo-pelvic complex.The same thing is happening with the shoulder.  We've gone from isolated thera band ER/IR to scapula stabiliztion.  And now we are going even further and looking at the thoracic spine and ribs.And if we go just 1 step further at both joints we end up where it all began in the first place...the core.

The Greats Love Proximal Stability

This is no where close to being a new concept.  Many of our professions greatest clinicians have been emphasizing the influence of proximal stability on the distal extremities for years.Shirly Sahrman always discussed relative flexibility/adjacent stiffness, PRI's focus is achieving a Zone of Apposition (ZOA), PNF (Kabat & Knott) has always advocated Proximal Stability before Distal Mobility, Gray Cook prioritizes Symmetrical Core Stability, Stuart McGill discusses Super Stiffness, DNS (Kolar) starts with a Centrated Spine for a Punctum Fixum, Kelly Starrett talks about Midline Stabilization, and Janda's Upper/Lower Crossed could be argued to be the result of poor core stability.Anyone that uses these approaches knows of the benefits of core stability for extremity function.It's becoming more and more common in clinics, training rooms, and gyms.  But it goes beyond empirical cases; the research on the influence of the core on the extremities seems to be increasing as well.I would bet that in several years, core training and integration for extremity dysfunction will be as common as hip strengthening for dynamic valgus.

The Core

We could sit here for days and argue over semantics on the definition of the core.  We can then spend another couple hours arguing about how it can be separated: inner core, outer core, local muscles, global muscles, anterior, posterior, lateral, etc.This is great and can provide for some interesting discussion, but these semantics don't change how the core works.I try to keep it simple and define the core is the center of the body.  It's your axial skeleton and all the muscles that connect to it.Regardless of your definition, the focus should be on how the core works, how to assess it, and how to train it for each individual patient.

The Developmental Perspective

Looking at movement through the neuro-developmental lens gives us an unbiased perspective of how we ALL started to move.  Every generation has developed motor functions through the same neuro-developmental kinesiology.  It's a pre-written genetic code with more than 6 million years of evolution.  We are all born with full mobility; and then we struggle our way from rolling, to sitting, to crawling, to walking.We develop our first movement patterns with minimal influence of external factors.  It's the purest form of movement that we have in this world.It's before shoes deprive our sensory input and lock up our ankles.  It's before we're forced into chairs and give away all sorts of proximal mobility.  It's before someone tries to coach or teach us how to move.  It's before we can be influenced by a certain model of movement (yoga, pilates, martial arts, powerlifting, sports, etc.).The developmental perspective shows us how humans move before the detrimental influence of their culture.Needless to say, it's a good standard to measure against.

How the Core Works

Developmentally, all movement starts at our core.  We start to control our head, we start to gain sagittal spinal stability, and then we start moving our extremities.  This combination of spinal stability in concert with extremity movement then drives the rest of the movement development.   Once we have this extremity motion integrated, we start rotating and rolling, then we sit up, then we go from creeping to crawling to cruising to walking.This is all basically a core motor control and strengthening progression.  The core stability demands increase with the each progression of the developmental milestones (least=supine/prone, most=standing/walking).  It's the first SAID principle our bodies have to deal with.If the core doesn't fire efficiently, the baby won't be able to perform the task and the baby will fall down.  Without an integrated core, the baby won't be able to use their extremities for manipulation and movement.In this manner, developmental kinesiology prevents humans from progressing to the next milestone without mastering the previous one.  It's natures perfect self-limiting exercise.Babies don't perform planks, do 3 sets of 10 crunches, or isolate their transverse abdominis.  Thats not how the core works.  The core works to create efficient proximal stability for the production, control, and transfer of force.  The core works to create a stable base for goal oriented movement.  It's a complex, integrated system of feed-forward and feed-back strategy.  And it is developed through the use of the extremities.It's important to note that this "efficiency" is not a measure of strength.  It's an assessment of the neuromuscular patterns.Core efficiency involves the complex coordination, timing, and motor control of ALL the muscles involved in the specific task.  From the big toe on the ground to the opposite shoulder, all muscles must be fire in concert with the core.  It's not just "pre-activating" your inner core.So what happens if your core isn't stable?  If you're not able to transfer force and stabilize your center of gravity?  If you're not able to centrate your center?

What Happens When the Core Doesn't Stabilize

What happens is that the next joint down has to do extra work to stabilize.  The next joint down can't transfer (unload) force to the proximal core.  The next joint down ends up taking on a lot more force.  The next joint down overworks to make up for the lack of efficient proximal stability.  The next joint down gets locks down in attempt to "stabilize" and becomes "tight".  The next joint down becomes inefficient.This is an example of how not having proximal stability leads to decreased distal mobility.So that hip might be restricted and feel tight because it can't transfer (unload) forces proximally because of a lack of core stability.  And those ankles might always be locked up because they might be constantly active as a postural balance strategy because of a lack of core stability (unstable center of mass=instability=terminal segment compensation).That's not to say it can't swing the other way.  With a lack of proximal stability, the distal segment will not be as efficient at producing force/torque.So that overhead shoulder might feel weak because it can't receive valuable proximal force production from the core.  And those achilles might be overworked because they're trying to make up for the lack of proximal stability from the hips and core.

Assessment & Intervention

Assessment

I assess the core using a developmental postural stability progression.  This progression is essentially going from lying on the ground to standing.  From a stable base to a narrow base.  From minimal degrees of freedom to maximal degrees of freedom (joints available).

Postural Assessment

Each posture is progressed from wide base of support to a narrow base of support.

• Supine/prone is assessed with either rolling patterns or foam roll marching (depending on client and space).
• Quadruped is assessed with Alternate UE & LE ("bird-dog").
• Tall & Half Kneeling is assessed with half kneeling to ensure that there are no asymmetries.
• Single leg stance is assessed with eyes open and eyes closed.

I usually assess people for 10-20 seconds in each posture.  I look for the movement quality, common pattern dysfunction, and compensatory strategies.  The goal is for the patient to stabilize the closed chain extremities through their core.  I don't get too caught up in the positioning of the open chain extremities.

Intervention

My intervention follows the developmental postural stability progression in a static to dynamic fashion (low threshold to high threshold).After I have their core movement assessed, I use these positions at their "Edge of their Ability" to develop reflexive static stability and core efficiency.  I usually tell my patients to "find the point where they struggle, but don't fail".http://www.youtube.com/watch?v=b06-S2F3qm0Once they can demonstrate the most difficult level of static stability (narrow base), I add either upper extremity or lower extremity dynamic movements in these postures.  From here, the possibilities are limited by your creativity.Some Examples:

• Upper Extremity: Wall Slides in Tall Kneeling, Plank with Reach, Quadruped T's, UE PNF Patterns in Developmental Postures

• Lower Extremity: Side-Plank with Hip Abd/Flex, Bridges with Marching, Plank with Hip Extension

• Both: Chops & Lifts, Single Leg Asymmetrical Deadlift, Resisted Quadruped Alt UE/LE, Turkish Get-Up, Quadruped Rocking, Crawling/BearCrawling

Bottom Line

• "Any purposeful movement first requires spinal stabilization" -Pavel Kolar

I try to add some core integration for all of my patients.  It's easy to do, there are tons of benefits, and the patients usually like it.  Plus, it taps into the hard-wired CNS developmental patterns.You can incorporate this tomorrow.  Just keep doing what you've been doing with your patient, but throw them at the edge of stability in one of the developmental postures.  They'll get more sensory input, and therefore a better motor output.  Their core gets integrated, and you have a new trick up your sleeve.  Everyone wins.Even if you don't buy into this whole proximal stability thing, you should at least consider it when that ankle dorsiflexion hasn't improved in 6 weeks.

Dig Deeper

Gray Cook:

Motor Control, Stability, and Prime Movers

Sequence of Core Firing

Edge of Ability  

Kelly Starrett - Midline Stabilization, Example of Midline Stabilization FaultSeth Oberst - Motor Control Priority Steve Smith - DNSLieberman, Daniel. The Story of the Human Body: Evolution, Health, and Disease. New York: Pantheon, 2013. PrintWalter, Chip. Last Ape Standing: The Seven-million Year Story of How and Why We Survived. New York: Walker &, 2013. Print.Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.Liebenson, Craig. Rehabilitation of the Spine: A Practitioner's Manual. Philadelphia: Lippincott Williams & Wilkins, 2007. Print.Studies:Moreside JM, et al.  Hip joint range of motion improvements using three different interventions.  J Strength Cond Res. 2012 May;26(5):1265-73.Leetun DT, et al.  Core stability measures as risk factors for lower extremity injury in athletes.  Med Sci Sports Exerc. 2004 Jun;36(6):926-34.Kibler WB, Press J, Sciascia A.  The role of core stability in athletic function.  Sports Med. 2006;36(3):189-98.Wilson JD, et al.  Core stability and its relationship to lower extremity function and injury.  J Am Acad Orthop Surg.  2005; Sept13(5):316-325Shinkle J, et al.  Effect of core strength on the measure of power in the extremities.  J Strength Cond Res. 2012 Feb;26(2):373-80Granacher U, et al.  The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: a systematic review.  Sports Med. 2013 Jul;43(7):627-41.Gottschall JS, Mills J, Hastings B.  Integration core exercises elicit greater muscle activation than isolation exercises.  J Strength Cond Res. 2013 Mar;27(3):590-6. --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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23 Things I Learned From McKenzie Part A

I have been following Erson Religioso, a PT and blogger, for quite some time now.  He has repeatedly (no pun intended) discussed the effectiveness of Mechanical Diagnosis & Therapy (The McKenzie Method or MDT).  He's a very knowledgable clinician and runs his social media with integrity.  Over the years he has provided a great deal of clinically applicable information and I have seen results in my practice using some of his methods.I decided I had to check out MDT first hand and learn about their method.  This past July I took McKenzie Part A - The Lumbar Spine with Dave Oliver.

23 Things I Learned

1) Physical Therapy is a mechanical profession.  We should look for mechanical problems.  If it's not a mechanical problem, refer out.2) Pathoanatomy is for surgeons.  It can cause a ton of fear / centralization if we start diagnosing pathoanatomy.3) MDT is not tissue specific.  It is a symptomatic and mechanically driven system.4) Don't give up so easy.  I used to stop people 3 or 4 reps into their repetitive motion if they had pain.  I learned in this class that if it's a derrangement you need to push through to get a true assessment.  Often times the pain doesn't only go away, but it gets better (green light).5) Don't be so afraid of testing flexion.  People flex thousands of times a day.  If you don't test it, they'll test it when they get back into their car after the eval.6) Practice changing quote: "When you put your hands on a patient it empowers YOURSELF.  When you teach a patient an exercise it empowers THEM."7) Chase their mechanical problems using the stop light system.  Red light is only if the pain remains after testing.8) Exhaust the sagittal plane of movement before giving up.  Don't stop at standing repetitive extension.  Push through all the way to extension in lying with overpressure before saying it doesn't work (as long as it's "stop light" appropriate).  See picture below for example of progression.9) If you're going to chase symptoms, it's best to do it through movement (MDT).10) Plus, if you find a derangement you can resolve their symptoms immediately and then start working on their movement dysfunction (SFMA).11) You're looking for 4 things during the evaluation:

Origin (where pain is coming from)

Classification (derangement, dysfunction, postural)

Direction (relation to symptoms)

Force (overpressure, repetitions)

12) Derangements often have variable symptoms (time, severity, flare ups)13) Derangement is when the joint is de-centrated (not in optimal alignment)14) Finding someone with a derangement makes your job ALOT easier.  You can then use repeated motion to clear their pain.  Since using this system the past few months, patients are amazed by how quickly their pain resolves.15) End-range extension in lying is when you lock out the elbows, exhale, and let the lumbar spine/pelvis relax (Lock, Blow, & Sag).16) Resolving a MDT dysfunction will be uncomfortable.  You have to remodel tissue.  It takes time.17) If there is a lateral shift, you need to fix it before going to extension18) Fixing a lateral shift can sometimes be like "pushing a rock up a hill"19) It's NOT an extension-based system!20) It's a end-range, repetitive motion system.21) End-range is extremely important.  Make sure you get there.22) Patient compliance and lifestyle (postures, ADLs) can make or break the outcomes23) Exercises taught to manage pain can also empower the patient during a potential future injury

My Thoughts

Overall it was a great course and I'm glad to have a better handle on the MDT system.I think it is a great system to use for any patients with pain.  People come into the clinic because they're in pain, not because they have a movement dysfunction.  Clearing out their pain is their #1 priority, therefore, it's your #1 priority too.  Plus, preventing acute pain from becoming chronic is one of the most important aspects of physical therapy.The only problem I have with MDT is their lack/disbelief of stability.  An example of this problem was evident during one of the live case studies.  A woman came in with back pain.  She had excessive motion in every direction (and probably a positive beighton laxity test).  Repeatitive motion exercises only made her worse.  Over the 3 days both directions were tried, and both increased her pain.  She was getting worse.  Without a stability approach what would happen with the rest of her plan of care if you were only using the MDT system?That's not to say it didn't work with the other 5 live case studies.  In fact, besides the hypermobile woman, all 5 patients had a significant decreases in pain after 3 days.  And 3 out of 5 of them were flexion based!MDT is an easy system to integrate into your practice.  It's more than just press-ups for disc herniations.  It teaches you how to use mechanics (repetitive motion) to assess and treat your patients symptoms.  There's no downside to testing repetitive motion and the potential upside is that you can resolve your patients pain in a matter of minutes.  Not a bad deal...

Dig Deeper

Erson's site is really the best place to go for more information on clinical MDT integrationMcKenzie --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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Lumbar Extension Dysfunction

Low back pain is one of the most common injuries we see.  Traditionally you always hear a lot of information regarding excessive lumbar flexion.  And with the amount of information readily available in our society, many patients already know this as well.  This has caused some therapists and patients to walk around terrified that the next time they bend over their L5-S1 disc will splatter against the wall behind them.  But what about the other direction?  What about the potential problems in extension patterns?We've concerned ourselves so much about "blowing out a disc" with flexion that we've completely overlooked extension problems.

Over Extension

Maybe it's because I practice in NYC where people are constantly on the move and always going 1,000 miles per hour.  Maybe it's because our society is spending more time sitting down and plugged in.  Maybe this excessive stress leads to a state of inhalation (PRI concept) which would increase lumbar extension.  Maybe it's our footwear.  But whatever the reason, I'm seeing ALOT more patients with a lumbar extension dysfunction.

When it Happens?

Most of the time the lumbar extension error doesn't present itself until you get the patient moving.  This is something subtle that they are repeatedly doing throughout the day as they move.  It's a micro-trauma that accumulates until they shoot over their pain threshold.You may be able to guess that it will be a problem when you assess their posture and see that you rest a glass of water on their sacrum because they're so anterior tilted.  But most of the time it won't come out until you look at their movement patterns and challenge them with loads.

Why it Happens?

Like all kinds of movement dysfunction, this extension fault is different for every individual.  To say conclusively that it happens for one particular reason would be overlooking the complexity of the individual.  A full assessment will give you a better picture of what's going on.Even if you don't know the exact reason, focusing on movement will allow you to correct the dysfunction without having to know the exact structural culprit.  And if you can correct the dysfunctional movement, then who cares what the exact pathoanatomical cause was?  Pathomechanics always trumps pathoanatomy in our field.So how do you explain the pathomechanics?  This dysfunction is easy to understand if you have a mobility restriction, but what if their SFMA is fairly clean and the breakouts all lead to stability/motor control dysfunction (no mobility impairments)?Since it often only presents itself with movement and load, it is a compensatory mechanism to stabilize.  Why go into extension?  Because the muscles don't have to work as hard in this position.  The closed packed position of joints is a stable position.  The body can rely on static osseous stability instead of dynamic myofascial stability.So what's happening is that these patients are relying on their lumbar facets for stability.  Instead of creating efficient core stability and transferring torque from their hips, they just compress and hang out on their facet joints.  Doing this over and over throughout the day and with load in the gym would make anyone's back hurt.

Assessment

As mentioned above, you may see an excessive anterior pelvic tilt (hyperlordosis) and the patient may complain of pain with extension activities.  This is a good start to your hypothesis, but you need to prove that they have a dysfunctional compensatory movement pattern before you blindly attack it.  I find the best assessment system for movement patterns to be the SFMA.9 times out of 10 someone with this dysfunction will fail the multi-segmental extension pattern.  When you break it out and find it's not a mobility issue, then you can rest assure that they probably have an extension stability/motor control problem.  This directs you towards rolling and a developmental stability assessment.Another key to this assessment is seeing how they move with the hip hinge.  This tests their ability to stabilize their spine and create torque from their hips.  If they can't control their lumbar spine and hips then they will hyperextend onto their facet joints for stability.  And this usually reproduces their pain.The video below shows a patient who has an extension stability/motor control dysfunction.  She is hypermobile and has no mobility restrictions.http://www.youtube.com/watch?v=I9xBxpJeYfQ

How to Fix It

If you're lucky and it's a mobility problem you will be able to resolve their restrictions and easily train the movement pattern back to normal.However, if it isn't a mobility problem then it isn't going to be an easy fix.  You can't just give them planks and dying bugs and expect the movement pattern to resolve.  While working on their anterior core and breathing will help, you will have to do one of the more difficult things in our profession...coach them out of it.  You have to fix their movement pattern.

Torque & the 1-Joint Rule

Kelly Starrett often talks about creating torque and the one-joint rule in his book "Supple Leopard".  These are great concepts you can use to assess and treat movement dysfunction.Our body moves (and stabilizes) from the torque that muscles create on our bones.  So it makes sense that some patients will benefit from verbal cues and education on how to create it.Kelly describes the one-joint rule as the general principle that "you should see flexion and extension movement happen only at the hips and shoulders, not your spine."  This of course doesn't mean that your spine shouldn't move, it just means that during high-load or high-velocity tasks your 2 ball & socket joints (hips/shoulders) should be moving while your spine stabilizes to transfer the forces.Using these rules as a blue-print to teach patients to stabilize their spine and create torque through their extremities can pull them out of the gumby like stability problem.  In the video below, Kelly takes someone from an extension dysfunction to a normal movement pattern simply by using verbal cues.http://www.youtube.com/watch?v=mjbvf0P0bas

Bottom Line

We traditionally concern ourselves (and our patients) about the dangers of lumbar flexion.  However, any excessive and misused movement is dangerous.  Lumbar extension is no different and is a common problem in many low back pain patients.This post also provides an example of how I have integrated Kelly Starrett's work with Gray Cook's SFMA approach.Sometimes clinicians can limit themselves by following only one system religiously.  By doing so you can miss out on some great aspects of other approaches.  I'll admit that I am biased towards the SFMA, but that doesn't prevent me from using other systems as well.  In fact I've found that adding other approaches in to your practice benefits you as a clinician, and more importantly it benefits your patient.Bruce Lee said it best: "Absorb what is useful, discard what is not, add what is uniquely your own." --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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Quadruped

The quadruped position is a very important developmental posture.  From this posture we learn to crawl and transition to half-kneeling (which then transitions into standing).  Through this posture we develop core, shoulder, and hip stability, learn reciprocal UE/LE motion, and begin to control our spine through our weight-bearing extremities.  The quadruped position has many details that are often lost or forgotten when training.  Mastering these subtleties and progressing within the edge of your ability will lead to a great effect on your stability.

What it Does

• Taps into Hard-Wired CNS Developmental Stage
• Increases Hip, Shoulder, and Core Stability
• Self-Limiting Posture
• Challenges Rotary Stability
• Develops Reciprocal Motion & Coordination
• Removes Ankle/Knee Compensations
• Allows for Unloaded Spinal Stability

3 Keys to Performance

1. Maintain Neutral Spine
2. Hips and Shoulders should be at 90 degrees
3. Do not allow any pelvis or shoulder girdle rotation

Common Faults to Avoid

• Hyperlordosis with leg extension
• Compensatory pelvic rotation (usually opening)
• Scapula winging and or elevation on weight-bearing arm
• Non-neutral cervical position (looking forward or cervical protrusion)
• Compensatory weight shift over weight bearing extremity
• High-threshold strategy

Clinical Use

Examination

Using this posture for assessment can determine whether a patient has a weight-bearing stability issue, an open chain compensation, a spinal stability dysfunction, or a combination of these dysfunctions.  Furthermore, it can help determine the specific position of instability (i.e. hip flexion vs hip extension, shoulder end-range flexion vs mid-range flexion).  Determining the specifics of their motor pattern dysfunction can help you further individualize your plan of care.For more advanced and active patients you can take them through a 6 level progression (see video below) to determine their level of stability and determine whether it is a static or dynamic dysfunction.  Make sure to pay attention to any asymmetries, compensations, or faults.http://www.youtube.com/watch?v=kK0-jpxMbos

Intervention (Train the Brain)

A proper assessment leads to a more effective intervention.  By taking the patient through the 6 level quadruped progression you can determine the limits of their ability.  Once you determine this you can train them within their edge of ability to improve their stability.  It's important to avoid compensations or making the exercise too difficult.  This should be a low-threshold training exercise.  Think about training the pattern instead of the muscles.After mastering the 6 levels of quadruped stability you can further add other extremity movements, resistance, or perturbations to make the exercise more difficult.  Many clinicians and trainers even use creeping, crawling, and even the bear crawl for exercise progressions.

Summary

The developmental perspective shows us that movement was developed in patterns, not by isolated muscle strengthening.  Using developmental postures can help to re-wire dysfunctional movement patterns.  Before progressing to more complicated postures (half-kneeling, single leg stance), make sure your patient is efficient in this quadruped position. --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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Hip Hinge

The hip hinge is a basic movement pattern that everyone must have.  When people have atrophy of this movement pattern they end up compensating in all sorts of ways (trendenlenberg, dynamic valgus, knee dominant movements, lumbar flexion).  This leads to decreased performance and increased risk for injury.

Why Hip Hinge?

If you want to truly load the hips then you have to know how to hip hinge.  The hip hinge is a hip dominant movement that is the basis for most athletic movements.  Sure, there needs to be a baseline level of strength at the hip joint.  But you can't really think clamshells and side steps are going bring your patients back to their highest activity level.Even if your patient isn't an athlete, they need to hip hinge.  Everyone has to do it, and has been able to do it at least at one point of their life (it's part of the developmental progression).  Furthermore, it's used for basic life movements.  The hip hinge is how you should be picking objects off the ground, it's how you should go from sit to stand, it's how you should move furniture, it's how you should do most activities throughout the day.

Hip Progressions

The basic progression for most strengthening exercises in rehab is to go from isolated isometrics to basic isotonics to dynamic movement patterns.  Seems pretty simple, right?  However, many PT's miss this last part.  This is where "bridging the gap" happens.  If you have your patients doing clamshells with black thera-bands and sidelying hip abduction with 10 pounds and you haven't started hip hinging, then you are probably wasting everyone's time.By working on your patient's hip hinge movement pattern you will not only be sparing their knees and backs, but you will be giving them a movement pattern that they can load up as much as they want for the rest of their lives.  They can either keep it as a basic ADL movement (sit-stand, picking up objects) or they can load it up to deadlift hundreds of pounds, crush a golf ball 300 years, explode past that pesky defender, or blast a forehand down the line.  Regardless of what you think your patients can do, it's best to leave them the option to choose themselves.

What is a Hip Hinge?

A hip hinge is a posterior weight shift through the hip joint.  It's a sagittal plane moment where the hips become the axis between the upper and lower extremity through a neutral spine.Hip hinge is the basis for most hip movements.  Developmentally we progress from the sagittal, to the frontal, to the transverse plane.  Since the hip hinge is the most basic and dominant sagittal plane motion for the hips, it is the best place to start movement patterns.  Before you start developing stability in the frontal and transverse plane, it is paramount to master the sagittal plane first.

Why it's Good

Loading up the hip and developing some serious strength and power is a great advantage of the hip hinge.  But it also has many advantageous effects throughout the body.

Benefits of Hip Hinge:

1. Maximizes the posterior chain
2. Decreases anterior chain dominance/stress
3. Spares the knees and spine
4. Allows for kinetic transfer of energy/force to the upper body

Hip Hinge vs. Squat

Before you teach the squat or the hip hinge, it is important to first understand the difference between the two (videos: hip hinge, squat)The deadlift is hip hinging at it's best.  So we will use it as an example in this comparison.If you are new to the deadlift and sqaut or have difficulty determining which movements are clinically hip dominated vs. knee dominated you can use this formula:Hip Dominated (Hip Hinge) = Vertical Tibia + Posterior Pelvis Movement + Moderate Trunk LeanKnee Dominated (Squat) = Angled Tibia + Inferior Pelvis Movement + Minimal Trunk Lean

Hip Hinge (Deadlift)

The hip hinge, as it implies, is a hip dominated movement.  It is a much simpler movement than the squat.  You really only use one part of your body (hips) to "push the ground away".  The main joint movement afferent input your brain has to deal with is in the hips, knees, and spinal angle.  An oversimplification of the physical requirements include: posterior chain activation, posterior chain mobility, spinal stability, reactive scapula retraction.

Kinematics

• Moderate Trunk Lean
• Pelvis Moves Posteriorly
• Hip Flexion
• Minimal Knee Flexion
• Tibia Remains Vertical

http://www.youtube.com/watch?v=lGAkXEd-bo0

Squat

The squat is more of a knee dominated movement.  However, it's not that simple.  It's much more complicated movement than the hip hinge.  It requires stability of all 3 planes and involves much more motion throughout the body.  You are "pushing the ground away" using 3 body parts (ankle, knee, hip).  The addition of 2 more joints to the motion makes the movement much more difficult to perform.  This additional afferent information will require equal efferent information to adequattely control the joint motion.  An oversimplification of the physical requirements include: anterior chain stabilization to maintain upright posture (core, hip flexors, anterior tibialis), significant ankle, knee, hip, & thoracic mobility, multi-segment eccentric control, and maximal triple-extension activation.

Kinematics

• Minimal Trunk Lean
• Pelvis Moves Inferiorly
• Deep Hip Flexion
• Deep Knee Bend
• Tibia Moves Anteriorly

https://www.youtube.com/watch?v=C-kKvNwJ1Uc

Assessment

I tend to use 4 movements to assess a patients ability to hip hinge: SFMA Multi-Segment Flexion, Quadruped Rocking, Hip Hinge with Dowel, and Squat.SFMA Multi-Segment Flexion: The sagittal plane should be the first movement you check in every patient.  If they can't master the sagittal plane, they'll compensate in another plane.  Don't chase your tail trying to fix a rotational problem when it's really a sagittal problem that compensates in the transverse plane.  Now I'll step off the soap box...MSF requires a posterior weight shift to touch toes.  If you patient can't touch their toes or doesn't posterior weight shift, then hip hinging will serve them well.Quadruped Rocking: This isn't just a childs pose test for lumbar flexion.  You are checking their ability to sit back into their hips in an unloaded position.  To perform, have them go into neutral spine and rock back as far as they can without losing their lumbar position.  If you patient can't maintain neutral spine (i.e. they go into flexion) while going into hip flexion then hip hinging is a good option.Hip-Hinge with Dowel: This exercise can give you a great view into their movement patterns and possible physical impairments.  It's best not to coach this and give alot of cues.  Simply perform the movement yourself, then ask them to repeat it.  Try to assess their movement pattern and associated compensations.Squat: The squat is complex and there can be many different impairments that prevent functional movement.  But if the patient cannot get their hips below parallel then the chances are they are so quad dominated that they can't shut them off to sit into their hips.

Intervention

There is no clear cut protocol and way to teach the hip hinge.  This is probably why there's no research on the movement pattern.  There are just way too many variables (in the patient, in the movement, in the exercises) to try to standardize in a study.  But this is a good thing if you are willing to put in the time and effort.  There are three main things you can control: the progression, the verbal cues, and the visual props.

Progression Continuum

The most important aspect of the progression is that you want to make sure your patient has mastered the movement pattern before you load it.  This is where most people go wrong.  They load the up deadlift with too much weight or start patients with single-leg deadlifts when they don't even have the pattern down.This is the clinical progression I have developed over the past couple years:Determining where your patient should start may take some time.  It's always better to have the exercise be too easy and progress them rather than have it be too difficult and frustrate and/or hurt them.

Verbal Cues

You don't want to cognitively overload the patient right off the bat.  I simply tell them to push their hips back without letting the knees come forward.  After I assess their movement pattern I will adjust the cues appropriately.  Other cue's I often use:"Push hips back" - "don't lock out knees" - "reach down and touch your knees"-  "allow knees to bend and go along for the ride" - "keep chest up" - "keep hips down" - "keep a double chin" - "act like you are taking a bow" - "stand tall at top" - "come all the way through with your glutes"

Props

Just like the verbal cues, you don't want to overload them and make them more focused on the props than the movement.  The initial movement pattern assessment determines which props I use.  Depending on each patient you will have to alter your props.  The one I find most useful and most beneficial for beginners is placing a stool in front of their knee (see video below).  This prevents any anterior translation of the tibia.  The good thing about a stool vs. an object that doesn't move is that when the patient gets feedback they will be forced to intrinsically stop the knee moving forward instead of an extrinsic stop where the patient just jams the tibia against a bench or wall.http://www.youtube.com/watch?v=xsjYQ6KBhwsOther common props (and what to use them for):Dowel (neutral spine) - Facing Wall (prevent excessive trunk lean) - Wall Behind (encourage posterior weight shift) -Bench (vertical tibia) - Plinth/High Box (target for posterior wt shift, partial reps) - Limited Weight Landing Area (prevents anterior weight shift)

Common Problems

This is some basic troubleshooting to consider when people are having difficulty with this movement pattern.  Remember, all of this stuff is not black and white.  It's a continuum.  It's usually not as clear and easy as categorizing patients into one pattern.  Some people may have a blend of all of these.  Hopefully this will at least give you a place to start.

1) Inability to Posterior Weight Shift (sit back)

= Decreased Hip Mobility, Decreased Posterior Chain Extensibility

2) Loss of Spinal Curve (hyper or hypolordosis)

= Weak Core, Inability to Stabilize Torso, Inability to Dissociate Spine and Hips

3) Excessive Anterior Tibial Translation, Stopping Short of Full Extension,  Too Much Inferior Movement

= Quad Dominated Pattern, Anterior Pelvic Tilt

Here is a video example of faults #2 & #3.

Bottom Line

The hip hinge movement pattern is essential for anyone that moves.  A loss of this movement pattern can lead to many deleterious effects.  By training the movement pattern you will give your patients the ability to perform ADLs and athletics without compensations and increased risk for injury.  Once your patient has the hip hinge down they can either simply maintain it for health and injury prevention, or use it to truly load the hips and build some athletic power.Isolated isometrics and basic isotonic strengthening exercises are necessary.  But to take our profession to the next level (and your patients) we need to "bridge the gap".  Try adding some movement training into your plan of care.  Your patients will appreciate it.Hopefully this article will give you an idea of how to integrate this into your practice.  And with every exercise you prescribe, try it yourself (but don't be this guy).

Dig Deeper

Christopher Smith - Squat vs. DeadliftEric Cressey - Mastering the Deadlift (check out all 3)DragonDoor - Deadlift for Body TypeDan John - Hip HingeT-Nation Deadlifting - 1, 2, 3Bret Contreras - Sumo vs Conventional, EMG Muscle Activation

Mike Robertson - Deadlift

Schwarzenegger - Deadlift

Tony Gentilcore - Coaching Cues

Jeff Kuhland - Hip Hinge

Anything by Chris Powers - it might not be intentional, but much of his research is basically on the hip hinge pattern

--The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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Breathing - Part II - Indications, Assessment, & Intervention

Part I of this series dealt with breathing anatomy and mechanics.  Knowledge and understanding of the anatomy and mechanics of breathing is essential for a proper assessment and intervention.  This post will expand on the previous post and go over some indications, assessment, and intervention for breathing.

Indications

So what type of patients do breathing mechanics apply to?  Pretty much anyone that moves or breathes.Seriously though, you should strongly consider breathing mechanics in all of your patients.  Even if it isn't the main culprit of their dysfunction, it might help return them back to optimal functioning.Some more specific examples:

• Spine, Hip, and Shoulder Dysfunction
• Postural Faults
• High-Threshold Patterns
• Impaired Neurodynamics
• Psychological (apprehension, anxiety, central sensitization)

Assessment

To keep it simple, you want to visually observe their posture and how they mechanically breathe.  Compare this to an ideal breath and look for any signs/symptoms of dysfunctional breathing.  Assess this in various postures (supine, seated, standing) and movements.  The patient doesn't need to know.  In fact, I find it better if the patient isn't aware.  If you do find a patient with a breathing dysfunction you can then go into a more detailed assessment with palpation techniques (discussed under dysfunctional breathing).Sure, you can make it more complicated by assessing breath holding times, questionnaires, and spirometry.  However, this puts the patient through unnecessary discomfort and may affect your rapport.  They walked into your clinic because they're having back pain, not because they want to talk about their breathing patterns and blow into some device.It's important to note that there is a great variance in breathing patterns.  Therefore it is difficult to create a protocol and thorough checklist for an ideal breath.  However, there is alot of evidence for dysfunctional breathing.  So it may be more clinically efficient to look for dysfunctional breathing rather than ideal breathing patterns.

Ideal Breathing

The ideal breath is a smooth, segmental, 3-dimensional motion.  During inspiration there is abdominal distension (circumferentially) and a postero-lateral lower ribcage expansion.  During expiration there is contraction of abdominals and pelvic floor that returns the ZOA to an optimal position as evident by a depressed sternum and IR of ribs (no anterior ribflare).Overall what you're looking for is the inspiratory cascade of events that leads to controlled increased intra-abdominal pressure and proper muscle activation.  On the exhale you want to see adequate expiration of air with no signs of hyperventilation.http://www.youtube.com/watch?v=t0u-bPZrP8g

Dysfunctional Breathing

What you never want to see is excessive accessory muscle activation, disproportionate shoulder movement, T-L junction hinging, or vertical ribcage movement.  Other signs include: mouth breathing, frequent sighs/throat-clearing, rapid and/or shallow breathes, and asynchronous breathsParadoxical breathing is a common breathing dysfunction.  This is when the patient inhales and there is a vertical and posterior motion of the ribcage and a hollowing of the abdominal cavity.http://www.youtube.com/watch?v=8TnrNrrEjuEOne of the biggest signs of dysfunctional breathing is lack of postero-lateral expansion of the lower ribcage.  This can be assessed using the MARM (Manual Assessment of Respiratory Motion).  Research has shown that the MARM can be be a useful assessment for dysfunctional breathing.  This test is simply performed by having the patient seated and facing away from you.  You place your fingers on the lower lateral ribcage and align your thumbs with the spine.  Then have the patient breath naturally while you assess for the postero-lateral expansion of the lower ribcage.  Patrick Ward performs a similar technique in this video around 3:15.

High-Threshold Strategy

This section is purposefully placed between assessment and intervent because it essentially both.  A high-threshold strategy is when an individual performs a task using excessive activity/tone in global musculature in a compensatory or protective manner.  Gray Cook has described it as when "the body is splinting instead of stabilizing".  One of the major signs of this strategy is dysfunctional breathing patterns.An example of this is when you give a patient an exercise that is too difficult for them.  They start to hold their breath and squeeze every muscle they have.  A patient won't be able to perform a proper breathing pattern if they are using a high-threshold strategy.So how do you use this to your advantage?  You can use breathing assessment throughout all of your interventions to verify that the patient is not using a high-threshold strategy to perform the task.

Intervention

There are many ways to treat breathing dysfunctions.  Which rabbit hole you go down depends on your patient and what they need.However, the first place to start for everyone should be from an educational stand-point.  It is advantageous to explain to the patient why breathing is important to them specifically (use knowledge from Part I).  Then you should teach the patient about dysfunctional breathing and what you expect for a proper breath.  To avoid overcomplicating this, I usually simply give the patient a cue that has them focus on the circumferential lower ribcage and abdominal distension.Some example cues I've heard and used: "breath into your lower ribs and abs", "breath into an imaginary belt around your stomach", "breath down and out", "inhale into a balloon inside your stomach", "push your breath down", "expand your ribs out with your breath" etc.  The possibilities are endless.You can also use tactile cues.  Put your hands or a theraband around their lower ribcage to increase sensory afferent input.  Then have them to breath into the resistance of your hands/theraband.For patients who have great difficulty with this or use paradoxical breathing patterns you may need to start simple.  I usually start with a simple progression of hi-lo breathing, lateral expansion breathing, and finally a combination of the two for an "ideal breath".  It's important to educate them and have them feel the difference in their hands and their body.  As the patient gets comfortable you can cue the patient to breath in through the nose and out through the mouth, exhale longer than the inhale, and try to expire all of their air.http://www.youtube.com/watch?v=IfZRnFD5m_QOther biomechanical interventions can be separated into mobility and stability categories.  Part I focused on the stability aspect of the inspiration, but it can also be used for mobility (yoga has been doing this for thousands of years).

Mobility

Much like ligament locking for joint mobilization/manipulation, the breath can be directed by altering postures and positions.  Leslie Kaminoff describes breathing as the act of "shape changing".  Using this theory you can alter your posture to direct the where the breath ("shape change") occurs.  It's physics.  The shape change from inspiration (expansion) will always go towards the place of least resistance.For example, if a patient has a restricted R posterior lumber quadrant, then you would put them in a childs pose reaching contralaterally with their R UE.  Since you closed off the L side by laterally sidebending/flexing and closed off the anterior R rib cage by flexing, the only place for the shape change to occur would be into the R posterior quadrant.  You can further increase the expansion (stretch) into this area using tactile or verbal cues to get them to breath into the postero-lateral R rib cage.Another mobility aspect of breathing is it's amplification of the parasympathetic NS.  This can be very advantageous when performing manual techniques or corrective exercises to increase tissue extensibility.  Muscle guarding and reflexive activation can be minimized by focusing on breathing.

Stability

As mentioned before with the high-threshold strategies, simply having your patient breath properly during exercises will help establish proper inner core stabilization.  One important consideration is that you must simultaneously monitor their posture.  You always want a neutral spine.  Performing a task with an anterior pelvic tilt not only causes compensatory mechanisms, but it prevents proper breathing mechanics (decreased ZOA, decreased eccentric abdominal & PF contraction).Again, the guy with a positive scour sign, hip impingement, and anterior pelvic tilt doesn't want to hear about breathing.  He just wants his hip to stop hurting so he can get back to golfing.  So instead of going into too much detail about the mechanics of breathing or working on isolated breathing exercises, simply have your patient breath with a neutral spine during all their exercises.  It's a great place to start and ensures that the patient is performing the exercise with the correct musculature.Since I have learned about the importance of breathing I no longer time my patients with a stopwatch.  I now have everyone counting their breaths (i.e. holding quadruped diagonals for 7 breathes instead of 30 sec).For advanced patients you can progress to "breathing behind the shield".  This is a term coined by the great Pavel Tsatouline.  It's a great way to incorporate breathing with core stability.  It describes the act of maintaining abdominal tension while breathing.  "Breathing behind the shield" is the balance of controlling intra-abdominal pressure and abdominal & pelvic floor muscle tone.  It displays that the patient is able to use the diaphragm's dual function: respiration and stabilization.Hans Lindgren has an amazing video on assessing and interventions for breathing and core stability.  At about 2:10 into the video he goes over a great technique to help you teach your patients how to "breath behind the shield".  This is a great place to begin and can be progressed through the developmental sequence.

Bottom Line

There are many ways to assess and treat dysfunctional breathing patterns.  Hopefully this article will give you a good place to start.  Below are some great articles, videos, and descriptions of breathing patterns.  As with every intervention, it is important to master this yourself before you try to teach your patient.

Dig Deeper

Dean SomersetHans Lingren - Core Stability Inside OutRosalba CourtneyErson ReligiosoSportsRehabExpert - Ron Hruska InterviewMike Robertson - Video Coaching - Stress & BreathingPatrick WardPostural Restoration InstitueConnor CollinsCraig LibensonBill HartmanTara RobertsonCraig LiebensonSimple Exercise - Crocodile Breathing

References

Tom Myers & Leslie Kaminoff.  The Breath in the Pelvis - Seminar (NYC 2012).Courtney R,Reece J (2009). Comparison of the Manual Assessment of Respiratory Motion (MARM) and the Hi Lo breathing assessment determining a simulated breathing pattern.  International Journal of Osteopathic Medicine.Courtney R (2009). The functions of breathing and its dysfunctions and their relationship to breathing therapy.  International Journal of Osteopathic MedicineCourtney R (2011).  Dysfunctional Breathing - It's paramaters, measurement and relevance.  Thesis RMIT University. (a must read - click here)Kaminoff L. (2006). "What yoga therapists should know about the anatomy of breathing." International Journal of Yoga Therapy.McLaughlin L. (2009). "Breathing evaluation and retraining in manual therapy." Journal of Bodywork and Movement Therapies.McGill S , Sharratt M ,Sequin J P. (1995). "Loads on spinal tissues during simultaneous lifting and ventilatory challenge." Ergononomics.Janssens L , Brumagne S, Polspoel K, Toosters T, McConnell A. (2010). "The effect of inspiratory muscles fatigue on postural control in people with and without recurrent low back pain." Spine.Hodges P , Heijnen I, Gandevia S C. (2001). "Postural activity of the diaphragm is reduced in humans when respiratory demand increases." Journal of Physiology.Hodges P , Butler J ,Mackenzie D K, Gandevia S C. (1997). "Contraction of the human diaphragm during rapid postural adjustments." Journal of Physiology 505(Pt. 2Wang S., McGill S (2008).  Links Between the Mechanics of Ventilation and Spine Stability.  Journal of Applied Biomechanics.McGill S, Sharratt M & Seguin J (1995). Loads on the spinal tissues during simultaneous lifting and ventilatory challenge. Ergonomics.Robey J, Boyle K (2009). Bilateral Functional Thoracic Outlet Syndrome in a College Football Player. N Am J Sports Phys Ther.Boyle K, Olinick J, & Lewis C (2010).  The value of blowing up a balloon.  N Am J Sports Phys Ther.Kolar P, Sulc J, Kyncl M, et al. (2010) Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J Appl Physiol.Kolar P, Sulc J, Kyncl M, et al. (2012).  Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain. JOSPT.Hagins M, Lamberg EM (2011). Individuals with low back pain breathe differently than healthy in- dividuals during a lifting task. JOSPT.Clifton-Stmith T, Rowley J (2011). Breathing pattern disorders and physiotherapy: inspiration for our profession.  Physical Therapy Review.Hruska R (2005).  ZOA Position & Mechanical Function.  Postural Restoration Institue.Cook, Gray. Movement: Functional Movement Systems : Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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