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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Breathing - Part I - Anatomy & Mechanics

The average person takes about 21,000 breaths a day.  This makes it one of the 3 biggest aspects of our patients life that we can have a profound effect on (other 2: posture & walking).This post will discuss the holistic effects of breathing, anatomy, and the important cascade of events for proper breathing and inner core stabilization.

Why Work On Breathing?

Because everyone is doing it.  Power lifters have been controlling their intra-abdominal pressure to lift massive weights for years.  Yoga and eastern medicine have been using breathing for over 2,000 years (PT isn't even a century old) .  Gray Cook and the SFMA require a full breath at the end-range of every movement test to achieve a FN.  The neuro-orthopedic approach leans on breathing and even mentions that a deep breath glides the median nerve 1 inch.  There is an increasing amount of approaches that are including breathing (PRI, SFMA, DNS).  Many of the leading experts in the field are incorporating breathing.  And there is more and more research coming out discussing the benefits of breathing.  So if you're not doing it, or at least aware of it, then you are probably that guy.

Holistic Breathing

Breathing has a huge influence on the entire body.  Breathing influences sympatho-vagal balance.  Dyfunctional breathing can induce hypocapnia (effect of hyperventilation).  Hypocapnia causes increased neural activity and synaptic transmission.  You know those patients that feel that every muscle is tight and you can never decrease their muscle tone for more than 24 hours?  Maybe it's because of their breathing.  Breathing can actually produce an amplification of the parasympathetic nervous system.  This can have a tremendous effect on muscle tone (a nervous system issue).Breathing also has a significant role in the circulatory system, pH regulation, and metabolism.  It has been tied to many psychological disorders and can have a major effect on self-regulation of stress and emotion.  Breathing even has an important role in some religions and spiritual practices.Breathing has a therapeutic, homeostatic, regulatory, psychophysiological, and spiritual function.  If your patients are alive, then breathing should be considered as an aspect of their care.

Breathing Anatomy

A global understanding of breathing anatomy can be expanded from knowledge of the deep front line.  This line from Anatomy Trains goes into the fascial attachments of the diaphragm in great detail.  Or simply stated, "the 12th rib is where walking meets breathing"-Tom Myers.

Diaphragm

The diaphragm has a dual function: respiration and stability.  It should be able to perform this dual function at all times.  A common injury is caused by a failure of this mechanism.  The overweight, sedentary, desk-jockey wakes up to shovel snow out of his driveway.  After 5 minutes he's exhausted and his diaphragm has to devote all of its power for respiration.  Now his diaphragm has lost it's stability function.  Now he can't control and use his intra-abdominal pressure (IAP).  And now he just hurt his back.Want another reason why we should know about the diaphragm's stability role?  It's the most proximal muscle...to everything.  There's nothing more proximal than the diaphragm.  It helps to organize and stabilize the upper and lower quarter.  Sue Falsone agrees that the diaphragm is the most proximal.  Regarding this concept she has said that she always starts rehab "from the belly button out."

Zone of Apposition

The Postural Restoration Institue defines the ZOA as the "cylindrical aspect of the diaphragm that apposes the inner aspect of the lower mediastinal (chest) wall."  This is one of the most important aspects of breathing.  The ZOA is responsible for:

• Efficient length-tension relationships of the diaphragm
• Maintains vertical alignment of diaphragm muscle fibers
• Allows postero-lateral (bucket-handle) movement of the lower rib cage

Overall the ZOA is paramount for proper diaphragm function.  Some have found it to be as much as 30% of the inner surface of the ribcage.  A decreased ZOA will result in inefficient diaphragm contraction, lung hyperinflation, increased accessory muscle use, lack of postero-lateral movement of the rib cage, and an increased anterior rib flare.

Abdominals & Pelvic Floor

The abdominals and pelvic floor play a huge role in inspiration (eccentrically) and expiration (concentrically).  During inspiration they contract eccentrically to increase the intra-abdominal pressure (i.e. stability)  and ensure that the ZOA is maintained long enough to produce postero-lateral expansion of the lower ribcage.  During expiration they concentrically contract to help push the diaphragm cephallically, thus restoring optimal ZOA.

Thoracic Cavity

The thoracic cavity is where the actual breath occurs.  It's where the air molecules and gas exchange occurs.  The thoracic cavity must have the appropriate amount of mobility to accommodate this pressure change and flow of molecules.  During inspiration the ribs must be able to ER and the spine must be able to extend.  During expiration the ribs must be able to IR and the spine must be able to flex.Breathing plays a major role in the hydration of the thoracic discs.  If you look at the anatomy of the ribs attachment to the thoracic spine it almost looks like a lever.  This lever actually pry's open the thoracic spine and elongates it, thus bringing hydration and nutrition to the discs.

Breathing Mechanics (Core from the Inside Out)

There is a cascade of events that leads to controlled intra-abdominal pressure through the activation of the diaphragm and core musculature.  By using the breath with the core you are achieving natural muscle activation and increased intra-abdominal pressure.  This pressurized stability is much more efficient than muscle activation alone (abdominal hallowing/isolated TVA activation).The best way to have a proper breathing pattern is to get it right from the inhale.  A proper inhale will put you in the correct position for a proper exhale.  Clinically there are many things that can go wrong with inspiration, whereas the only thing that often goes wrong with expiration is decreased expired air (hyperventilation/decreased ZOA).The inhale is the initiation of core stability.

Inspiratory Cascade of Events

1) Diaphragm Concentrically Contracts

2) Beginning of Increased IAP

3) Abdominals and PF Eccentrically Contract

4) Controlled Increase in IAP & Inner Core Stability

Bottom Line

Understanding breathing anatomy and mechanics will allow you to easily assess and intervene respiration.  The effects of proper breathing are: adequate respiration, proper biochemical balance, decreased/prevention of psychological distress, and most important for physical therapist - natural activation of the inner core stability.  Part II will deal with ideal & dysfunctional breathing patterns, assessment, and some simple interventions.

Dig Deeper

Dean SomersetHans Lingren - Core Stability Inside OutRosalba CourtneyErson ReligiosoSportsRehabExpert - Ron Hruska InterviewMike Robertson - Video CoachingPatrick WardPostural Restoration InstitueConnor CollinsCraig LibensonBill HartmanTara RobertsonSeth Oberst - 1 & 2

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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Basic Hip Strengthening

Chubbs was right.  It’s all in the hips!Hip strength is extremely important for your musculoskeletal health.  The hip muscles are connected from your pelvis to your femur.  This connection means they will not only have an influence on your hips, but also effect your back and your knees.  In other words, your hips help stabilize and translate forces from your legs to your trunk and vice versa.  In addition to this anatomical/biomechanical relationship, our society has a very high prevalence of back and knee pain.  So maybe instead of another "core" program or a new squat technique we really just need some hip strengthening.  This post will discuss the importance of hip muscles, the effects of hip strength, and how to start strengthening them.

It’s Hip to be a Glute

When it comes to preventing injuries and increasing athletic performance, the hip muscles are hard to beat.  They have a great influence on 3 planes motions and are heavily used in everything from walking to hitting a tennis forehand down the line.  The Gluteus Maximus and the Gluteus Medius are the 2 main muscles of the posterior hip that can easily be strengthened to improve performance and prevent injury.

Gluteus Maximus

This muscle is the most powerful external rotator of the hip and has a major role in controlling the hip as a pivot in the sagittal plane (hip hinging).  Because of the size and orientation of this muscle it is very important for supporting the hip in all planes of motion.

• Primary - Hip External Rotation, Hip Extension
• Secondary - Hip Abduction

Gluteus Medius

This muscle is essential for controlling the hip and trunk motion in the frontal plane.  It prevents the trendelenberg gait pattern (walking like a penguin).

• Primary - Hip Abduction
• Secondary - Hip External Rotation, Hip Extension

Hip Muscles Importance

These muscles preventing your hip going into a flexion/adduction/internal rotation moment.  When this position occurs with movement it is often called Dynamic Valgus.  Throughout the day (walking, sit to stand, stairs) and in athletic activities (agility tasks, jumping) your hips are at a great risk for this movement dysfunction.  Failure to have adequate hip strength to prevent dynamic valgus can potentially lead to various injuries (IT Band syndrome, ACL tear, hip impingment, low back pain, etc.).

Effects of Decreased Strength/Motor Control of the Gluts

At the Knee

The knee is basically a simple hinge joint.  It flexes and extends.  If your hips aren’t strong enough to support the reactive forces that accompany movement it will compensate with excessive motion at the adjacent joint.  This means that when your hips fail you begin to introduce rotation and side bending into a hinge joint (the knee).  Once a joint begins to function in a different way than its structure it is just a matter of time before it breaks down.

At the Back

Think of the pelvis as a shelf for the lumbar spine.  If that shelf is tilted one way (from weak hips) then your spine will have to compensate and bend to maintain an upright posture.  This leads to excessive compression on the spine and prevents its normal motion.  You cannot have dynamic trunk/core stability without dynamic pelvic stability.

Why Hips Are Weak

Don’t take it personally.  You can blame it on the most probable reason why your hips are weak - our society.  The increased amount of time in the static sitting posture puts the gluteal muscles in a lengthened position.  This position stretches the muscle out, thus causing decreased contractile potential (decreased strength).  In other words, your gluteal muscles go from tight effective movers to a thinned out weak tissue.The problem is further worsened because your body is much smarter than you are.  It adapts and begins to compensate with other muscles to achieve the necessary movement.  This is a natural survival mechanism.  However, once this compensation is set in, you will be strengthening the compensatory muscles instead of your gluts every time you exercise.  Add this to the fact that most of our motion occurs in the sagittal (front-back) plane and you've set yourself up to turn your strong gluteal muscles into soft cushions.

How to Strengthen Them

Here are 4 basic hip strengthening exercises.  This is a good base to start from before progressing to intermediate/advanced exercises.  Never sacrafice quantity for quality.  Perform exercises in a slow, controlled manner.  Stop immediately if you experience any pain.http://www.youtube.com/watch?v=9zzts_Ojrso&feature=plcp

References

Powers, Christopher M. "The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective." Journal of Orthopaedic and Sports Physical Therapy (2010)Nadler SF, Malanga GA, Feinberg JH, Prybicien M, Stitik TP, DePrince M. Relationship between hip muscle imbalance and occurrence of low back pain in collegiate athletes: a prospective study. Am J Phys Med Rehabil (2001)

Equipment

You can get the exercise bands here.  Start with green and work your way up.[subscribe2] --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.

 [subscribe2]