Only You Can Prevent Forest Fires (Chronic Pain & Self-Management)

this article originally appears on The A&G Project

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Chronic pain is an epidemic.Not only is this a problem for the individuals who suffer from pain, but also for our society.The economic costs of inefficient care and failed short-term treatment plans have led to an inefficient healthcare system.  Worse, these short-term passive pharmaceutical solutions have destroyed the lives and communities of many.As a society we need to look at chronic pain through a different lens.  One that incorporates the complexity of the situation and the realistic length of care.To accomplish this, our focus needs to change.  Instead of the clinician providing a short term solution and patient receiving a passive fix, healthcare should focus on clinician led education and active patient self-management.Clinical experience and current research show that outcomes are directly correlated with patient self-efficacy and compliance.  With the perspective of the clinician as a teacher or guide, the patient is encouraged to adopt the active role in their recovery and lifestyle that will lead to better outcomes.  This is not only much more effective, but also more efficient.In a powerful article, Holman and Lorig suggest a 3 fold change in our healthcare system:"The prevalence of chronic disease and the scope of its consequences have created a dramatically new situation in health care. Patients, health professionals, and the health service must now play new roles:

1. The patient—who must be responsible for daily management, behavior changes, emotional adjustments, and accurate reporting of disease trends and tempos—becomes the principal caregiver. Expressed in economic terms, health is the product of health care, and the patient, as a principal caregiver, is a producer of health. As in any production system, a producer must be knowledgeable about the product and skilled in the production process.

2. The health professionals, in addition to being professional advisers and partners in the design and conduct of medical management, become teachers in developing the patient’s management skills. In the present system, physicians, nurses, and public health workers are not trained for this role.

3. The health service becomes the organizer and financial supporter of the new roles for the patient and health professionals, focusing on assuring continuity and integration of care."

SUMMARY

The path to changing our healthcare system and our nation's health is already available.  We just need both the medical practitioners and the patients to get on board.

Medical practitioners need to stop looking for short-term solutions and acknowledge the complexity of an individual's health.

Patients need to stop looking for passive solutions and become an active leader in managing their health.

At The A&G Project in Asheville, we use this philosophy with all our patients.  It's the Jerry MaGuire philosophy.  Less volume of patients.  More individualized care.  And a focus on giving you the tools to manage your health so that you can achieve the best quality of life possible.

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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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The Problem with Smartphones

• "Men have become the tools of their tools." -Henry David Thoreau

Before I proceed and alienate everyone, I first want to clarify that I am not against technology and I don’t think smartphones are inherently bad.  I’m not trying to pull a John Connor and convince you to rage against the machine and destroy your cell phone.  In fact, I think technology is a critical component of our culture’s development.  Smartphones can be extremely helpful.  Not only can they end many arguments with instant fact-checking, but they provide an  endless supply of free information and the ability to connect with almost anyone in a first world country.  This creates many opportunities that wouldn’t exist otherwise.But like my mom always says, “everything is okay...in moderation.”The problem arises when smartphones go from a tool to a behavior.  Soon after this, addiction ensues.  Next thing you know you’re so dependent on your cell phone that you’re looking for outlets in public places.I know what you’re thinking, a cell phone addiction isn’t that bad as far as addictions go.   It’s just a cell phone, right?  I would strongly disagree.  Not only are all addictions/attachments are bad, but cell phone addiction can have some serious side effects.  To make this evident, I’ve created this list to help people understand the dangers of a cell phone addiction.

25 Reasons Why Your Cell Phone is Bad for You

1. It’s an Addiction (like a drug) 2. Promotes Static Posture (text neck, text claw, slump back, decreased novel sensory input, etc.)3. It’s a Distraction4. Exposure to Radio Frequency Electromagnetic Fields5. Increases Stress6. Can Damage Your Hands7. Blue Light8. Damages Vision / Eyes (Myopia)9. Reduces Downtime10. Reduces Situational Awareness11. Endangers Kids12. Makes You A Bad Parent13. Impairs Gait (disturbs the way you walk)14. Increases Sedentary Lifestyle and Risk of Obesity (even the blue light alone alters metabolism)15. Disrupts Sleep (click here to understand why sleep is important for your health)16. Decreases Attention Span and Capacity17. Decreases Quality of Interactions with Those Around You (damages relationships)18. Tends to promote shallow work instead of deep work19. Prevents Creativity and Daydreaming20. Makes You A Dangerous Driver21. Creates Unnecessary “Work”22. Increases Risk of Mental Health Problems (depression, anxiety, narcissism, etc.) - especially social media use23. Harvests More Bacteria Than a Toilet24. Inhibits Interactions With Surrounding Environment/Nature25. Makes You Less Homo Sapien

• “The danger always exists that our technology will serve as a buffer between us and nature, a block between us and the deeper dimensions of our own experience.”-Rollo May

10 Things That Will Help

1. Treat it like an addiction2. Become aware of your phone use (use an app to assess the time you’re on your phone, yes, I do appreciate the irony of this)3. Leave your phone in another room4. Limit the amount of times you check social media per day5. Don't check social media or emails until late morning/early afternoon6. Put your phone out of reach when you’re spending time with others or doing activities that require attention7. Turn off notifications8. Focus on other things (mindfulness, hobbies, books, etc.)9. Shut off all screens at least one hour before bed10. Take a Digital Sabbatical--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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Guest Post: Biomechanical vs. Anatomical Breathing

Guest Post: Biomechanical vs. Anatomical Breathing

By Cameron Yuen

This post was inspired by a discussion I had with Aaron about the StrongFirst snatch test. This test, which basically involves snatching a 24kg kettlebell 100 times within 5 minutes, is well known for it’s ability to leave even the most conditioned athletes gasping for air. Training for this test usually involves working on technique, strength, and endurance. However, training to improve breathing efficiency is often overlooked. After all, we breathe automatically for the most part, and when we do become conscious of our breath during exercise, we generally just default to breathing harder and faster. But this doesn’t have to be the case; changing your breathing pattern is one of the easiest approaches to improving performance.This article will highlight two of these strategies. Biomechanical breathing, which is ideal for short and intense exercise, and anatomical breathing, which is best suited for exercise requiring endurance and efficiency. These breathing styles follow the idea that just as there are different movement strategies depending on the type and goal of exercise, there are multiple ways to breathe depending on the demands of exercise.

Diaphragmatic Breathing

Learning to use your diaphragm is key for maintaining tension in biomechanical breathing, and relaxation in anatomical breathing. So before getting into the nuances of each strategy, I highly recommend you check out Aaron’s articles on breathing here and here. He does a great job breaking down the anatomy and mechanics of the diaphragm, and how to start implementing diaphragmatic breathing in treatment/training sessions. To get comfortable with diaphragmatic breathing, try this quick and easy supine breathing drill:https://www.youtube.com/watch?v=qxiE-bX1FjgTry to breathe down into your stomach so that your bottom hand rises and falls with each breath. The top hand will rise automatically as the ribs expand. After you get comfortable with this, place your hands around your waist, and try to make your breath expand laterally and posteriorly to push out against your hands. Ideally, your abdomen should be expanding from all sides as you breathe in.

Biomechanical Breathing

If you have ever lifted weights, you have probably used biomechanical breathing. Inhaling is matched with the eccentric phase of a movement, and exhalation is matched with the concentric phase. In biomechanical breathing, breath is used to increase intra-abdominal pressure (IAP), and optimize force production and transfer by creating a rigid core.  This strategy works well with ballistic movements, when external loads are high, and when a lot of tension is needed for a short amount of time. Here is an example of biomechanical breathing used during an overhead press:https://www.youtube.com/watch?v=hUCcfA7acJ0Similarly, for a barbell back squat, you would begin the descent (eccentric) by bracing your trunk in a neutral position, followed by a large diaphragmatic breath. Co-contracting the muscles of the core, and then pressurizing the compartment with the diaphragm increases IAP, and creates a very stable trunk. As you ascend from of the bottom of the squat (concentric) you exhale slowly. This lifts the diaphragm and decreases IAP. By breathing in this manner, you increase IAP as you flex your hips, which protects your spine by buffering the large flexion moment created by the weight. However, this strategy can be very fatiguing since you are using your diaphragm to create core stability and breathe at the same time. Therefore, biomechanical breathing should be reserved for anaerobic exercises requiring a large amount of core stability and tension.

Anatomical Breathing

Anatomical breathing on the other hand, matches breath with movement to decrease the amount of work needed for breathing. This approach is commonly used in yoga, pilates, and some martial arts, but can really be used for any type of movement with a high endurance component and lower external loads.Simply put, any time a movement compresses the rib cage and lungs, you exhale, and naturally let the pressure exerted on your lungs drive the air out. Whenever a movement causes your rib cage and lungs to expand, or when the ribs spring back from being compressed, you inhale. This strategy takes advantage of the passive elasticity and compliance of the rib cage to drive air in and out of the lungs, and decreases the workload on the respiratory muscles.For example, if you were to do kettlebell swings for high repetitions, you would exhale as you flex your hips and swing the bell between your legs. In this position, you would be compressing your ribs and abdomen with your arms, which naturally forces some of the air out of your lungs. As you swing the bell forward and your arms float to the front of your body, you inhale. Your ribs spring back and expand as you extend your hips, allowing some air to flow into your lungs. Of course, your respiratory muscles still have to work with this strategy, but they are assisted by passive movement of the ribs, and don’t have to fight against external compression.https://www.youtube.com/watch?v=ejXajYcbFsEIn this video, I take a relaxed inhale as the kettlebell floats up, then exhale as my arms compress my ribs during hip flexion. As you progress from swings to snatches, there are quite a few different ways to implement anatomical breathing:https://www.youtube.com/watch?v=KOIEtsxtxsoIn addition to lower intensity exercise, anatomical breathing can be used to facilitate mobility drills, especially those involving the rib cage and thoracic spine. Take for example a side lying windmill movement. By taking in a large breath as you begin the movement, the rib cage expands and drives thoracic rotation as you continue reaching. This can be repeated with each inhale driving more thoracic rotation and shoulder flexion.https://www.youtube.com/watch?v=VUBtk-9GeEkIn this video, I inhale as I begin the movement, then exhale as I come back to the hands together position. I then take larger and larger breaths as my ribs and thoracic spine open with each repetition.

Summary

These breathing strategies can feel foreign at first, but give them a shot during your next training session. If you are lifting heavy weights and require a lot of tension, biomechanical breathing is a good choice. If you need more relaxation and endurance, try out anatomical breathing. It may take a bit of concentration at first, but learning to breathe differently depending on your activity can have a profound impact on your performance.

About Cameron Yuen

 Cameron is currently a PT student at New York University, and research assistant at the Human Performance Lab at Lehman College. Before moving to New York, he was a strength and conditioning coach in San Diego, California. Outside of school, Cameron enjoys reading, practicing martial arts, and spending time with his two dogs. More of his writing can be found at his website: www.CameronYuen.com      [subscribe2]

Course Review: Chris Johnson Treadmill Analysis Workshop

I was very lucky to be mentored by Chris Johnson after PT school.  I observed and worked part-time in his clinic for almost a year.  I learned a tremendous amount from him and was excited to get an update on his approach during his Treadmill Analysis Workshop this past Wednesday.Chris is the premier running expert.  He doesn’t practice what he preaches, he’s a master of it (2x Kona Qualifier).  He dives deep into research to stay current on the latest evidence and to improve care.  And most importantly, he spends a ton of time treating and training endurance athletes.Needless to say, he has some valuable information to share.

Take Home

It’s all about cadence.  Increasing step rate is a control parameter that causes many advantageous changes (decreased stress on knees, hip, less vertical mass oscillation, less energy absorption, decreased ground reaction forces, etc.).  You want people to be around 170-180 steps/minute.  Assessing cadence should be a priority in your running analysis.

4 S’s to Look at

• Strike (Rearfoot, Midfoot, Forefoot)
• Sound (Overstrike, Slap, Clunk)
• Step Rate (# of contacts/min)
• Shoes

17 Random Things I Learned During the Course

*many of these are either quotes from Chris or paraphrased1) #1 activity outside of running is lifting weights2) If you run and you don't lift, you'll get injured3) Fastest runners he sees tend to over pronate and be toe out (pathomechanics aren’t the end all be all)4) Strike patterns will likely change during the race5) Most injuries occur at knee and below (endurance running)6) Faster you run, the more the forces shift proximally 7) My Favorite Quote From the Course - "It’s not born to run, it's built to run"8) Strength, control, and range requirement increase with increased time on ground9) Increased step rate of 10% did not increase O2 consumption or HR.  Chris recommends increasing between 5-10%, depending on the individual.10) A step rate below 160 is a problem11) Glute max not important for endurance runners. It's more about the glute med.12) Say "Full footed stride" instead of heel strike. Heel strike has a negative connotation now.  #PsychologicalPriming13) Overall Goal - get people running barefoot in shoes14) Have people run with a metronome15) Music matters16) Pump arms faster and your feet will catch up (increasing cadence) 17) Running is rhythm and timing

The Protocol

It so simple it’s mind blowing.  I’ve already done this a couple times in the clinic with great outcomes.

1. Count the steps on one leg for 30 seconds
2. Multiply by 4 (156 on L pic)
3. Increase no more than 10% (164 in this case)
4. Hold up metronome to patient and give only one cue
5. "Run to the beat of the metronome" (right pic)

A video posted by Aaron Swanson (@aswansonpt) on Dec 4, 2015 at 4:54am PST

Exercises

Chris has tons of running drills on his YouTube page.  Many of his exercises deal with practicing the skill of running and preparing the body for an efficient midstance phase.  Why would you let someone run if they can't perform a clean single leg hop?He has an insane attention to detail and, as you can see, is very strict with the movement.I highly recommend checking out his page.https://www.youtube.com/watch?v=gMf6G4M7f9U

Bottom Line

I remember my brother coming home from one of his drumming lesson and he couldn’t wait to show me the new beat that he had just learned.  Apparently, he learned a drum beat that allows you to play 80% of all popular rock and pop songs.  Surely this didn’t allow him to play Buddy Rich, but mastering this pocket beat allowed him to play most songs on the radio.  He could easily jam with many other musicians after learning that beat.Chris didn’t dive into the complexity of running.  Instead, he showed us the most effective “pocket beat” for runners.  It may not fix every runner, but I bet it will help at least 80% of them.  Overall it was a great workshop and I highly recommend to anyone that runs or works with runners.

Dig Deeper

Effects of step rate manipulation on joint mechanics during running.

Energy absorption reduced @ knee & hip when step rate increased above preferred

Increasing step rate by 10%

Reduced impact load

Less vertical center of mass (COM) velocity at landing

Less energy absorption or (-) work Greatest effect @ the knee

Increased step rate 10% did not increase O2 consumption or HR

Hip muscle loads during running at various step rates

With increased step rate, mm forces observed to increase during late swing, particularly from the HS & gluteals

Increasing running step rate reduces patellofemoral joint forcesInfluence of Stride Frequency and Length on Running Mechanics: A Systematic Review

There was consistent evidence that increased stride rate resulted in decreased center of mass vertical excursion, ground reaction force, shock attenuation, and energy absorbed at the hip, knee, and ankle joints.

Decreased ground contact time yielded a sig increase leg stiffness.  Conversely, decreased ground contact time sig increase leg stiffness

Select Injury-Related Variables Are Affected by Stride Length and Foot Strike Style During Running

Increased stride width leads to decreased frontal plane forces (i.e. decreased ITB stress)

Step width increases linearly as stride length decreases

Biomechanical Differences of Foot-Strike Patterns During Running: A Systematic Review With Meta-analysis FOOT STRIKE PATTERNS OF RUNNERS AT THE 15-KM POINT DURING AN ELITE-LEVEL HALF MARATHON Variation in Foot Strike Patterns during Running among Habitually Barefoot Populations Foot strike patterns of recreational and sub-elite runners in a long-distance road raceProspective comparison of running injuries between shod and barefoot runners [subscribe2]

Problem & Solution

Our brain is quite complicated.  It is constantly going through extremely complex processing to achieve many different outputs (movement, speech, vision, thoughts, emotion, pain, allostasis, etc.).STRESS is one of the most influential factors on our brain's ability to process efficiently.  And in today's society everyone has had it, many people live in it, and some people can never escape it.Stress an epidemic and it will likely get worse with time.

• “Stress-related ailments cost the United States an estimated $300 billion per year in medical bills and lost productivity, and our usage of sedative drugs has shot off the charts: between 1997 and 2004, Americans more than doubled their yearly spending on antianxiety medications like Xanax and Valium, from $900 million to $2.1 billion. And as the psychologist and anxiety specialist Robert Leahy has pointed out, the seeds of modern worry get planted early. “The average high school kid today has the same level of anxiety as the average psychiatric patient in the early 1950s,” he writes. Security and modernity haven’t brought us calm; they’ve somehow put us out of touch with how to handle our fears” | Excerpt From: Clark, Taylor. “Nerve.”

Fortunately, this situation can be improved with mindfulness.But first, it is important to understand why stress is a problem for the brain.

The Problem = Stress

Arnsten, Amy F. T. "Stress Signalling Pathways That Impair Prefrontal Cortex Structure and Function." Nature Reviews Neuroscience Nat Rev Neurosci 10.6 (2009): 410-22

• “Stress impairs higher-order PFC (Prefrontal Cortex) abilities such as working memory and attention regulation.  Thus, attention regulation switches from thoughtful ‘top-down’ control by the PFC that is based on what is most relevant to the task at hand to ‘bottom-up’ control by the sensory cortices, whereby the salience of the stimulus (for example, whether it is brightly coloured, loud or moving) captures our attention.”

Stress clogs up the brain's processing ability.  It creates excessive noise (e.g. increased alpha power) and disrupts the system's ability to process normal sensory information (among other things). 

The Solution = Mindfulness

Kerr, Catherine E., Matthew D. Sacchet, Sara W. Lazaret al. "Mindfulness Starts with the Body: Somatosensory Attention and Top-down Modulation of Cortical Alpha Rhythms in Mindfulness Meditation." Front. Hum. Neurosci. Frontiers in Human Neuroscience 7 (2013)

• “Higher-order cognitive processes including selective attention and working memory are enabled by the basic ability to filter irrelevant sensory information while focusing on relevant information”
• “Localized attention to body sensations enables subsequent gains in emotional and cognitive regulation by enhancing sensory information processing in the brain”

Mindfulness practice of specific internal sensations (e.g. body scan) helps to modulate the noise in the system (improved alpha power regulation) and promotes improved sensory information processing. 

An Analogy - Your Brain as a Concert

Let's consider the brain as the concert venue and the people as the different parts of the brain.When you have stress the concert venue (brain) becomes a loud rock show in a small club.  You can't really hear anything else that's going on (increased alpha power).  You can't communicate with anyone without shouting (why you only feel pain and discomfort when you're stressed).  You can barely move.  People keep bumping through because they "know someone up front" (poor attention).  That guy that's crowd surfing kicks you in the head.  Someone spills their drink down your back.  You can't see the stage because some idiot in front of you is trying to film it with his iPhone.  And it's just a matter of time before someone starts to yell out something no one wants to hear - "freebird!".Needless to say, this is not the best environment for communicating and organizing plans.In contrast, when you focus on the present sensations within your body the concert venue (brain) becomes a calm symphony concert at an outdoor amphitheater.  Everyone has space.  It's not too loud, you can have a conversation with the person next to you (decreased alpha power).  You can easily walk over to the other side of the venue (attention regulation).  You can not only the stage, but the rest of the venue as well.  And no one is shouting anything you don't want to hear.Don't get me wrong, I love going to rock shows just as much as anyone else.It's important to make sure the noise comes from the Marshall Stacks and not from inside your head.

Conclusion

Unfortunately telling people to quit their jobs, stop paying their mortgage, and hire a nanny are not realistic.  Some people will not be able to modify their lifestyle and will continue to have high stress levels.So what do you do about this?The same thing you would do for someone that has a structural dysfunction that you can't change.  You give them an exercise to help strengthen the system and improve resilience.For these overly stressed individuals this can be anything from a simple body scan meditation to an hour long Qi-Gong class.  It doesn't have to turn them into a vegan hippie, it just has to bring their attention focus to their body.  It has to bring them back to their internal sensations.

• “If you are depressed you are living in the past.  If you are anxious you are living in the future.  If you are at peace you are living in the present.” ― Lao Tzu

There is nothing more present than your own body and breath, right now.

[subscribe2]*There are many apps, websites, and albums with mindfulness practice.  I've put together a playlist of some of the free body scan meditations below.  Feel free to leave your favorite meditation app or track in the comments.

My Secret Acupuncture Experiment

I ran a secret experiment on our acupuncturist, Mila Mintsis.But before I go into the details, it’s important to know a few things about the human body.

4 Facts to Know

1) The nervous system controls the way we move (muscles are just the “puppets”)2) The autonomic nervous system has a huge influence on our movement

• Sympathetic = tightens muscles for fight or flight, can increase pain

• Parasympathetic = relaxes muscles for rest and relax, can decrease pain

3) Sympathetic Activity EXTENDS our body

• Too much sympathetic activity tightens our big muscles (global mobilisers)

• Puts us in a High Threshold Strategy

• This can lead to back pain, tight calfs, hip pain, shoulder pain, neck tightness, etc.

4) A simple an easy test for the nervous system is a toe touch

• If you can’t touch your toes, one of the culprits could be too much sympathetic nervous system activity - thus too much extension and muscle tightness (muscle tone)

My Experiment

I simply assessed the subject's toe touch before and after acupuncture.I didn’t want Mila to know what I was doing.  I wanted her to be “blind” to the experiment.  She could have easily used Acupuncture to loosen specific muscles and increase range of motion.  To get an unbiased result, she couldn’t even know I was doing an experiment.After acupuncture the subject had a dramatic improvement in his toe touch and a significant decrease in his perception of tightness.How did this happen?  Mila didn’t perform acupuncture with the intention of improving his toe touch.  So there is no kinesiological or mechanical explanation.  What it comes down to one of the most beneficial side effects of acupuncture - decreased sympathetic activity and increased parasympathetic activity.  Less stress, more rest (for the brain and body).  Just after one session, the tight extensor muscles were calmed down, the autonomic nervous system was more balance, and his movement significantly improved.

References

Li, Qian-Qian, Guang-Xia Shi, Qian Xu, Jing Wang, Cun-Zhi Liu, and Lin-Peng Wang. "Acupuncture Effect and Central Autonomic Regulation."Evidence-Based Complementary and Alternative Medicine 2013 (2013): 1-6.Andersson, S., and T. Lundeberg. "Acupuncture — from Empiricism to Science: Functional Background to Acupuncture Effects in Pain and Disease Pain and Disease." Medical Hypotheses 45.3 (1995): 271-81Frank C, Kobesova A, Kolar P. “Dynamic Neuromuscular Stabilization & Sports Rehabilitation”. International Journal of Sports Physical Therapy 2013;8(1):62-73.Porges, Stephen W. The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-regulation. New York: W. W. Norton, 2011.Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010.Thelen, Esther. "Dynamic Systems Theory and the Complexity of Change."Psychoanalytic Dialogues 15.2 (2005): 255-83.Postural Restoration Institute - video on extension  [subscribe2] 

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

Be sure to check out Part I for my thoughts on Crossfit and Mistake #1.

Mistake #2 = Not Training Unilaterally

Our bodies are inherently asymmetrical.  Don’t believe me?  Here are a couple examples of this natural asymmetry: we have a liver on the right, a heart on the left, 3 lung lobes on the left, 2 on the right, the stomach is tilted, one kidney is higher, the right diaphragm has a better zone of apposition, each brain hemisphere is lateralized for different tasks, and our left-otolitic dominance makes our motor system prefer the right side of our bodies.  On top of this, there are many other possible asymmetries and different morphologies due to genetics/ontogenetics.Not only are our bodies asymmetrical, but we live in a very asymmetrical world.  Everyday activities are asymmetrical; you push the car pedals with your right foot, grab your wallet out of the same pocket, open doors with your right hand, use the computer mouse on the same side.  Sporting activities are asymmetrical; you shoot with your right hand, kick with your right leg, swing a golf club to the same direction everytime.  And then there is just plain handedness.These asymmetries are normal and usually not a problem.  However, sometimes these asymmetries become too significant.  The imbalances become too much for the body to handle.This asymmetrical problem is taken to the next level when you add a symmetrical load to the system.  Symmetrically loading an asymmetrical system is the formula for injuries.  And this is one of the biggest mistakes Crossfitters make.While this applies to the entire body, it is critical in shoulders.  There are two reasons why:

1) You have a much more prominent handedness than footedness

2) Your legs benefit from some unilateral weight bearing activities everyday (walking, stairs)

Therefore, your upper extremity asymmetry is accelerated much faster compared to the lower extremity.  In other words, a right handed person can pretty much go all day without using their left arm at all.Fast forward to this person going from not using their non-dominant arm for most of their life (or past few years) and then throw a barbell at them.  It’s not going to go well.  The symmetrical external load (barbell) won’t be met with a symmetrical internal force (muscles).  Bringing a symmetrical exercise to an asymmetry is a recipe for disaster.Look at your car for an analogy.  If you car alignment is off, it’s going to cause some big problems.  Not only is most of the load going to be dumped onto one side, but it will also prevent a smooth straight path.  With the alignment off, the car will naturally want to veer from straight.  But it is being driven in a straight path, so the car has to pull (compensate) to maintain the desired direction.The same thing happens at your shoulders with barbell exercises.  One shoulder will get too much of the load, the other has to compensate to keep it straight, and it becomes an internal tug-of-war to keep the all important straight bar path.  Therefore, if you have a shoulder asymmetry, then the whole time you are cleaning, pressing, or snatching your shoulders will be compensating against each other.As mentioned in Part I, over time compensations lead to decreased performance and injuries.So what do you do about this?  Start brushing your teeth with your non-dominant arm?  Do barbell cleans with one arm?  Walk on your hands?

A Suggestion

The best thing you can do is incorporate some single arm (unilateral) strengthening into your weekly workouts.  This will not only prevent injuries, but it can also be used as an assessment.  If you can strict press 70# with your right arm, but only 50# with your left, then what do you think is happening when you strict press with a barbell?There are many different ways to work on unilateral strengthening, but in my opinion kettlebells are the best equipment to accomplish this.  They allow for the same metabolic burn, similar technique work, multi-joint strengthening, and most importantly - unilateral strengthening.  Pavel said it best "Your body has to adapt to the barbell while the kettlebell works with your body."Here’s a list of some unilateral shoulder exercises that can be done with just a kettlebell and some space:

Armbars, Bear Crawls, Quadruped T's, TGU, Single Arm Push Ups, Half/Tall-Kneeling/Standing KB Strict Press, Farmers Walks (overhead, rack, suitcase), Single Arm KB: Swing, Squat, Clean, Clean & Squat, Clean & Strict Press, Clean & Push Press, Snatch, Unilateral Suitcase Deadlift, Plank KB Pull Through

There are plenty of great coaches that can probably come up with some amazing unilateral upper extremity WODs.  There’s not just one right way to do it.  As long as you are training unilaterally and exposing weakness you will be decreasing your risk of injury and improving performance.For clinicians there is this Clinical Pearl

• If someone comes in with dominant side shoulder pain from bilateral/symmetrical training, the fix may be to strengthen the non-dominant side

Bottom Line

Like anything that becomes popular or trendy, there quickly becomes a group of people that jump on the bandwagon and a group of people that protest against it.  But this isn’t EDM, this isn’t Instagram, this isn’t the new iPhone.  This is simply another opportunity to help people stay active and exercise.  It’s not for everyone, but it’s not for no one.Medical professionals need to focus on ways to reduce injury and improve the activity rather than just pointing out what we don’t like.  Crossfit coaches need to focus on what’s best for the athletes health rather than what will give them the best workout.  And the Crossfit athletes need to be educated on the risk of lifting with poor technique and/or with a significant asymmetry.

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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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.

 [subscribe2]