May Hits (2014)

1) Do you know about the anti-icing movement?  Many are advocating against cryotherapy post injury.  Some blindly jump on the bandwagon, some feel threatened and become defensive, and most of us just want to know why.  I've recently come across a couple great articles on the theory and evidence that explains why we should not ice injuries.  Even if you continue to ice, you should at least know what it really does (e.g. numbing effect, descending modulation, body temp regulation, placebo).

• Dr. Minkin, Josh Stone, Kelly Starrett, Jeff Cubos, SportsPhysio, Aaron Hutchins, Poor Rats

• To sum it up "Groceries In, Garbage Out"

• Groceries In - inflammation brings in tissue healing cells, ice prevents the flow of these important cells

• Garbage Out - icing actually constricts the lymphatic vessels, pushing the inflammatory proteins out from the lymphatic vessels and back into the interstitial space - the muscle pump is best for reducing swelling/inflammation

2) Here's a nice site for reviewing medical examination/screens.3) David Epstein: Are athletes really getting faster, better, stronger?4) GMB shares their 5 Essential Movement Skills.  Some very interesting and useful stuff.  I frequently squat and bear crawl, but I rarely perform the other 3 movement skills.  So I tried them out while no one else was looking.  I found out that I have difficulty rolling backwards, the crab walk takes more effort than it should, and I cannot cartwheel to my left.  I haven't felt this awkward from movement in a while.  Thanks GMB!5) "A Reset is an intervention that will heighten sensory awareness so that the patient moves and feels better (quantity, quality, or both)".6) Dean Somerset has a nice review of Speed Ladder Drills and what they really do.7) Eric Cressey always has the best shoulder advice.8) Many know about the patients that cannot extend their thoracic spine, but what about the ones stuck in thoracic extension.  Quinn Henoch goes over what this postural/movement dysfunction looks like and how to address it.  Some great PRI stuff with a weight lifting lens.9) A nice review of nutrition for exercise.10) Optical illusions are a great way to explain outputs.  We know pain is an output from the brain.  Inputs are processed in the CNS and the result (output) can be pain.  This is hard for patients to understand.  Optical illusions can show patients that the "illusion" is an output from the brain.11) One of the best things I've read this month from Andreo Spina - "It is the principles utilized during the selection of exercises, not the exercises themselves that determines the extent of functionality".  Couldn't agree more, read the full post here.12) "Neural signals are related less to a stimulus per se than to its congruence with internal goals and predictions, calculated on the basis of previous input to the system." -Karsten Rauss13) This is a fun frontal plane stability exercise to play around with.14) "Is the T6 area a place that is perhaps biomechanically more at risk than other parts of the nervous system especially when you consider what humans do with their bodies these days?"15) Molly Galbraith goes over the 5 Biggest Mistakes Women Make with Their Training Programs16) "From a motor learning perspective, our brains are designed to move us through, and interact with, the surrounding environment. Using our body helps us learn more quickly. The more sensory inputs that children experience through free-play, the better they understand this interaction" Seth Oberst goes over why we need to stop sport specialization and promote free-play.17) Eric Cressey has a similar article here.  "Very few American kids are exposed to the rich proprioceptive environments that not only makes them good athletes, but also sets them up for a lifetime of good movement."18) Erson's 5's - 5 Things to Look for in an Evaluation: Symmetry, Motor Control, Breathing, Thoracic Mobility, Directional Preference19) Adam Meakins has a nice post on his 10 Commandments of Physical Therapy.  I agree with all of these.20) Mike Robertson has 2 great posts on Energy System Training (EST).  He goes over what it is, the science behind it, and why it's applicable to our species (performance & recovery).  Check it out here & here.21) "The enteric nervous system (ENS) is one of the main divisions of the autonomic nervous system and consists of a mesh-like system of neurons that governs the function of the gastrointestinal system. It comprises an estimated 500 million neurons and is so complex it has been dubbed the second brain."22) 4 Biggest Mistakes People Make with the Functional Movement Systems (FMS/SFMA)23) Squats vs. Hip Thrusts: What You Need to Know24) Explain Pain 3 (Day 1, Day 2, Day 3, Day 3-Part 2).  Good review of the conference.  Here are some gems.

"explaining and reconceptualising pain is the best approach we have to treating chronic pain.  However one of the barriers to doing this is health literacy."

“we treat processes, not anatomy”

"Conceptual change, while a type of learning, can be differentiated from other types of learning as it requires a fundamental change in the content and organisation of existing knowledge as well as the development of new learning strategies."

"Pain = (credible evidence for danger) – (credible evidence for safety)"

"central sensitisation patients are not heat sensitive (unlike in peripheral sensitisation – think sunburn and a hot shower) but can be cold sensitive."

“pain is always equally real, regardless of any process of peripheral or central sensitisation”

"neurons that fire at a theta rate are inhibitory "

“Pain is a multiple system output constructed by an individual pain neurotag. This signature is activated whenever the human concludes that body tissues are in danger and action is required and pain is allocated an anatomical reference in the virtual body”

"In chronic pain, thoughts alone can be enough to fire a disinhibited neurotag and elicit pain." 

"Increased activity in the SNS can add to the “inflammatory soup” in an unhealthy tissues, can activate Abnormal Impulse Generating Sites (AIGS) and can dribble out adrenaline into the dorsal root ganglion leading to upregulation of adrenoreceptors." 

"in chronic pain, neurotags can become both sensitised – easier to fire off with a wider variety of ignition cues at lower intensities, and disinhibited – imprecise and less refined."

"Explaining pain is not ‘advice to be active’, but rather explaining the benefits of activity.  Explaining pain is not advice that ‘hurt doesn’t equal harm’, but rather explaining why hurt does not equal harm."

Use Hypnotic Language

"The extent to which a person can recall precisely what occurred during the event, even down to the angle of their feet, the extent to which their knees were flexed etc, may provide a clue as to how precise the protective encoding is within their brain."

25) People You Should Know - Shirley Sahrmann created the Movement System Impairment Syndromes - a big influence on many of today's physical therapists (whether they know it or not).  Path of Instantaneous Center of Rotation and Relative Flexibility/Stiffness are some great concepts that can be used with every patient.26) Top 3 Tweets

• Mark Reid, MD ‏@medicalaxioms  - For two large industries in America, a human being is a place to deposit 1) Calories and 2) Pharmaceuticals. Both sold at a profit.
• Neil deGrasse Tyson ‏@neiltyson  - The limits on your enlightenment come not from the age you stopped going to school but from the age you stopped being curious
• Chris Thomas ‏@ChrisThomas7  - Mastering simple skills frees up the mind to perfect complex skills. Gradually bring the mind & body together without conscious thought

27) This is what a 0 on the FMS Hurdle Step Looks Like            [subscribe2]

4 Mistakes People Make with the Functional Movement Systems (FMS/SFMA)

I am a big fan of the FMS (Functional Movement Screen) and SFMA (Selective Functional Movement Assessment).  Together these screens and their associated principles make up the Functional Movement Systems.

I've been using this system for a couple years and have had a lot of success with it.  The more efficient I become at this approach, the more my outcomes improve.

I still have much to learn and am by no means an expert, but I thought I'd share the 4 biggest mistakes I see people make with the Functional Movement Systems.

4 Functional Movement Systems Mistakes

1) It's Not a Kinesiology or Biomechanics Test

The SFMA and FMS are both seven baseline movements that are used to assess how someone moves.  The big point here is that this is not a kinesiological test or a biomechanical test.  It’s not a strength, stability, or a mobility test.  It is not a test for anything in isolation.

It’s a complex neuro-based movement assessment.  It incorporates all the peripheral inputs coming into the CNS (mobility, muscle tension, joint ROM, position, tensegrity, vision, vestibular, etc.).  It incorporates how these inputs are analyzed and processed in the CNS (movement history, expectations, motivation, ANS state, etc.).  And then, it incorporates the output of this process - the physical movement we can see.

Essentially, the top tier tests are screening your neuro-tag for a standard 7 movements.  It shows what movement looks like in your brain.  It shows how the inputs are processed into outputs.  And this happens continuously in real-time throughout the entire movement.

This isn't just a theory.  It's how human movement works.

Anytime you loosen up someone's ankle DF (inputs), it needs to be integrated in the CNS (processing) for the specific movement pattern that was dysfunctional (outputs).  Sometimes this will spontaneously happen after creating mobility, other times you need to "show" the brain the new mobility and create the new movement neuro-tag.

2) 7 General Movement Standards

One of the big complaints I hear is that “people do more than just 7 movements”.  While this is a brilliant observation, it doesn’t debunk the system.

We can all understand Bernstein's Problem (Degrees of Freedom Problem).  The amount of freedom of the joints, coupled with the kinetic pulls of all the different muscles/fascia/connective tissue, basically creates an infinite amount of possible ways to move.  Therefore, the nervous system has an infinite amount of motor programs to choose from.

In other words, with the plethora of variables in human movement, there cannot be just one "right" way to move.

And this is a good thing; it allows our species to have more options to choose from when trying to adapt to a specific environment or task.

The problem exists in the practitioners job of assessing the infinite.  How do you go about testing the infinite ways of movement in a 45 minute eval?

This is where the SFMA/FMS comes in.

It is simply the best standard we have for efficiently screening the infinite movement patterns.

It is a funnel to find the dysfunctional movement family.

How does this apply to your patient's specific problem?

Simply look at the variables associated with the movement screen and match it with the patients dysfucntional movement or functional complaint.   You should be able to find something in common with your patients specific movement problem and one of the 7 movements (FMS or SFMA).

An example may help understand this concept.

If a patient fails MSF (Multi-Segmental Flexion), it means that this individual will likely have difficulty with movements that shift their COG behind their BOS, or lengthen a their posterior chain, or involve a hip hinge, or involve lumbar flexion, or require motor control of trunk flexion, etc. (see picture below for everyday common movement patterns).

It doesn't only mean that they can't touch their toes and fail a test.  It doesn't mean they need to move exactly like the MSF screen every time they bend forward in their life.  It just means their MSF movement pattern is dysfunctional and this will likely affect many of the other infinite movements that share the same variables.

In other words, it narrows the infinite and points you towards a family of movement patterns that need work.

3) It’s More Than Screening for Impairments

A common misconception about the SFMA is that it's only used to find local impairments.

Yes, finding the local impaired segment and tissue dysfunction is important.  But what’s more important is how the local impairment affects the global movement pattern.

Impairments cannot exist in a purely isolated fashion.  Impairments only exist in the context of the whole human body.  It’s not until the impairment adversely affects a movement (or posture) that it becomes a problem.

For example, an isolated latissimus dorsi restriction doesn’t mean anything by itself.  There are plenty of people who sit at desks all day, don’t exercise, and never lift their arms overhead.  Therefore, this impairment rarely becomes a problem for them.  But if this same person goes out and tries to hit a tennis serve over the weekend, this becomes a serious impairment that affects their MSE (Multi-Segmental Extension) movement pattern.  Compensations will occur and the risk of injury will increase.

Yes, the lat restriction is important, but it only becomes a dysfunction in the context of movement.

The goal of they system is to determine the local impairment AND the movement patterns that are most significantly affected.

4) It's a Screen & Assessment, the Intervention is Wide Open

This mistake often occurs as a result of the first 3 mistakes.

Most people are able to address the local impairment, but some have difficulty integrating this new input into the movement pattern.

The movement pattern intervention is basically an application of the concepts to the individuals specific assessment.  There is no cookie cutter protocol to follow.  It's open to the practitioner, the client, the environment, and the task/goal.

If you understand that it’s a complex neuro-based movement system, then you can understand there are an infinite amount of options to achieve the same result.  First address the breakouts (inputs), then integrate them back into the global movement pattern (processing), and finally re-assess the movement pattern (output).

Gray Cook has discussed this process in his 3 R's approach: Reset, Reinforce, & Reload.

Again, it helps to first think of it as a family of movements patterns.  Try to create similar sensory inputs that are “relatives” of the top tier movement pattern.  They don’t have to be identical twins, you just have to be able to tell that they’re related.

If the patient fails MSF, address the local impairments, then integrate them back into the movement pattern.  To do this, just pick an exercise that shifts their weight back, or flexes the trunk forward, or eccentrically lengthens the posterior chain, or rounds the lumbar spine, or requires a hip hinge.  Or a combination of those variables.

The same thing goes for the FMS.  If the patient fails the hurdle step, work on something that stabilizes the stance leg in hip extension, or open chain hip/knee/ankle flexion, or the scissored position (hip flexion & extension), or work on something that stabilizes the trunk upright in the dysfunctional scissored position.  Or a combination of those.

What you choose as your intervention should depend on the results of the movement screen, the breakouts, the examination, your patient, and your own treatment style.

If this open territory makes you uncomfortable, the System has a nice 4x4 exercise progression based on the neurodevelopmental perspective.  This may be the closest thing you will find to a "protocol" for movement patterns.

In the end, it doesn't matter what approach you use to address the findings in the screen and assessment.

There are many different ways to achieve the same thing.

As long as it simulates the similar inputs of the movement pattern, you should get a positive change.  If you don’t get a positive change, the screen will tell you.

And this is may be the most valuable aspect of The System.  It allows for you to "check your work".  It gives a clear indication for which interventions work, and which ones don't.

The System allows you to methodically add and subtract interventions until you achieve the desired outcome.

It gives you efficiency and effectiveness, while taking nothing from the way you currently treat.

Bottom Line

The Functional Movement Systems is a very useful clinical tool.  There is much more to this approach than simply screening 7 movements.  Understanding the concepts and principles of this approach will help to prevent errors and increase efficiency and outcomes.

Disclaimer

I do not work for or have any affiliation with the FMS/SFMA System.  This post does not represent the System or anyone affiliated with it.  This is simply my interpretation of the system and some thoughts that will hopefully improve people's understanding of it.  --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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April Hits (2014)

1) This is a MUST READ for anyone that puts their hands on their patients.  Erson shares 5 profound articles that changed his career.2) StrongFirst Tactical Strength Challenge Program3) "Think of PNF as a way of means of feeding the sensorimotor system specific purposeful information to create a purposeful and functional motor strategy" - Ramez Antoun4) Post-Activation Potentiation - A phenomena by which muscular performance characteristics are acutely enhanced as a result of their contractile history (Brett Contreras).  You can use this to improve movement patterns and performance.5) Bret Contreras goes over some advanced high-threshold core trainings for higher level clients.  Good stuff and a reminder to take it to the next level when you can.6) "Our perceptions are formed through a process of multisensory integration. This means that, for example, sensory information from the eyes can change how something tastes, or that sensory information from the ears can affect how something feels." - Todd Hargrove on the Marble Hand Illusion Study7) "A dissection study by Gibbons and Mottram (2004) found a 3^rd layer situated deep to the previous 2 described with short fibres that cross the sacroiliac joint (SIJ) and have relations with multifidus, the deep hip intrinsics and the pelvic floor."  They call this layer the Deep Sacral Gluteus Maximus.8) "the language of movement is written in feel, not in words or pictures" - Gray Cook goes over when to coach and when to correct9) How many patients do you see that get injured because of the elliptical?  Seth Oberst goes over why this isn't the ideal "exercise" for your patient in this post.  "When we can't feel the ground, we adapt thru maladaptive co-contraction (like walking on ice) in the leg musculature reducing movement efficiency for when it matters most - like doing actual athletic or sport movements, even walking."10) Subjective history may not always be accurate.  "Every time you pull up a memory, say of your first kiss, your mind reinterprets it for the present day, new research suggests. If you're in the middle of an ugly divorce, for example, you might recall it differently than if you're happily married and life is going well."11) Short muscles are a problem.  Not because of adaptive restrictions, but because of the vicious neuromuscular cycle.  Muscles that are in a shortened position often have increased neural drive (neural activation).  This means they often become over facilitated and need to be inhibited...not stretched.12) Bridge Progressions from Chris Johnson.  I particularly like the variation on the 2nd exercise and have started prescribing it in my practice.13) Interesting study on rotator cuff repairs: "Patients who underwent rotator cuff repair have improved function and reduced pain, regardless of the structural integrity of the repair. Patients with an intact repair have greater strength than those with retears."14) It seems like mobility is getting all the credit these days.  And for good reason, tons of mechanoreceptors, allows for fewer compensations, centration, motor control, core pendulum theory, correlated with lower morbidity, etc.  But what about good ol' fashion strength?  Strength is an important physical characteristic that allows your patients to move better and increases their ability to adapt to physical stress.  Think about your older patients.  If they're having trouble going from sit to stand, is an ankle mobilization or lower extremity strengthening program going to help them more?  Recent research is now backing up the importance of strength in regards to mortality.  Don't forget to get people stronger.15) I wish this would have been around back when I took biology.16) "Sleep complaints are present in up to 88% of chronic pain disorders and at least 50% of patients presenting with insomnia also suffer chronic pain."17) Lifestyle has a great influence on recovery.  Here are 4 lifestyle choices that I like to discuss with my patients.18) During my last affiliation of PT school my CI, Marcus Forman, used to always preach that "the devil is in the details".  He was right in more ways than I could have imagined.  Mike Reinold goes over the details of the simple hip flexor stretch.  Don't let your patients hack up this stretch.19) Erson's 5's - 5 Things Your Patient Needs for Successful Outcomes: Education, Mobility, Symmetry, Stability/Motor Control, Homework.  5 Cervical Radiculopathy Treatments - I've recently been amazed at how well kinesiotaping works for symptom relief. - 5 Modern Ways to Look at Manual Therapy20) A review of pain from Move Forward.  A physical therapist's guide to understanding pain.21) I wrote up this article on grip strength and the rotator cuff for Physiospot.22) Eric Cressey gives 5 tips for people performing/teaching boot camp class, crossfit, and/or other metabolic resistance training classes.  This can improve performance and decrease risk of injury for those participating in these types of classes.23) I'm a big fan of Adriaan Louw and his work.  Zac "Review Machine" Cupples wrote this up about his course (including a great Predator reference).  I've always liked the ion explanation: "When someone is extra sensitive, the nerves increase their resting excitement level so action potentials more readily occur. Adding more ion channels to less myelinated areas can further compound this sensitivity.  Fun fact – Ion channels change every 48 hours, and therapy can positively influence the change."24) Nice review of Andreo Spina's course - "The longer the muscle is when it is contracted, the more force through the tendon/connective tissue at the attachment site" - "All connective tissue (muscles, bones, fascia, etc.) are all just different expressions of the same material."25) People You Should Know: Nikolai Bernstein is the one of the Godfathers of motor control and motor learning.  Read about his Degrees of Freedom Problem ("Bernstein Problem").26) Top 3 Tweets of the MonthTim Cocks (@altThinq) live tweeted some great stuff from Explain Pain 3.  Look at #ExplainPain3.

• @medicalaxioms - It takes considerable knowledge just to realize the extent of your own ignorance. –Thomas Sowell
•  @altThinq - Our current understanding is that as the brain learns it develops precision through inhibition of neurons #ExplainPain3
• @graycookPT - Most of us are too verbal in our movement instruction. We should cause a change, not coach a change.

27) This is pretty much what my exercise routine was during March Madness.                   [subscribe2]

The Art of Recovery (Part 2 of 2)

Part I went over stress, tissues, the nervous system, and many of the factors that are involved with recovery.Throughout a PT session there are many opportunities to influence the patient's health; both for the immediate and long term effects.  This post will go over the 4 factors of recovery that I often try to discuss with patients before they are discharged from Physical Therapy.

4 Factors of Recovery

Each of these 4 factors could be a book on its own, let alone a blog post.  To save myself some of the mental stress of going over each of them in-depth, I'll just briefly describe the factors and some methods for improvement.Before you start educating patients, it's important to follow the golden rule:

• Don't prescribe anything you haven't tried yourself

This goes not only for exercises, but the lifestyle changes as well.  If you don't sleep well, have never meditated, and eat bad food, then you shouldn't try to influence other people.

Sleep

Sleep is a difficult one.  Going to bed at a descent hour is extremly difficult these days.  Youtube, reddit, twitter, league pass, and Netflix (how can you just watch 1 episode of House of Cards?).  But it's one of the easiest ways to improve recovery.Sleep gives us the lowest level of stress (internal & external) on the body.  This low level of stress allows us to get out of the red and into the black.  It lets us recover.  Both mentally and physically.The science behind sleep (and why we need it) is still not conclusive.  But we do know that sleep plays a huge role in hormone regulation (melatonin, GH, TSH, testosterone, cortisol, etc.), augments immune system function, improves cardiovascular function, increases cognition, and improves neural function (stimulate oligodendricytes, myelin, neural development/repair).  Plus, the supine position puts the lowest load on the body.Sleep expert at NIH, Dr. Michael Twery, sums up these benefits of sleep nicely; "Sleep affects almost every tissue in our body."So even if we don't know all the reasons behind why we sleep, we at least know that it's good for you.Most experts agree that you need at least 7 hours of sleep a night.  Of course it varies from person to person, but if you're getting less sleep than 7 you might have trouble recovering from the day's cumulative stress (especially if you've put extra stress on it; i.e. workout, injury).

Improving Sleep

 

Mental Stress

Today's culture creates quite a problem.We have these bodies that were developed from over 6 million years of evolution.  This slow, progressive, evolution of our physical body has given us the genes we have today.  Even though we've become a different species than our ancestors, we still share many of the same genes.  Thus, we share a similar body type as our ancestors.On the other hand, our cultural evolution has skyrocketed in the last 10,000-50,000 years, leaving our physical bodies way behind.  And this cultural evolution continues to progress at an exponential rate.  The Agricultural and Industrial Revolution were the first big events that changed the way humans live.  Now we have the Information/Telecommunications Revolution. We are spending more time plugged in and less time present with our bodies.  From this cultural evolutionary perspective, we don't share much in common with our ancestors.This creates a mismatch between the environment we live in and our physical bodies.  In other words, our bodies are not made to live in today's cultural environment.The result of this, and the fact that we often treat the symptoms instead of the cause, is what Daniel Liberman refers to as dysevolution.  A product of this dysevolution is the increasing amount of mental stress/disorder and physical dysfunction.Luckily for us, there is a method to help prevent or decrease this mental burden - Meditation.

Meditation

Meditation has been around for possibly 5,000 years.  Needless to say, it has some empirical evidence.I have taken UCLA's on-line meditation course with mindfulness expert, Diana Winston.  While this by no means makes me an authority on the subject, it has educated me on some of the science behind meditation and how to apply it.The benefits of meditation are incredible and the profound effects cannot be overstated.  Many people talk about the life changing effects of this practice.  Even some of the most successful people in our society have credited meditation as a big part of their growth and accomplishments.But even if empirical evidence doesn't convince you, modern research has shown many positive effects.

Research Has Shown That Meditation Can

• Improve Physical Health (e.g. cardiovascular, immune system)
• Improve Mental Health (e.g. anxiety, depression)
• Improve Emotion Regulation
• Decrease Sympathetic Drive
• Improve Attention (e.g. conflict attention, improve flow)
• Improve Brain Function (e.g. neurodevelopment, gyrification)
• Decrease Pain
• Improve Well-Being

Sounds pretty good, right?And did I mention that it's free and easy?  Well...it's free and physically easy.  Developing your meditation practice is a process and requires some motivation and mental effort.  But don't take that as a deterrent, it's not exhausting or mentally fatiguing.  In fact, most people feel energized after meditating.  The most difficult part is getting started and developing the habit of meditating.I think one of the best places to start is with Diana Winston's 5 minute breathing meditation (YouTube).This is a great place to start for 3 reasons:

1) Everyone can perform 5 minutes

2) It goes over the basics and gives you a standard guideline for future meditations

3) The diaphragm is the only voluntary muscle that can directly influence the autonomic nervous system.  Breathing augments the parasympathetic response of meditation.

It's important to note that I don't immediately jump directly from discussing a painful shoulder to giving them a 5 minute meditation recommendation.Before I prescribe meditation to a patient, I first educate them on the autonomic nervous system continuum (sympathetic vs. parasympathetic).  Then I begin to explain some of the benefits of meditation and how it can aide in their recovery.  If they are receptive, I simply write down my meditation recommendation (above), tell them to type it in on google, find a quiet place, and try the 5 minute meditation.One benefit of our accelerated cultural evolution is that there are now plenty of meditation guides, timers, apps, and techno-bio-feedback devices that give people an easy way to stay on top of their meditation practice.

Diet

Bringing up diet is a lot like bringing up politics.  Everyone has an opinion and no one knows what's really going on.Do we eat nothing but bacon?  Is carbohydrate a bad word?  Is there a chocolate diet?However, more science and less propaganda has allowed for a recent paradigm shift in diet.  We're only scratching the surface and the answers will vary per person and per culture.  But it has gotten a lot better than that terrible food pyramid we were taught to believe.Trends will come and go, but I feel that there are 5 facts that would help most people.  Of course there are a lot more to these "facts" than a simple sentence, but hopefully it'll give some direction for nutrition choices.

5 Nutritional Facts

1. Avoid Processed Foods
2. Eat More Vegetables
3. Avoid Simple Carbohydrates
4. Fat is Not Bad for You*
5. Stay Hydrated

I don't think these 5 Facts will change as they seem to be backed up by basic physiology, logic, and evolutionary medicine.  We may learn more about the specifics of each category, but the basic principle shouldn't change.  For example, it is now well known that fats are good for your health, but research is finding out which specific types of fats are healthy and which are detrimental (i.e. trans fats).

Exercise

The benefits of exercise are enormous.  Exercise improves the musculoskeletal system, controls weight, increases life span, reduces diabetes risk, improves mental health, reduces risk of some cancers, improves cardiovascular fitness, and improves sleep.Exercise is also beneficial for recovery both:

• Immediately following a bout of stress

• For the long term ability to adapt to stress.

The immediate beneficial effects of exercise for recovery should be focused on the circulatory system.  The goal is simply to get blood and fluids moving around.  This should include some active dynamic stretching, mobility work, light stabilization, and/or light aerobic exercise.The long term effects of exercise are much more complicated.  This requires specific individualized programming that involves periodization and deloading.  People should have a normal overall fitness and exercise routine to help stress the body for an individualized adaptation.  Because in the long run, the body can only handle what the body is adapted for.There are many great articles regarding the physical aspect of recovery.  Check the references provided below for more detailed information.

Bottom Line

It's often not the over-training, as much as it is the under-recovery.You can have the greatest training program and the best workout session from the best coach in the world.  But unless you are able to recover from it, it won't matter.Bernard Hopkins, record holder for chronologically oldest boxing champion, sums this series it up nicely:

• "Lifestyle is the make or break of any athlete."

I would even go one step further and say that lifestyle is the make or break of anyone's health.

Disclaimer

Now I'm not saying you should go out and give your patients a full nutritional prescription or start discussing their childhood to determine why their boss stresses them out.  Instead, you should just be assessing the factors that influence their recovery and offering some general advice (if you are educated).  Anything more than this would be beyond health promotion and fall out of the scope of your practice.If someone is interested in a more in depth answer, you should refer out.  The patient will benefit from a greater health "team" and the person you refer out to may even start referring in to you.

Dig Deeper

Signs & Symptoms of OvertrainingChen, Jui-Lien, Ding-Peng Yeh, Jo-Ping Lee, et al. "Parasympathetic Nervous Activity Mirrors Recovery Status in Weightlifting Performance After Training." Journal of Strength and Conditioning Research25.6 (2011): 1546-552.Porges, Stephen W. The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-regulation. New York: W. W. Norton, 2011.Walter, Chip. Last Ape Standing: The Seven-million Year Story of How and Why We Survived. New York: Walker &, 2013Lieberman, Daniel. The Story of the Human Body: Evolution, Health, and Disease. New York: Pantheon, 2013. PrintNutritionSugar is a Drug - Rejection of Low-Fat Dogma - Kris Gunnars Science - 11 Problems with the Modern Diet - Don't Fear the FatsPrecision Nutrition - Boosting Recovery, All About RecoveryHydration - Len KravitzBulletProof - Diet Infographics -SleepInfoGraphic - NIH - 11 Benefits of Sleep - Neural Repair - Sleep "Hacking" - Supplements (1, 2) - How Athletes Sleep - FatigueScience - Study on Performance - James Clear's Informative Sleep Guide - Farnam Street Shane Parrish's Science Summary - NYTimes Schwartz - Sleep & Pain Correlation - Healing Power of Sleep - NeuroSleep InfoGraphic - 10 Reasons Why Sleep is Good - GMB - Sleep Deprivation = Cell Damage - Fix Circadian Rhythm - 2015 National Sleep Foundation Recommendations (Hours Per Night) - TNP on Sleep & Pain - Non-Obvious Sleep Solutions - Wear Sunglasses at Night (here & here) - Scientific American How to Be A Better Sleeper - Sleeps Role in Obesity & Psychological Disorders - 7 Steps to Better Sleep - Body in Mind's Sleep, Pain, & Recovery - Eric Barker 5 Ways to Sleep Better - Sleep is good for learning and memory - The New Yorker "Why Can't We Fall Asleep" - Relationship Between Sleep and Pain - Understanding Sleep - Sleep Builds Good Hearts - Optimizing Sleep for Memory - Sleep Restriction Therapy - Nick Littlehales 90 minute cycles and Ronaldo - National Institute of Health: Why Sleep is Important - Sleep removes neurotoxic waste from the brain - NYT Sleep. Clean. - NYT Sleep Problems and Type 2 Diabetes - Sleep & Recovery from YLMSportScience - The Sleep Judge on the Health Benefits of SleepReimund, E. "The Free Radical Flux Theory of Sleep." Medical Hypotheses 43.4 (1994): 231-33.

"Removal of excess free radicals during sleep is accomplished by decreased rate of formation of free radicals, and increased efficiency of endogenous antioxidant mechanisms. Thus, sleep functions essentially as an antioxidant for the brain."

MeditationUCLA Mindfulness Awareness Research Center - Mindfulness Research Summary (Flock L, Flaxman G) - Gyrification - 7 Myths of Meditation -23 Ways to Reduce StressUCLA  - Mindful Awareness Practices (MAPs) I for Daily Living (On-Line).  2013.ExerciseCDC - Harvard - Exercise & the Brain -Mike Robertson - 6 Tips for Recovery , Aging AthletesEric Cressey - 3 Tips for Aging AthleteChris Beardsley - RecoveryKevin Neeld - Post-Game Sympathetic Dominance, Overtraining & RecoveryDan John - Recovery TipsPatrick Ward - Rest, Recover, Regenerate Part 1, 2, 3, 4, 5Seth Oberst - RecoveryEric Bach (via Dean Somerset) - Recovery - Deloading 

Blair, S.  Physical inactivity: the biggest public health problem of the 21st century.  BJSM.

Fountain of YouthThe 23 Hour Plan--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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March Hits (2014)

1) Communication is just as important as the intervention.  Seth Oberst writes a great post on the difference between external and internal cues.  "It's now being shown that athletes focusing on the results of the movement are producing more force, jumping higher, generating better performance in stressful situations, and increasing fluidity and multi-tasking."2) Evolution has shown us the importance of diet and the jaw on our growth as a species.  Here's an interesting site on the jaw and it's relation to the co-morbidities.3) Want to learn how to pistol squat?  Click here.4) A PRI influenced series on "Unlocking Secrets of the Pelvis (Part I, II, III, IV)" by Robert George.5) The never ending patella vs. hamstring ACL graft battle.  Mike Reinold goes over recent research that showed more revisions are performed on hamstring grafts.  "When we really assess the numbers, it is clear that both graft options are great choices with low revision rates.  Even though we are comparing the two, realistically the revision rates after ACL reconstruction are low for both hamstring grafts and patellar tendon grafts."6) Nice article with some PRI and DNS concepts for abdominal training from Mike Robertson.7) This is some great stuff from Jeff Cubos.  Quotes from Andreo Spina followed by his explanation of each quote.  I also re-read this post from Spina on fascia, solid-state biochemistry, and theoretical physics.  You might not want to speed read through this one.8) More evidence on proximal influence: "...rehabilitation professionals should consider incorporating balance training, as an integral component of core stability, into the rehabilitation of athletes with shoulder dysfunction."9) This sums up our dysfunctional nutrition views: 11 Graphs Showing What is Wrong with the Modern Diet10) Lorimer Moseley on Bioplasticity: "It seems to me to be a fairer reflection of what we know about ourselves and it is a sensible umbrella term for the changes that occur across multiple systems when, for example, pain persists, or when, for example, we try to change pain."11) "We all want our magical hands, brilliant exercises, and genius programming to cause specific advantageous adaptations that give our patients super-human like powers.  But the sad truth is, even if we put a magic spell on a patient, they will only get better if they can adapt from it."  Recovery Drives Adaptation12) Zac Cupples reviews Explain Pain.  Great stuff.  "The therapeutic goal is to alter representations, deactivate painful neurotags, and reduce the perception of threat."13) "Connective tissue is both fluid and container, a sea and a retort, the medium in which chemical re-organization occurs (Juhan). It is fluid crystal, a ‘dynamic rhythmic matrix which operates as conductor for many different kinds of energy: mechanical, elastic, hydraulic, electro-magnetic, gravity, heat, sound and light.’  (Peters).  Shifts in our emotional state are linked to perceptions of a change in the state of our connective tissue, including a sense of flow and ease, or fullness, or lightness, or constriction or density." - Roz Carrol14) If you enjoyed the NFL Combine, you should check this out.  Mike Robertson goes over the strength & conditioning components of each test.15) Advanced Lat Stretch for the athletic population.16) "This shows that the adductors have better leverage as hip extensors in hip flexion, whereas the glutes have better leverage as hip extensors in anatomical position. Also, the sum of hip extension moment arms is greater in hip flexion compared to anatomical position." - Bret Contreras post on hip extension during the lockout phase of a deadlift.  For less adductor activity during extension, try emphasizing extension at neutral.17) 3 Different "Happy" Lives - Martin Seligman

Pleasant Life

Engagement (Flow)

Meaningful Life

18) Erson interviewed pelvic floor specialist, Julie Wiebe.  Some good stuff here.  4 Gems: 1)“Trust that the body is a self righting organism. Our job is to guide the process.” Norene Christesen, PT.  "  2) "I didn’t make them better, they made changes in how they thought about, used or moved their body and saw results. " 3) "Our stability system actually runs off the breath cycle." 4) "the pelvic floor is parallel in its action to the diaphragm, they work together, so it is important that clinicians know how to integrate them along with the TA and multifidus into their programming for stability, strengthening, balance, etc."19) 1-Arm Offset Kettlebell TRX Rows20) Gait Guys (via Erson) - The Deadmill.  Treadmill pulls the hip into extension, knee into extension, and ankle into dorsiflexion.  The problem is that this passive pull on these joints causes a stretch reflex (muscle contraction) and inhibition of the antagonist.  It robs the user of glutes, quads, and ankle DF.  How many runners do you see that need glute & quad strenth and ankle DF ROM?21) "True movement intelligence therefore doesn’t exist so much in the movements themselves, but in their interaction with the environment." - Todd Hargrove22) Top 3 Tweets of the Month

• @deansomerset - Knowledge without application = useless. Application without knowledge = dangerous. Always know more than used, never use more than known
• @DrAndreoSpina - To fully understand human health study human #evolution
• @PikeAthletics - Strength is an attitude, not only a physical quality.

Note: Some use twitter to promote and sell their products, some use twitter to troll and argue, and some, like @ZBrulet, use twitter to share knowledge and improve movement.  If you have any interest in S&C, you need to follow him.23) WOD of the Day - Snatch and Roll for Embarrassment             [subscribe2]

The Art of Recovery (Part 1 of 2)

One of the most difficult questions to answer in rehab is: "when will I get better?"Coming out of grad school my response was usually mumbling some ridiculous time period with a deer in the headlights look on my face.  I had no idea.  I knew the tissue healing timetable...and that was about it.  I had little experience with specific injuries and didn't yet understand the complex, multi-faceted factors that influence recovery.Now I'm a little better at hiding that deer in the headlights look, I have more clinical experience, and I know more about the art of recovery.

Stress

Before diving into recovery, you have to understand a little more about the stressors that cause recovery and adaptation.There are two types of stress: Internal Physiological Stress and External Environmental Stress.The Internal Stress is an on-going battle to keep our physiological homeostasis.  We have to adapt to these cellular stressors to make sure we can continue to keep all of our systems functioning together.  This type of stress is perpetual as long as you're alive.The External Stress is what happens when we interact with our environment.  It's how we adapt to function and survive in our surrounding habitat.  This can be physical and/or mental stress.

• Physical Stress includes any external force/load that is applied on the body (e.i., getting out of bed, walking, sitting in a chair, carrying groceries, bring a beer to your lips, etc.).  Even gravity counts as a physical stress.  But don't use that as an excuse to skip your next workout.

• Mental Stress includes all the sensory input and complex psychological processing.  This is an extremely complicated system and cannot be overlooked.  Even listening to music elicits a certain amount of mental stress, let alone listening while texting your friend, checking your email, and trying to avoid walking into people on the sidewalk.

Unfortunately, there is no way to completely avoid stress.  Trust me, with Netflix binge watching I have given it a good shot.  Nevertheless, if you are alive, and you live in an environment, you will have to deal with these internal and external stressors.  And this is a good thing (to a certain extent).

• Stress Must Occur for Adaptation to Occur

All of these different types of stressors are compounded on the body.  In other words, it's cummulative.  The external stressors are added to the internal stressors, and it forces your body to adapt (both physically and mentally).  If your body can't adapt, if it can't recover from the stress...bad things will start to happen.

The Art of Recovery

I know, it sounds like a book you'd see in the self-help section of Barnes and Nobles.  But I've come to realize how important recovery is when you look at the big picture.We all want our magical hands, brilliant exercises, and genius programming to cause specific advantageous adaptations that give our patients super-human like powers.  But the sad truth is, even if we put a magic spell on a patient, they will only get better if they can adapt from it.

• Adaptations Occur During Recovery

Simply put, your patient won't be able to adapt to physical stress without a proper recovery.  The gains will be diminished, non-existent, or even reversed.  And if this short term lack of recovery continues over time, it can lead to a very damaging effect.This applies to everyone; from rehab to strength and conditioning.  Whether it's a post-op ACL or a PR deadlift session, recovery drives the adaptation.Stress can either cause an adaptation or push them further down the biological stress path.

Tissues Heal

Tissues will naturally heal.  Our bodies have a great capacity to repair themselves.Tons of people injure themselves everyday and don't need any rehab or exercises to recover.  Their tissues heal with time (providing they don't do anything stupid).  They just ride the natural progression towards recovery.Understanding this simple concept is a big part of recovery.Since the tissues are going to naturally heal themselves, you better make sure you and your patient don't do anything to disrupt this process.  This comes down to educating your patient on the factors that influence their recovery.  If all you do is control these factors of recovery, the patient will physiologically get better (not talking about pain and/or movement patterns).After you have the preventative/augmentative aspect of recovery covered, you can start to try to create the right environment for the patient to heal in.  This comes down to controlling the specific stressors (seed) you apply to the patient (soil) in the clinic.

Factors That Influence Recovery

The Art of Recovery is an individualized process that depends on who your patient is and what injury they have.  Everyone is different and requires a different recovery process.You can't apply a cookie cutter approach to recovery.  It won't work.  There are too many patient variables to consider: coping style, lifestyle, social factors, occupation, expectations, education level, learning styles, previous injuries, expectations, economic status, goals, cultural background, etc.It needs to be tailored for the human being you are working with.So where do you start?Start by understanding all the factors that can influence recovery.  Specifically, the external environmental factors, since these are the ones both you and your patient have the most control over.  And these external environmental factors can be used to influence the internal physiological factors.Our species will respond in a similar manner to all these factors.  Regardless of who you are, a bad diet, lack of sleep, high level of stress, and lack of exercise will adversely affect your recovery.  However, the degree to which everyone is affected by these factors will differ.Once you understand this complex concept and some of the variables involved, you can then start to assess and individualize these factors to the person's specific needs.It's important to realize that many of these factors can either positively or negatively influence recovery.

Assessing the Patient

Recovery can be viewed from the lens of the nervous system (Autonomic NS).  The nervous system oversees and affects all of the other systems, especially when dealing with stress.Everyone will be on a continuum of sympathetic and parasympathetic dominance.  Where they lie on this continuum depends on many components, but global perspective can help to assess how much stress a person has.If there is a lot of stress (internal & external), the body will be in more of a fight or flight mode (sympathetic) trying to recover from this stress.  If your body is adapted and not as stressed, it will be more relaxed (parasympathetic) and closer to homeostasis.You can generally tell what system is more dominant by spending some time with the patient.  You can just globally look at their symptoms, interactions, affect, demeanor, and body language.  Or you can get a little more objective using the cardiovascular system (heart rate variability).Either way, you need to determine where your patient stands.  Are they too far on the parasympathetic side and need some added stress to initiate positive adaptation?  Or are they too far on the sympathetic side and need to reduce some of the cumulative stress to allow for recovery?In general, your body recovers better on the parasympathetic side.  Especially in today's over stimulated world, everyone could probably benefit from getting a little more parasympathetic.  Just realize that some people will need more work to get there.  And the goal is to get to a state of neutral, not to push your patient into a coma for recovery.

Influencing Recovery

How to influence these factors is a whole other animal.  Because of the complexity of patient variables, it is impossible to have a protocol for influencing recovery.  Developing this approach is much like pain education, it really needs to be specific to the patient.There are 2 things you should take into consideration:

1. People respond differently to different methods of recovery
2. People may not be able to change certain factors

Instead of dogmatically forcing certain methods or certain factors, listen to your patient and work with them on what they can do.For example, the new father with a busy work schedule may not be able to get 7 hours of quality sleep every night.  It's just not in the cards.  So instead of beating a dead horse on sleep, you should educate and promote one of the other factors.  He can probably improve his diet/hydration, exercise for 20 minutes, find 5 minute to meditate, or reduce his technology use at home.And this doesn't need to be a 10 minute lecture or a big intervention.  It is just an open discussion with the goal of educating the patient and helping them improve their recovery.How you educate them is up to you, but if they don't know, they can't change it.  And if they can't change it, that perfect exercise won't "grow" to be the adaptation you were hoping for.

A Role in Promoting Health

All you can do is educate and try to sell the patient on recovery.  In the end, their recovery is in their own hands.But also consider that you are doing more than just advocating recovery.A side benefit of focusing on factors that influence recovery, is that you are also promoting a healthier lifestyle.  Not only will they recover more efficiently, but their overall health can dramatically improve with small changes.  This could make a big impact on their quality of life.And think about the effect this could have on our healthcare system.Someone that sleeps 4 hours a night, doesn't exercise, eats bad food, is stressed with work, and sits in a chair for 80 hours a week will cost the healthcare system A LOT of money.  If this person could change at least one of those factors they would be in much better health and put less strain on the healthcare system (if 25% of the population were more fit, it would save over $58 Billion per year).

Bottom Line

Many times we become so worried about applying the perfect stress that we forget about the importance of the patient adapting to it.We can get so caught up with movement patterns, mechanics, pain education, and manual techniques that we sometimes overlook some of the easy ways to help a patient recovery quicker.  Educating and attempting to control the factors that influence recovery is not only a part of their current rehabilitation, but it's also a big part of their overall health.So the next time your patient inquires about "when they will get better", take the opportunity to discuss some of the factors that influence their recovery (and their health).

Dig Deeper

References will be provided in Part II.Signs & Symptoms of Overtraining  --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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February Hits (2014)

1) One of the best things about PRI is their interdisciplinary approach.  They've done a great job at providing holistic care.  Specifically, PRI Vision is putting out some great stuff.  PT's have been stuck advising the same ergonomics with the same reasoning for the past 30 years.  Heidi Wise goes over a more methodical way to address your patient's ergonomics (Part 1 & Part 2).2) Kevin Carr goes over some great Row Progressions.  Use these for your patient.  Use these for yourself in the gym.3) The language you use with your patient has a huge impact.  Be positive and optimistic.  Don't talk over their heads.  Don't scare them with patho-anatomy and diagnoses.4) Mike Boyle clears up some things on ACL "prevention".  "The bottom line is that a good strength and conditioning program is also the best ACL prevention program.".  This article is a must read for anyone that works with ACL patients.  Like Charlie always says, Rehab=Training.5) Gray Cook & Stuart McGill got together for a discussion on their different approaches to movement.  Jeff Cubos puts all the reviews in one place here.6) The Gait Guys have a nice quick review of gait analysis.  Knowledge of potential foot pathomechanics helps assessment.7) Anything that the body does can be chased back to neuroscience.  Here's a Top 10 Neuroscience TED Talks list.8) "Why you would want to turn your lat on to reach overhead is a puzzle to me, as it limits shoulder flexion and scapular upward rotation, draws the humerus into internal rotation (closes down the subacromial space), and pulls the spine into an extended position (excessive arching).  What folks really should be doing is a subtly posterior tilting the scapula to free up space at the front of the shoulder, and facilitate upward rotation." - Eric Cressey9) More evidence for the importance of scapula upward rotation.10) Sleep is an important variable of recovery.  Read about it in this series.11) Developmental Stability is a big part of what I do.  It's natures perfect self-limiting exercise.  It's the hominin's first SAID principle.  It's something every patient can benefit from.12) Neuroplasticity is a gift.  This is a long read, but well worth it.  "Neuroplasticity is an intrinsic property of the human brain and represents evolution’s invention to enable the nervous system to escape the restrictions of its own genome and thus adapt to environmental pressures, physiological changes, and experiences.” -Dr. Alvaro Pascual-Leone13) A nice quick review of Andreo Spina's course - Functional Range Conditioning.14) The importance of breathing is often understated.  If your patients can't breath right, they're going to have a bad time.  Seth Oberst goes over breathing in his 4 part series (I, II, III, & IV).15) Here's a nice EMG chart summarizing the glute med activity with specific exercises.  The side-plank wins.  But keep in mind, EMG studies should be taken with a grain of salt:

1) Do you want a stabilizing muscle firing near a full maximal contraction (strength vs stability, timing vs. force, efficiency, task purpose)?

2) Too many variables to consider with the subjects (exercise history, potentially influencing impairments, past injuries, motivation, etc.).  Keep it individualized; not everyone will elicit 74% MVIC of their glute med during the side plank.

3) The reductionistic isolated muscle approach can cause a blunder by overlooking the complexity of movement patterns and biomechanics.

16) "Don't believe that the neck is connected to the core?  Try lifting your head up in supine without activating your core.  It's impossible."-What I tell patients that don't buy into the proximal influence17) "Diffuse noxious inhibitory control (DNIC) is one of several varieties of “descending modulation”, by which the brain alters the amount of nociception (pain) signal coming in."18) Gray Cook wrote a great piece about the new Standord University strength and conditioning approach.  Here's 2 articles (1, 2) on their approach and how they've reduced injuries by 87%.19) Top 3 Tweets of the Month

• Emily Soiney - The key to the Frontal door is in the Sagittal lockbox. #PRI
• Seth Oberst - Hip impingement not just structural issue. We can unimpinge many athletes with mobility and spinal control. Don't just rush to surgery.
• Craig Liebenson - "FMS is not a biomechanical or mechanism of injury screen. It evaluates sensory input."

20) When you can't run outside, you have to find a way to make the treadmill interesting.           [subscribe2]

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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January Hits (2014)

1) Pain and Central Sensitization is a growing topic in our field.  And for a good reason, pain is the #1 reason people come to see us.  Plus, chronic pain is becoming more and more common.  It's great having so much information available to learn about these topics, however, there isn't a lot of information on the specific clinical application.  I sought out pain expert, Adriaan Louw, to answer some clinical questions on pain science in this months post.2) Charlie Weingroff goes over some theory on why ankle mobility is important for glute activation.  He also has a great article on how different body types tend to move and perform.3) Neurological Warm up from XLAthlete.  There's at least one thing from here that you can use on your patients tomorrow.4) The "Knees Out" cue is great to prevent dynamic valgus.  However, sometimes it forces patients into a severe varus positin at the knees or a severe inversion moment at the ankle.  I've also seen a lot of patients struggle to keep their big toe down when trying to keep their knees out.   Derrick Blanton uses the cue "drive the lateral heels" to help avoid these mistakes.  The more cues you have, the more patients you can help.5) Hebb's Law - "Neurons that fire together, wire together"6) So we need to stop icing?  "Now a study from the Cleveland Clinic shows that one of these recommendations, applying ice to reduce swelling, actually delays healing by preventing the body from releasing IGF-1 (Insulin-like Growth Factor-1), a hormone that helps heal damaged tissue (Federation of American Societies for Experimental Biology, November 2010)."7) Zac Cupples PRI Advanced Integration Day 1, Day 2, Day 3 & Day 4.  The PRI approach seems like a bottomless rabbit hole.  These reviews will help get you deeper.  "When I have the ability to flex, I have greater variability to change. In extension, movement blocks more likely occur. If you think about the human body, how many joint’s closed packed positions involve extension? "8) Nutrition is a lot like politics.  Everyone has an opinion, trends and buzzwords are all you hear about, and no one knows what is really going on.  Luckily for us, Kris Gunnars creates a great post on the science and research behind nutrition recommendations.9) I'm a big fan of the SFMA and global-neuro-movement-approaches.  This is a great post on some of the SFMA principles.10) If everyone did this everytime they looked at their phone, neck pain would decrease by 723%.11) I remember learning about the importance of intensity in my exercise physiology classes.  Of all the variables (load, duration, frequency, etc.), intensity may be the most important.  And the fitness industry is now taking advantage of this important variable.12) The Gait Guys go over some of the potential dangers of activating an inhibited muscle.13) Some great conversation on the latest tendinopathy research with Peter Malliaras.  Download the podcast onto your phone and give it a listen.14) Eric Cressey went over his top articles for the year.  I remember this one on 15 Static Stretching Mistakes was extremely useful.  I think anyone that works with movement should be forced to read it.15) Seth Oberst has a great post on the cervico-mandibular relationship.  "Anatomically,  a forward head changes the line of pull of several muscles (the infrahyoids) running from the mandible (lower jaw bone) to the sternum and even the scapula. This new alignment causes an altered pull on the jaw jamming up the delicate, sensitive disk within the TMJ."16) MDT Clinical Pearls for the flared up patient from Erson.17) 3 Great Quotes from this Article on Setting Goals

• "When helping patients set goals, it is imperative to understand the Contrasting Effect, which refers to beginning the goal setting process with the ideal future, then contrasting it to the current condition.  This creates motivation, optimism, and positivity."

• "It is key to remember to start with a picture of the patient’s ideal future, and then work backwards for greater chances of success."

• "We are not ultimately the one setting the goals for our patients. It is our work to extract the goals that are most important to them and then use our expertise to support them in succeeding."

 18) The deadlift is a great shoulder exercise.  The distraction force causes reflexive stabilization.              [subscribe2]