Archive for the ‘Therapeutic Exercise’ Category

 

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Last weekend I had the opportunity to attend Dr. Craig Liebenson’s seminar for the second time. I first saw Craig over 4 years ago in Toronto and that review can be found HERE. It was funny reading my old review because much of my thoughts on the course and its content have not changed except for a few key details.

When I first took his seminar I was less than 2 years in practice and was still very new to a lot of the concepts being taught. This time, with more years under my belt, I was better able to understand the concepts being presented and had a firmer grasp on how to apply what works for me and leave behind what doesn’t. Unlike 4 years ago, this time I was actively thinking about patients in my practice that would benefit from the concepts taught without overwhelming myself with minutia. I felt better able to appraise what was being taught, both the good and the not so good.

First of all, this course is almost impossible to review based on its concepts because it doesn’t really have any specific method or model to it. This course was a mishmash of content derived from many other schools of thought. The course notes, I must admit, aren’t fantastic as they are mainly filled with quotes, pictures, and charts without much context as to why they are there and how to decipher their applicability to what we do in our practices. This makes going back to review the material challenging as there is minimal framework as to why certain slides are put into the manual. In short, the manual is hard to follow.

Here is a sample of what was touched on

  • The inactivity criss (obesity, diabetes, low back pain prevalence etc)
  • Postural “dysfunction”and our culture of sitting
  • Exercise as the best medicine
  • Traditional vs functional approach
  • The “Mag 7” functional exam (Toe touch, wall angel, overhead squat, single leg balance, single leg squat, single leg bridge, respiration/belly breathing)
  • Stuart McGill’s “Big 3” (Bird dog, curl up, side bridge)
  • Kettle bell exercises
  • Core activation drills (wall press dead bug, side plank hip thrusts, stir the pot, plank rolls)
  • Crawling patterns and the developmental sequence

While sitting in the audience listening to the course content I made a list of what I liked about the course and what I really thought could have been done without or at least modified. I will share a few pros and cons as I saw them.

Pro: Craig is fantastic at getting his audience to change their gestalt on patient care. He challenges course participant to incorporate more active care into the assessment and treatment of each patient. He is very good at giving tips and “tricks” to help patients see the value of active care over a passive care. I talked to a few people in attendance who really wanted to try more active care in their practices after this course and I think that’s fantastic.

Con: Many times on the course he would use a demo who had pain doing a task such as a squat and would do an exercise drill with them, often targeting the core or another area of the body far removed from site of symptoms and then re-assess their pain in front of a crowd of at least 75 people. Each time the participant would say they felt better and was better able to do the functional test they had issues with before the exercise intervention took place. No one ever said what Craig did with them didn’t help (I personally never bat 100, do you?) This smoke and mirrors show wowed me 4 years ago, but now I kind of take it with a grain of salt as anyone when pressured  by a course instructor in front of a huge crowd of peers would say they felt better due to confirmation bias. Dr. Andreo Spina has an excellent video explaining why he doesn’t use demo’s in his course. Basically, you can temporarily trick the CNS into “better” movement but the results are often very short lived. I think without knowing it, he may have made it seem like a simple corrective exercise is a cure-all, when we know it’s not. One other point that needs mentioning is that when he was instructing participants on how to do the exercises, he made it look easy. The problem is that most clinicians aren’t treating healthy and fit 20-30 year olds with awesome body awareness, which is what the crowd demographic was. We are treating chronic pain patients with huge gaps in motor control and exercise capacity. This fact alone makes applying the concepts much more challenging then was let on in the course.

Pro: I liked how Craig was able to introduce the audience to many other approaches such as SFMA, DNS, McKenzie etc without bashing any one approach, stating many times that they each have value and are all tools that can be used depending on the patient in front of them. Many times I have found course instructors need to bash another course or instructor in order to legitimize their methods/ideas. This manufactured controversy might appeal to contrarians (like me) , but it also looks unprofessional. I like Craig for his non-guru approach to functional medicine and does a fantastic job of letting people know their are “many roads to Rome” as he liked to say.

Con: This next point is just a personal opinion, but I found the lecture components to be quite preachy at times. At one point I counted over 25 quotes, one after the other, in his power point slides. He literally read quote after quote, which I think only served to dissuade the audience from paying attention because it started to feel more like a church sermon then a rehab course. Only this time it became quite confusing as to how and why certain quotes fit into the topics we were discussing.  I personally could have done without the excessive number of quotes used to drive home points.

Pro: Simply put, I got some pretty awesome corrective exercise ideas that help with “buy in”. Since the course I have incorporated some of his exercises like the side plank hip thrust as a post test “re-set” and have had great results. For example, I had a new patient who had ++ knee pain with single leg squatting. I had him do it 3-4 reps, each time being sore. I then had him to the side plank hip thrusts with the painful leg on the downside and after about 10 reps we re-tested his single leg squat and he literally said “holly shit, how did you do that!?” because his pain was virtually gone. Now, I know that won’t last and there is a lot he needs to keep doing, but nothing beats that kind of buy in for patients to trust what I am saying and the motivation to comply with the home program. I am also sure a number of other drills would have worked, but hey..I can’t argue with those results. In all fairness, there have been a few other cases where the corrective drills didn’t make a change and I needed to think of other things on the fly. The course just gave me more ideas that really help the patient see the need to do exercise to help with their pain complaint. For this reason alone the course was well worth the time.

In all honesty I took this course again to help motivate me to keep pushing active care in both my assessment and treatment. I found myself “succumbing” to patient preferences for passive care and as a manual therapist it was easy to do that. It’s a huge challenge in a service industry (and yes, private physio is just that) to not cave to what the patient wants. I always give exercises based on what I see as being issues, but I found myself being more lax with patient compliance. I needed a kick in the butt to get creative to find ways to get better buy in because I am a firm believer that passive care is great and helps with symptoms, but it will not provide the fix patients need if exercises isn’t the staple of the program. And I know I get so much more job satisfaction if patients get better quickly and their goals are met. That just doesn’t happen nearly as well with passive care (manips, mobs, needles, soft tissue therapies etc). This course was great at giving that push I knew I needed.

Overall, I would recommend this seminar for it’s inclusiveness for other ideas in the rehab world and as a way to get your feet wet in the “functional” approach if you are growing tired of a structuralist model of looking at the body. You can find out when Dr. Liebenson will be in a city near you by clicking HERE.

Please feel free to ask me any more specific questions you have about this course in the  box below 🙂

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Today I wanted to share some practical exercises I give to many clients who come in with all sorts of issues from knee soreness to lower back pain. As many of my readers know, I am a very big proponent of gluteal strengthening for many lower body issues. In fact, I would go as far as to say that if I could only give one exercise to all my patients, it would most likely be something that targets the gluteal muscle group. This muscle group consists of the gluteus maximus, minimus and medius. All 3 of these muscles have different, yet very integrated roles in lower body  stability and mobility.

The gluteal muscles as a whole are responsible for:

  • Hip extension
  • Hip abduction
  • Hip external rotation and internal rotation
  • Raising the body up from a forwardly displaced position (think deadlift)
  • Lifting the body out of the stooped position (think squat)
  • Femoral, patellar and tibial alignment (knee pain? check the butt!)
  • Stabilizing the lower back and sacroiliac joint via its attachment into the thoracolumbar fascia (Back pain? check the butt!)
  • Keeps the pelvis level for walking and running

….This can get to be a pretty exhaustive list!

The following is a great quote from fitness expert Mike Boyle that perfectly explains why the gluteal muscles are so important and how their function can become “lost”:

“The truth is that glutes are essential to survival. Low back pain expert  Professor Stuart McGill , author of Low Back Disorders, describes the loss of glute strength and size as gluteal amnesia and goes on to implicate lack of strength in the glutes for the debilitating back pain that afflicts so many. The cure for gluteal amnesia is an addanasstomy.  The truth is we sit too much, we take too many elevators, we skip too many stairs. The result…Loss of glute function and the relative disappearance of the bodies most vital muscle. Then to top it off we go to the gym and do what? Of course, we work on our upper body. No wonder everyone’s back hurts.

In clinical practice, I have found it hard to get some people to actually understand how to contract their glutes without substituting with other muscles (mainly the hamstrings). I think many reading this blog post  can relate when I say that teaching activation exercises can be a frustrating process when the trainee, who usually sits 5-7 hours/day at work, can’t contract the right muscles given the appropriate cues. The good news is that I have found the following exercises to be very helpful in getting my clients to “feel” the right muscle working so we can get them doing higher level activities without as big of a risk of injury or muscle imbalance.

1) Hip flexor stretch! 
As I state in the video, it maybe of little use to try and strengthen the butt if the client is sitting in excessive anterior pelvic tilt with tight hip flexors. This “lower crossed syndrome” type of client needs to get more optimal pelvic alignment before we can hammer away at glute activation drills….they won’t be able to do it. There may also be some reciprocal inhibition happening when you stretch the hip flexors to get more gluteal activation…might be a reason to explain how stretching the hips almost automatically helps some clients activate their glutes.

2) Prone figure 4 leg lifts
Do you have patients who complain of hamstring tightness or spasm even with a simple glute bridge? If so, try this exercise first and the see how their bridge improves! Only caveat here is that the client has to have enough hip ROM to get into the right position

3) Fire hydrants to monster walks
Great exercises to get the glute medius to fire and to teach the patient what it feels like to use these muscles.

4) Hip thrust
This is an exercise I give to many clients as it works better than a bridge to isolate the glute max muscle for the reasons I state in the video. When doing this exercise, make sure the client doesn’t substitute lumbar extension for hip extension…they have to be ‘ready’ to do this exercise.

So there you have it. Some of my go-to exercises to target many common issues I see daily in the clinic. What do you use to target the glutes? How do get those challenging patients to turn on their glute muscles?

Thanks for reading!

 

Homunculus Man!

The following blog is going to be a review of a recent study I read and a topic that has really been on my mind for the last several months. Essentially, from my visits to SomaSimple.com and reading Jason Silvernail and Barrett Dorko’s expert writing on the topic of pain, I have started to question my motivation for practicing the way I do. In making this short and simple, I will only say that being a reflective practitioner has made me question the framework I have chosen to use to treat my patients. When a client comes to be with chronic back pain, I assess them biomechanically and start manual therapy, patient education and corrective exercise to either “hold” the manual work I have done on them or to strengthen areas I deem as being weak leading to a painful dysfunction. But am I doing all that I can to help? Am I really even scratching the surface in terms of finding the cause of their pain? What if pain is actually all in the brain? What if the representation of pain from their back is so pronounced on their brain that manual therapy and exercise alone just won’t be enough?

The article I read that discussed just this is called ‘A neuroscience approach to managing athletes with low back pain’.  It comes from the journal Physical Therapy in Sport and was published in 2011. Basically, the premise of the article stipulates that recent neuroscience research into the biology of pain suggests that clinicians (me) involved in the management of the athlete with LPB should embrace a biopsychosocial approach by engaging the brain and nervous system. What does that mean? How does one even do such a thing? These are the questions I had and this article did a decent job of explaining it.

As per the article, a true biopsychosocial model includes a greater understanding of how the nervous system processes injury, disease, pain, threat and emotion. These components work homogenously to create the sensation of pain. This model includes several categories, some of which we are very good at working in at and others we probably should be doing more of. The categories include our working understanding of functional anatomy, biomechanics, tissue pathology, pain mechanisms, representation, psychosocial issues, and fear avoidance.

For me, the most interesting of these categories is representation. Essentially, this model of pain takes on the brain and its processing of pain to treat a patient. New functional MRI (fMRI) scans have allowed scientist to show that when the brain processes information from tissues, many areas are activated to deal with the THREAT of an injury, disease, or situation. These areas, via connections in the brain, generate a “pain map”, which is commonly referred to as a Neuromatrix. The key point here is that the neuromatrix is NOT dependent on any specific tissue (disc, facet, nerve etc), but rather the impending THREAT of pain. “Emotional pain uses similar area to physical pain”. Therefore, if the sum result of the brains processing of information concludes that tissues are in danger (real or perceived), it is logical for the brain to produce pain as a means of protection. This means that anytime the brain perceives pain even from non painful stimuli such as bending forward, or back exercises, this map activates and pain is produced. The problem is when other “maps” form in the brain regarding beliefs, perceived knowledge about pain, and social issues are formed.

Maybe that patient with chronic pain that I was speaking about before has built in maps of pain that can’t be fixed by manual therapy. What if his original back pain started when bending over to pick up a pencil? What if he also had financial or relationship issues when the pain started? These issues all factor in to his current pain state and how it needs to be addressed. The article does a fantastic job of summarizing this by stating:

“Therapists treating athletes with LBP should realize that by addressing the tissue issues (e.g. joint strain, instability etc) with typical therapeutic interventions (e.g. spinal stabilization exercises, manipulation etc) they are only addressing one of the perhaps many issues associated with the development of LBP. The athlete may have such an innate fear of LPB that any activation of the amygdala may activate the LBP map, even though “the tissues have healed”. If medical care continues on the path of seeking the injured joint or tissue and results in more medical tests, more opinions, and more failed treatment then fear itself may increase and LBP may persist”

We have all had those patients that just never seem to get better…don’t lie, I know you all have! Maybe with these patients treating their tissue through whatever technique or exercise you like to utilize is just not going to work. They might require a biospsychosocial model to help them understand their pain and reorganize those maps in their brains to really make them believe that hurt does NOT equal harm and that they will be just fine. The article makes the case that we must educate our patients on pain biology and why they feel pain. With a firmer understanding of their pain and why they experience it via educational sessions, it has been shown to have immediate improvements in patient’s moods regarding pain, improved physical capacity, and a better outlook on their future.

The article concludes by saying we should not abandon our manual therapy techniques at all. We should do all that we are doing so well with our clients, but we need to incorporate pain education by addressing the psychosocial aspects of pain, especially fear, anxiety, and faulty knowledge regarding the cause of their pain. Some practical advise would be:

  • Do NOT tell clients they have degenerative disc DISEASE! All they will here is that they have a disease and the fear and anxiety will surely become elevated. Instead tell them they are experiencing a normal phenomenon with ageing and that pain is only temporary and they should continue with their ADLs as tolerated.
  • Do not show clients pictures of their herniated discs, osteophyets etc. This does nothing but make them think they have a physical deformity in their back that requires surgery or will never get better on their own. Instead, explain that thousands of people have the same imaging findings and have zero pain! There is very little correlation between MRI/Xray findings and pain.
  • Explain that hurt does not equal harm and that pain will go away with appropriate care. Explain that manual therapy serves to reduce pain by stimulating the nervous system…not by moving a bone back in place. This breeds a dependence on passive care that, in my opinion, is so unfulfilling to treat.
  • Include aerobic exercise into your treatment of chronic pain. Aerobic exercise has been shown to help clients who have a very widespread pain neuromatrix. It helps by increasing oxygen and blood to various tissues and has been shown to actually decrease nerve pain from sensitized nerves, help patients sleep better, improves mood and reduces depression.

This article talked about so many great ideas on why we feel pain but I think I gave to the gist of it. Empower your patients to be active in their recovery. Challenge them to not let their pain “win” and they are stronger than their pain.

For a phenomenal resource that can be easily used to teach pain concepts and why we experience it, I would urge you to check out the patient education book ‘The Pain Truth and Nothing But‘ By Dr. Bahram Jam of the Advanced Physical Therapy Education Institute. It is simple to read, funny at times, and highly entertaining.

For a great educational video you can easily show your patients, take a look the youtube video ‘Understanding Pain: What to do About it in less than 5 minutes:

 

Reference:
Puentedura, E., and A. Louw. “A Neuroscience Approach to Managing Athletes with Low Back Pain.” Physical Therapy in Sport 13 (2011): 123-33. Print.

 

Today’s blog post comes at the request of a few of my back pain patients. Over the past few weeks I have been talking with my patients about their back pain. I have come to realize that some of  these patients genuinely believe they injured their back from bending over to tie up their shoe, picking up a pen off the floor, or reaching for that jar at the bottom of the fridge (all real storey’s about “why” they hurt their backs)…and every time I hear a story like this I have to shake my head….

I think patients think their back is like this...

Patients must believe their backs are about as sturdy as a Jenga tower if they think those simple actions caused their backs to go out. I have to always tell my patients that 9 times out of 10, the pain they’re experiencing is due to many weeks, months, or years of misuse. It is only when the body is tired of trying to compensate for faulty movement (or lack of moevemnt) do they experience pain.  When asked about their gym routines (for the ones that actually go!), almost always do they proudly mention that they do sit ups and crunches as part if their core routine. This is a sure fire way to slowly but surely hurt the back.

Without getting into it too much detail, Dr. Stuart McGill out of the University of Waterloo has done the research and we now know that flexion based exercises (like sit ups and curls) are BAD for the back…and in reality, it doesn’t even train the core in a functional manner at all. Here is a quote from Dr. McGill’s book “Low Back Disorders”

“Too many exercises are prescribed for back pain sufferers that exceed the tolerance of their compromised tissue. In fact, I believe that many commonly prescribed flexion exercises result in so much spine compression that it will ensure that the person remains a patient. The traditional sit-up imposes about 730 lbs of compression on the spine at each repetition. The National Institute of Occupational Safety and Health (NIOSH) has set the action limit for low back compression at 730 lbs; repetitive loading at or above this level is linked to higher injury rates in workers, yet this is imposed on the spine with each repetition of a sit up!”

I said earlier that a sit up is functionally a rather stupid exercise. It trains the rectus abdominus to act as a thorax flexor. While the muscle does have the properties to act as a flexor, its real job lies in its ability to be an anti-extensor. The abs functional job in the human body is to control the rate of spinal extension as apposed to producing spinal flexion. For example, try leaning back while sitting on a workout bench. While leaning back, put a hand on your abs…they are firing like crazy! Why? Because they are contracting eccentrically to make sure you don’t fall off the back of the bench. This is their job in life and sport… the obliques, rectus, and transverse abdominus are ANTI-MOVEMENT muscles. They stabilize the spine and prevent spinal buckling or shearing from occurring. With this in mind, training them as flexor muscles is about as useful as training your biceps by only doing curls…sure you’ll make them look nice (nothing wrong with that!) but you’ll be missing out on all that they can do!

My patients always ask me then “Ok Mr.wiseguy physio, if I can’t do sit ups or crunches, how else am I going to work the core?” Here are my favourite (and safe!) core exercises listed in no particular order:

Chops and Lifts: LONG video demo by Gray Cook but I think it’s worth the time. He explains this far better than I ever could

 

McGill big 3 (plus stir the pot): Another great video with Prof. McGill explaining WHY these exercises are good…plus they are backed my tons of high quality research

 

Deadbug: Great exercise because it uses the core to stabilize the extremities while not putting any load through the back

 

In summery,

  • Your back doesn’t “go out” from picking up a pencil, it was already dysfunctional but you just didn’t know it yet
  • Functionally, the core acts as an anti-extensor and anti-rotation unit–not as a upper body flexor
  • A good core exercise is one in which the extremities move against resistance while the core is stationary working to stabilize the back
  • Sit-ups and crunches suck…they do more harm than good
  • The exercises I listed above will not only make your core stronger, but they will in most cases help your back pain

As always, questions are always welcome

Jesse Awenus, PT

Remind you of someone?

Oh, another HUGE reason for back pain is sitting too much at one time (hmm, I should probably get up). Here is a GREAT and simple exercise sheet you or your clients can use to help stay back pain free at work (courtesyof Dr. Craig Liebenson)

Love this picture!

A few months ago I wrote an article on how muscle tightness might be a result of a skeletal imbalance as apposed to simply a shortened muscle. I discussed how an anterior pelvic posture might actually lengthen the hamstrings due to their origin and insertion being forced further away from one another leading to a series of events that causes the hamstrings to group to seem tight. In this case, the hamstrings aren’t tight, thy’re in tone via the sympathetic nervous system telling the muscle group to stay tense as not to allow tearing to occur. Read my previous post HERE to get caught up.

Awesome Diagram

Professor Janda was a revolutionary in the field of muscle imbalances. Through both study and observation he derived what we now call the upper and lower crossed syndromes. In today’s society where we sit almost all the time, the lower crossed syndrome is almost epidemic! Think about it for a second…when you get up in the morning you sit to have your coffee, have breakfast or read the paper. You sit in your car to get to work, and most of us sit almost all day at work! Then we go home and sit down to eat dinner and relax in front of the T.V! That is a lot of sitting. If you don’t think sitting is detrimental to our health, click HERE to find out more.
From a biomechanical perspective, sitting puts the hip flexors in a shortened position for hours on end. This causes the gluteal muscles to “turn off”in what Professor Stu McGill calls Gluteal Amnesia (reciprocal inhibition). When the glutes turn off and the hip flexors become tight, we see the pelvis pulled anteriorly and then (to make matters worse) the lower back paraspinals get placed in a shortened position and the rectus abdominus gets places in a lengthened position. These changes only help to solidify the pelvis is an anterior position. Clinically, you can measure this by simply looking at the angle between the PSIS and ASIS. In her book Muscle Testing and Function, Florence Kendall states that the PSIS should be no more than 5-10 degrees higher than the ASIS.

See the belly on her? You might have a belly and it has NOTHING to do with your weight...

 

If it is higher, you might consider the patient has having an anterior tilt. Other things to look at are as follows:

Size of lumbar spine lordosis: An increased lordosis indicates the hip flexors and lumbar spine erectors are pulling the pelvis forward which creates an extension moment at the lumbar spine. As stated in the picture above, an increased lordosis might make it look like you have a spare tire around your waist…even if you’re skinny!

Positive Thomas Test: If the psoas, iliacus (NOT iliopsoas!) or rec fem are tight it will be evident in this test. Personally I like it because it’s fairly objective and a positive test is easy to identify. I don’t have the studies off hand, but I can only assume inter-rater reliability would be quite good. It’s hard to miss a leg popping off the table during the test!

 Hip bridge test: Have the patient do a bridge and palpate the glutes and hamstrings. Which are they using more? In the bridging position, the hamstrings are in a shortened position and because of this they should be using mainly their butt muscles to extend the hips off the table. If they are using too much hamstring, or they complain of muscle cramps in the hamstring, they have gluteal amnesia (a weak butt).

 So what do I do clinically for clients that have this issue (and MANY do!)?  There are a few different techniques I use depending on subjective complaints but on the whole, this is what I do (and it’s not rocket science).

1) Lengthen the hip flexors (rectus femoris, psoas, iliacus, and even tensor fascia latta if need be. I like to do this as a PNF (contract-relax) stretch in the Thomas test position because I can get all the above muscles at pretty much the same time. I also like this position because it prevents the lumbar spine from being pulled into extension as seen so much in people who try to stretch their hip flexors.

2) I do soft tissue work to the lumbar spine erectors to try and decerase their tone. I will often follow this by manually rotating the pelvis posteriorly to increase the stretch of the paraspinals and to simply help place the pelvis back where it should be. I like doing my posterior pelvic mobilizations in a side lying position.

3) Glute strengthening/activation. You can literally have a whole post dedicated to glute exercises but for simplicity sake I usually start off by having my clients’ squeeze their glutes while they feel the muscle contract while I palpate the hamstrings. I want to teach them how to fire up their butt while not using their hamstrings…often easier said than done! Mike Reinhold has a great modification to the bridge that I give my patients to strengthen their butt. Here is the video:


4) Core strengthening. Again, not getting too detailed here because there are 100’s of ways to do this. For my average sedentary clientele I give McGill curl ups, plank modifications (off a wall, on knees etc) or even crook posterior pelvic tilts to fire the rectus abdominus and push the pelvis posteriorly. For my athletic patients I like to give front/side planks with harder modifications, dead bug, stir the pot using a physioball, or shoulder touches in a pushup position

5) I do a lot of soft tissue release to the hip flexors, hamstrings, lower back thoracolumbar fascia and paraspinals. It makes the client feel better and hey, is that ever a bad thing?

 6) EDUCATION!! I always tell my clients they need to get up every 30-40 minutes to take a walk around the office. No one position for any extended period of time is good for the body…the lotion is in the motion! I have given my clients instructions to use a stop watch or there is even an app one can download on their home screen that will make a buzzing sound every 30 minutes reminding them to get up.

As always, different patients need different things and this is a general overview of what I do. By no means is it exclusive. A cookie cutter approach will yield cookie cutter results.

Thanks for reading,

Jesse Awenus B.A Hons (Kin), MSc.PT
Registered Physiotherapist

“functional training” is now the standard for exercise programs these days. We all hear about sport specific training for sport specific results. While I think many of these concepts are great, I do think much of it is overkill. I may offend a few people here, but I feel like many trainers have “brainwashed” young athletes and their parents into thinking that they need to do highly specific and tailored training programs for little Johnny to make the NHL. All kinds of gizmos and gadgets have been produced to supposidly give athletes the “competitive edge”…just walk into any golf store and see the amount of complete rubbish there is out there. Ironically, the nature of golf is such that those that play the sport often have a little ( or a lot more) expendable income then those that play other sports. Funny how their are sooo many “must have” items being sold to golfers…i’ll let you draw your own conclusions as to why.

How does all this relate to physiotherapy? It is my contention that no amount of sport specific or functional training will drastically help an athlete improve their game until their fundamental biomechanics are correct. You can’t build a house without first constructing a solid base…same goes for people! You can’t train a body if the body isn’t in a position to be trained…well you can, but the results will be minimal at best…and here is where i start my shpeal on WHY we develop low back pain and why training before correcting the WHY is a waste of time..and money!

Clearly the bulk..i’d say about 75-80% of low back pain (LBP) patients I see cannot identify a particular offending event (no specific injury). Ironically, the onset of LBP is often associated with the very simple act of bending forward.

If there is no singular event then it must be what we do day in and day out that triggered the pain (the foundation of the house isn’t where it needs to be). If we can identify the cause of the pain, then logic assumes we can eliminate the consequence–back pain

In its simplest form, the body is a series of body parts linked together. Each segment has a specific role and influences its neighboring segments.

The ground breaking work by Mike Boyle and Gray Cook, both respected trainers and therapists respectively, have developed a system that assigns either a stability or mobility role to each segment. These responsibilities alternate as one progresses from the feet to the head….called the Joint by Joint Theory

For example, the body starts out with a stable foot followed by a mobile ankle, a stable knee and mobile hip, a stable lumbar spine(low back), and a mobile upper back..etc

Issues arise when links or body segments assume an inappropriate role-that is a mobile segment becomes restricted or stable. This then forces the segments above and below that area to change their role. For example: When our hips get tight (from sitting so damn much) we have to find a way to keep our body mobile. Our body does this by forcing the low back to move from a stable are to mobile area. This places stress on areas that shouldn’t have stress and a whole cascade of events can unfold…leading to pain.

Remember that song we learned as kids…” the shin bone is connected to the leg bone, leg bone is connected to the hip bone…” That song was right on the mark…everything is connected!!!

When the low back moves too much we develop pain in the back but possibly in other areas as well (neck and shoulders..even knees). It therefore makes little sense to me, to train an unstable area using mobile activities..such that are done in hockey and golf training. We must first fix the biomechanical problem before we can allow mobility drills to be done…functional rehab at its best!

There are many things that can be done to fix seemingly unrelated problems. These include manual therapy, soft tissue release, postural reeducation and of course corrective exercises. If you are in pain and don’t know why, chances are something is “out of whack” and needs to be looked at.

Any and all questions are always welcome

Jesse Awenus B.A Hons (Kin), MSc.PT
Physiotherapist

It’s been a while since I posted an article or “blog” post on my page. I just finished a few courses and needed to spend time doing a few other things over the weekends so writing took a backseat. Now I’m happy to report that I’m back and will start writing weekly posts again!

Today I would like to talk about on of my favourite joints (Yes, I said favourite joint) in the body…the shoulder complex! There is so much stuff going on in the shoulder and rehab and treatment of shoulder pathology can be a tricky process. For starters, most people come to see me with shoulder pain after having the issue for months (or even years!) and they expect me to magically do something to their shoulder for the pain to go away…sigh. Short of an acute injury to the shoulder, most issues stem from muscle imbalances which occurred from over use, postural issues (a big one!), or a combination of many biomechanical factors…which take time and diligence to go away.

The discussion on how to assess the shoulder and surrounding area is beyond the scope of this post. I will simply state a few clinical “pearls” that often help with what is commonly known as subacromial impingement. When you get that “pinch” in your shoulder when raising your arm overhead, you may have the condition that I’m going to be talking about now.

So what do I do about this problem…2 things come to mind first.
1) Address the thoracic spine (or midback)!!! If you have a crappy sitting posture and lean over a desk all day, chances are you will get shoulder issues. Why? Simply put: you are slowly closing off the space that shoulder has to move. Here is a nice little Youtube video describing the condition:

2) Strengthen the shoulder force couples:
Most of us are upper trap dominant and lose the ability to fully contract the lower traps and serratus anterior. If this happens, our arm bone will go up when we lift up our arm, but the shoulder blade will lag behind causing the bones to but up against one another as seen in the youtube clip above.

How do I treat a classic subacromial impingement? I usually start my addressing biomechanical factors such as thoracic spine mobility. Manual therapy including mobilization, manipulation, ART, myofascial release, and PNF stretching work well to that end.

But the REAL work is on the clients end. Some conditions respond well to passive care such as tension headaches or ankle stiffness (with exercises done as well). But shoulder issues are 90% on the patient and 10% on the therapist. That means I’m just the coach with these types of patients. I direct my patients on what to do and how do to the exercises and it’s up to them to adhere religiously to the program. It’s sad to say that this is why many shoulder clients fail to achieve maximal results…cause many want a “quick fix” which isn’t always possible.

Based on research and what I see clinically, here is a list with youtube links to common exercises I give to restore proper scapular stability and kinematics

1) Pushup plus:
This exercises targets the serratus anterior muscle. The job of this muscle is to aid in scapular upward rotation, protraction and keeping it firm to the ribgage. A weak serratus anterior can result in scapular winging (h)

2) Lower trap “Y” raises:
This exercises can be done on a flat table but doing it on an incline helps reduce the chance of arching through the low back while completing the exercise. NOT a lot of weight (if any) is needed to do this exercise well

3) Scapular “W” retraction/external rotation/posterior tipping exercise:
This is my new favourite exercise because it works so many things at once. It really gives you bang for your exercise buck! This simple yet highly effective exercise works the scapular retractors (rhomboids/middle traps), external rotators ( Teres Minor/Infraspinatus), and posteriorly tips the scapula which conteractes a tight pec minor which acts to anteriorly tip the scapula…which is a bad thing!

4) The classic row exercise:
With so many of us sitting in front of computers all day with slouched posture, doing upright rows to promote scapular retraction is critical. It also helps with thoracic spine extension!

5) Dynamic Hugs:
this exercise also works the serratus anterior but is less intense then the pushup plus. I give it to my older clients with shoulder issues or those who can’t get into a pushup position.

These are starting point exercises for those with classic subacromial impingement. Overhead athletes will require more “functional” exercises since there shoulders usually have specific adaptations to the demands placed upon them from the game. Along with exercise, I often employ a stretching program since I find the posterior capsule to be an issue with many people who have shoulder pain. I also use my manual therapy skills to help restore motion and try to help with immediate pain reduction (not always successful) haha.

For a GREAT refernce on shoulder issues and to get an understajnding of where many of my exercise ideas come from please visit www.mikereinold.com
Mike Reinold it an athletic therapist and physiotherapist for the Boston redsox and his posts on his site are great! I read them weekly.

Please comment with anything you do for your shoulder clients. It’s all good in my books.

Thanks for reading!!
Jesse Awenus B.A Hons (Kin), MSc.PT
Registered Physiotherapist

Main reference used:
Current Concepts in the Scientific and Clinical Rationale Behind Exercises for Glenohumeral and Scapulothoracic Musculature
httpp://www.jospt.org/issues/articleID.2290,type.2/article_detail.asp

Dr. Greg Lehamn’s site: I advise you all to take a look..I can’t believe he lets us read ths stuff for free!
http://thebodymechanic.ca/2011/01/18/shoulder-impingement-rehabilitation-part-one/

Ok, here it is…part 2 of it’s all in the hips. In my last post I discussed the importance of strong gluts for the prevention of knee pain. I explained what the glut muscles do and what happens when they go wrong. Suffice to say, there would be a lot less “pattelofemoral” pain patients in the world if we all worked on strengthening our hips!

Before I begin I want to say that the following exercises are for beginner to intermediate athletes and for those who have knee pain that COULD be attributed to the hips. Like I said in my last entry, there are other factors to knee pain but in any case, there is nothing wrong (or unsafe) about training the hips so I’m confident I wont hurt anyone by giving them some tips and videos. PLEASE note: don’t assume that these exercises will “cure” you of knee pain. I will always always always recommend getting a specific assessment by a trained professional such as a physiotherapist or chiropractor to determine the exact cause of your problem…you knew that was coming lol

Here is a list of exercises I like to give my patients with weak hips that are causing knee and low back pain:

1) The single leg bridge:

This exercise is great for 2 reasons. First and foremost, it strengthens the glut max (butt muscle) on the weight bearing side very well if done correctly. Secondly, this exercise is single leg and as such, the glut medius and minimus are working to control the non weight bearing hip from dropping down to the side. If this exercise is too hard to do..i.e you cant lift up high enough to make your hips level, you can do the double leg bridge…same idea as this, but you use 2 legs to bring your butt up instead of just one.

2) The “telephone” book exercise:

This exercise is tricky and is hard to explain in writing. Basically, you stand on a step (or telephone book lol) with one foot. You drop the other foot that is not on the step down my lowering the hip on that side. You then have to focus on contarcticing the glut med muscle on the weight bearing side to hike up the hip on the non weight bearing side. It’s best to hike the hip up higher then the hip on the weight bearing side for maximal benefit…don’t bent the knee on the weight bearing side much because that is cheating

3) Side lying hip abduction:

This one Is self explanatory…but here are a few key points to know:
a) When raising the leg up, do NOT let the hips roll back. You must try and keep the shoulder, hip and knee parallel. Keep your hand on your hips to sense if they are falling back or not…or do the exercises in front of a mirror if possible.

b) People with weak gluts will cheat in this exercise by using the hip flexor muscle tensor fascia lata (TFL) to raise the leg up instead of using the glut med. You will know this is happening because instead of keeping the leg straight out beside you (or even a little bit extended is best) the leg will come forward…you will flex the hip while abducting the leg because the TFL will do the work for the lazy gluts!

In the video, he uses a plastic band around the ankles to increase resistance. That is a good idea, but poorly executed. The band should ideally be just below the knees for maxiaml effect…having the band around the ankles is a) too hard and b) promotes the use of the TFL over the gluts

4) The Bird Dog:

The dude in this clip actually does a good job of explaining the exercise and common mistakes that are made. Just watch the clip and do what he says 😉
I know the video says this is a killer abs exercise (and it is)…BUT, this exercise is also a great glut max exercise and glut med stabilization exercise. It’s kind of advanced but I thought I’d throw it out there.
To make it easier—Don’t involve the arms. Just extend the legs out one at a time. Hold the leg out in an extended position for 10 seconds, bring it back down, and then do the other leg. This will still target the gluts but won’t do as much for the abs or back..

Do each of these 4 exercises 10 times. That is one set. Do 3-4 sets per day of each. If you develop pain while doing ANY of these exercises, STOP right away!! No need to hurt yourself here haha

As always, feel free to ask any questions you want. There are many more great glut exercises out there (squats, deadlifts etc), but these are the ones I find work well for the majority of people I see. For a personalized exercise program see a trained professional!

Thanks for reading!

Have you ever had knee pain? This could be from running, playing sports, or dance training. If you said yes to this, you are definitely not in the minority on that one! Of all the lower extremity joints, the knee sustains the highest percentage of injuries, particularly among physically active people. For example, the knee has been reported to be the most common site of overuse injuries in RUNNERS, triathletes, and basketball players (1). For all the women reading this, I am sorry to say that you have a much greater incidence of knee pain as compared to males…there are reasons for this I won’t get into now because it’s not relevant….but if you want to know, write it in the comments section

Let me start by saying there are MANY causes of knee pain and this article will NOT address all of them. However, this article will talk about a VERY common finding that often translates into anterior (front) knee pain, lateral (outside) knee pain, and even medial (inside) knee pain. If you take only one thing away from this article, this should be it…many causes of knee pain have NOTHING to do with the knee at all. I am tired of seeing therapists (of all disciplines) treating knee pain with ice, ultrasound, rest and mini squats wile squeezing a ball between the knees to train the VMO (inner quad muscle). Those treatments directed at the knee do nothing for the CAUSE of the problem and are only treating the symptoms…which will yield less then stellar results for the patient.

Current research is leading to the conclusion many of the overuse (running etc) conditions of the knee are not conditions of the knee at all. Many types of knee pain may be related to poor stability at the hip, but present as knee pain. The analogy frequently used to describe why this occurs is the rope analogy: If I put a noose loosely around your neck, stood in front of you and pulled on it, you would tell me that the back of your neck hurt, if I stopped pulling, the neck pain would disappear. Nothing was ever really wrong with your neck –the neck was simply the endpoint at which you felt the pain….same goes for the knee!

Quick anatomy lesion: you have muscles on the sides of your hips called glut medius and glut minimus  Along with the glut max (butt muscle), these muscles work to keep your hips level in single limb stance and they also work to control how far your femur adducts (goes towards midline) and turns in (internal rotation)….this adducted and internally rotated position of the knee is called valgus knee stress

Soooo who cares about gluts this and gluts that?…I want to know about KNEE PAIN! I venture a guess some of you maybe saying that, but those silly gluts have everything to do with knee pain. Unfortunately, our population is dominated by sagital plane strength (we do everything in the forward and backwards position) and weakness in the frontal and transverse plans (side to side and turning motions)….in other words, we are typically strong when we bring our knee to our chest (sagital plane), and weak when we bring ours legs out to the side (frontal plane)…which is the job of those damn gluts! Even more unfortunate is the fact that exercise outside the sagital place are often neglected in rehabilitation and strength training programs (2). This creates a problem because we don’t train those oh so important glut muscles that control our hips and therefore control how our knees move.

LONG story short: when we have weak gluts we tend to place our knees in very stressful positions when running, walking, jumping, and weight training (squats!). This valgus stress places excessive force on certain parts of the knee causing what is commonly called patellofemoral pain syndrome (PFPS). This leads to the pain that is felt in the knees after a long run, playing a game of basketball, or skating in hockey. Therefore, training the gluts to align the hips and keep the knees in a more optimal position during single leg activities will SIGNIFINTLY reduce the incidence of knee pain..and keep the pain away!! (who needs Advil or Tylenol when all you need is some specific rehab directed at key muscles to end pain?) Research also shows that strengthening these hip muscles can actually reduce the likelihood of athletes tearing the ACL of the knees…..the hip muscles are IMPORTANT!

If you want me to write another piece on HOW TO train these hip muscles please comment on this article! ANY questions, comments, criticisms are more then welcome.

Thanks for reading!

References:
1) Journal of Orthopaedic and Sports Physical Therapy: The influence of abnormal hip mechanics on knee injury: A biomechanical perspective. February 2010, volume 40, number 2

2) Mike Reinol.com: Solving the patellofemoral mystery: page 31-32