Lower Back Instability

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Much is said about the core. Almost everybody is offering "Core Stability Programs" now. So what gives? First one should understand the etiology of core instability:

1. Tight Hamstrings: In our modern world, we sit all day and our hamstrings are allowed to gradually shorten. If you are a runner, you never really stretch out your legs, so your hamstring is not stretched to its full length then either. Same with cycling. So what? Well tight hamstrings limit the mobility of the pelvis during activities such as bending and lifting, which in turn, requires that the lumbar spine take up the slack. Over time, this shift of motion responsibility to the lumbar spine will have the effect of increasing the mobility in one or two motion segments of the spine. (A motion segment is a disc plus the vertebra attached above and below.) The bottom line is that tight hamstrings are a causative factor to the unstable motion segment of the lower lumbar spine.

2. Weak Abdominals: Our sedentary lifestyle again is responsible for the chronic weakness in our abdominals. There is a "stretch weakness" that exists as well with the abdominals being inhibited by the tight hip flexors and lower back muscles. This is referred to as a "lower cross syndrome". Tightness of hip flexors, coupled with weakness of the abdominals, especially the lower abs reduces the capacity of the trunk to successfully" stabilize" the lower back.

3. Progressive Failure of the Disc: Over time, as we age, it is very common for the disc itself to fail. Failure of the disc over time for several reasons including mechanical wear and tear, leads to excessive "play" in the motion segment making segmental instability a very real problem in many people. Coupled with tight hamstrings, weak abdominals and tight hip flexors, the unstable segment is put under more duress during motion, and as such bears the load of bending and lifting that should rightfully be borne by other structures.

4. Restricted Thoracic Spine: The T-spine is naturally restricted and over time becomes even more restricted resulting in reduced backward bending ROM and reduced ROM into rotation. The loss of this ROM leads to an increased demand for movement in the lower lumbar spine as well as the cervical spine.

When you put all this together with the fact that we have become a sedentary population, over weight and out of shape it is no surprise that the spine breaks down and structures in the spine fail.

Add to that one more fact:

5. Deep Muscle Inhibition: Pain the back is coupled with deep paraspinal muscle guarding, which in turn produces prolonged inhibition of those same muscles through a neurological mechanism. This gradual weakening of the deepest muscles adjacent to the spine are the final "nail in the coffin" of the unstable segment.

OK, so what about core stability exercises, do they work?

In short, the answer is "yes". What core exercises do is stabilize the spinal column by squeezing the organs against the front of the spine and wrap the the trunk in a casement of muscle that is rock hard front and back. The idea is to provide support to the spine through positive pressure that prevents the spine from collapsing or moving excessively under load.

Complementary to the core stability exercises, another key is to strengthen the deep spinal muscles, such as multifidus, in order to provide local stability on a segmental level.

So to summarize, in order to improve athletic performance, reduce segmental back pain, stabilize the lower back and the core, you need to do a good solid core program. I will elaborate on that in a later post.

Long Standing Sacro Iliac Joint Pain

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One of the things I see in people who suffer long standing SI joint dysfunction is the "reluctance" of the Si joint to remain stable once the dysfunction has been reduced. It seems that almost regardless of the subluxation (up slip, down slip, anterior torsion, posterior torsion etc), the joint wants to "return" to the subluxed position.

To help stabilize the joint after reducing a subluxation, I employ two strategies that are muscular and one that is not.

The nature of the SI joint is that there are no muscles that cross the Si joint that are useful for stabilization purposes. The Piriformis originates on the inside of the Sacrum and should be perfect for stabilization purposes, but because it inserts on the Greater Trochanter of the femur, it is useless for stabilizing the SI joint.

Instead, we have to look forward to the Adductors which insert onthe inferior pubic ramus and also the Abdominals which insert on the pubis. These muscles are better suited to maintain the stability of the pubic symphesis and indirectly, the SI joint.
Try these two exercises to stabilize the SI joint:

• Sit on the edge of a firm chair, lean over, your knees apart, and put your elbow on the inside of one knee and your hand onthe inside of the other. Squeeze as hard as you can while also at the same time trying to be as relaxed as you can. Repeat this about 8 or 10 times. You are looking or a palpable click to occur in the groin indicating that the pubic symphesis has reduced. this does not always occur though, so if it does not occur, not to worry.

• Lie on your back, both knees flexed up toward your chest. Place a hand on either thigh near the knees and push as hard as you can with both the knees and hands so that you do not let your thighs actually move. You should feel your stomach muscles working hard.

The other stabiliation idea is to use an external fixation, like an SI Stabilization Belt. I like one you can purchase here. It is caled the BOA Sacro-Iliac Belt. Be sure to size it properly, and when you wear it, keep it snug. Also, as an alternative this one is also a good suggestion.

The thing about reducing an SI Jointsubluxation is that after I have sucecssfully reduced the joint, it often wants to return to its former subluxed state, and after each successive reduction, it often takes longer and longer sublux again. My advice is to be very patient. Allow weeks to successfully treat the joint so that it stays reduced. And while you are undergoing treatment, use the belt and do the exercises I suggested for longer lasting relief.

Finally, I think that you should use ice religeously. By that I mean 30 -45 minutes of ice plus water (not those blue ice packs that you throw inthe freezer, not frozen corn or peas, actual ice) right on the skin. Make sure to include water, or risk frost bite.

My Stiff Neck

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People often experiences a stiff neck with or without headache. sometimes this stiffness can last for weeks. There are a few things I suggest that seem to be effective dealing with this problem. But we need to start with the anatomy.

Think of the cervical spine as a mobile column with a bowling ball held on top. remember, your head weighs about 10% of your body weight. The "wires" that hold the head onto the neck are muscles, the Levator Scapula (picture on the left) and the SCM, (picture below). The levator is the muscle most widely thought to be associated with a stiff neck.

In a prefect world, the position of the head over the neck would be in an erect posture with the neck more or less straight up above the shoulder girdle.

Think of a helium balloon, the balloon hovers in the air the string straight up and down. In order for the head to be in a similar position above the shoulder girdle, the guy-wire muscles Levator Scapula and the Sternocleidomastoid will occupy positions in space that give them mechanical leverage.

Gravity works though, and as a result, posture is often poor with a forward head that puts the guy wire muscles of the cervical spine at a mechanical disadvantage. The result is that they have to work harder to hold the head up. Their increased effort leads to increased compression of the joints of the spine. The result is muscles that are over working and accumulating metabolic by products that are irritating to them, joints that are continuously compressed causing irritation of the structures in and around them, and a physical body that is easily fatigued and inefficient in movement patterns and strategies.

The result can be an acquired stiff neck with headaches or without. Sometimes the neck joints can be irritated enough or have accumulated enough destruction to actually irritate the nerves that feed the arm causing pain, numbness, tingling or weakness into the arm or hand as well.

For the purposes of this blog, I am going to focus on only the postural stiff neck with no radicular symptoms.

To reduce your stiff neck, try this:

1. Catch yourself with a forward head position, and bring your head back over your shoulder girdle (think about that balloon floating on top of the string, and make your head do the same on top of you neck).
2. Do 30 minutes of aerobic exercise to get the accessory muscle of respiration (your neck muscles) to actively contract and relax for ong periods of time submaximally so that they can relax.
3. Put a rolled up towel behind the neck, pull it over your shoulders to the front, grab with both hands and pull the towel down toward your feet. Then let your head bend backwards and when all the way back gently rotate left and right. PAIN FREE>
4. If it hurts to turn left, then practice turning into the pain by turning left repeatedly. Do so gently, and just knock on the door of the pain, don't move through the painful range.
5. Remember, the neck joints and structures are very small. You don't need to move too far or work too hard to actually be very helpful to the neck. I like to say about the neck that "Less is More".
   
   Try these techniques to resolve your local neck pain without any radicular symptoms of pain or numbness or weakness.

To Stretch or Not to Stretch?

There is a lot of mythology in circulation regarding stretching.

The resting tone of a muscle is established neurologically. What that means is that organelles in the muscle called the muscle spindle, which controls the quick stretch mechanism of the muscle, determines the sensitivity to stretch of the muscle, and it also seems to be involved in establishing the resting tension in the muscle. So in a nutshell, that means that stretching does not seem to impact the resting length of the muscle.

So why stretch?

Well, I can think of a few reasons to stretch. First of all, when it comes to competing, a little pre-competition stretching has been shown to improve performance. The reason for this is surmised to be that the actin and myosin relationships in the muscle are optimized allowing the muscle to work more efficiently. And clearly you see top athletes stretching before and after competing for sure. What is current practice in competitive athletes today is what is known as an "active warm up", which is made up of little movement patterns that are part of the full motion package that the athlete will engage in. I also know, though, that top teams spend a lot of time stretching to prevent injury in professional soccer players for instance. So there is still uncertainty.

I also believe that when one stretches, one is taking the joints through a more complete range of motion, which will have a positive impact on the articular cartilage. Cartilage requires intermittent compression plus gliding to be properly nourished, and stretching might get you to take your joints through a full ROM without overloading them.

Additionally, the same idea is true for your dense connective tissues - the ligaments and capsules get maximally stretched when the joint achieves maximum congruence, which occurs at the end of the range of motion of a joint. So at the end of the joints ROM, the cartilage is maximally compressed and the ligaments and capsules are maximally stretched, all of which helps prepare the tissue for activity. I imagine that the dense connective tissues imbibe water as they relax after being maximally stretched for a few seconds, and it is that process that "protects" them from overuse injury during activity.

Stretching also activates both joint receptors and muscle receptors in areas being stretched that are inhibitory to the muscle and relax it for the moment. Does this relaxed muscle stay relaxed? I don't believe so. I believe that muscles get longer if you "play them longer". What I mean by this is that if you use a muscle in a longer range, say by following through while kicking a football for example, then your muscle will gradually tolerate a longer resting length. Muscles are very elastic. If I cut your biceps tendon at the elbow, I could take the end of the muscle and walk across the room with it, more or less, and if I let go of the end I was holding, the muscle would recover its resting length.

"What about yoga?" I hear you asking...Well in yoga, you don't just stretch, you activate the muscles in longer ranges which is why people who practice yoga actually become more flexible. But they also increase the flexibility of their joints, and their muscles are encouraged to be active through longer ranges, hence appear to be longer because of stretching.

Whats the bottom line, to stretch or not to stretch?


I think that stretching is a valuable practice to engage in for injury prevention purposes in active people. Stretching helps prepare the muscles,tendons, and the joint dense connective tissues including the cartilage be prepared for loading. I do not think that stretching makes you more flexible in your muscles per se though. So yes, before and after exercise, stretch. In Anderson and Anderson's classic book, Stretching, there is a great 10 minute daily total body stretching routine. In my mind, that's all one really needs to do as a routine stretching practice.

Beyond that, it is really up to you, and if you do more and feel better for it, by all means go ahead.

If you intend to stretch, it pays to warm up a bit before you do so. I suggest a 5 to 10 minute warm up before you stop and stretch, then you will be ready to compete, you joints and other dense connective tissues lubricated and hydrated, your muscles prepped for activity, and your brain in the mindset for competition.

Managing Acute Back Pain

I wrote an article for the Journal Orthopedic Clinics of North America a few years ago with my colleague Mike Kane, PT a physio in Yakima, WA. The premise was Functional Rehabilitation Strategies of the Lower Back. In that article I laid out the full picture, and also talked about acute lower back pain (LBP). Since 80% of people suffer lower back pain, and a third of them in the last 24 hours, I thought that I would share my successful strategy for dealing with acute back pain in greater detail.

First of all, realize that most episodes of lower back pain are self limiting. Very often, the pain will resolve within a few days, and 8 out of 10 times, within a month, 9 out of 10 times within 2 months.

Because we are not very good at diagnosing LBP (something like 15% of the time is a diagnosis determined to be accurate), the underlying cause is not really important in dealing with acute LBP.

The literature strongly suggests that a person suffering LBP should not curtail their activities. If you are a runner, keep running, a walker, keep walking, a swimmer, keep swimming.

But lets say you experience a severe episode of LBP with or without pain into the leg, you should know this: It is a medical emergency if you actually lose control of your bladder. If that happens, go to the ER immediately. You only have a limited amount of time to address this problem or you face the permanent loss of bladder control.

In the alternative, here is my fail safe almost 100% successful acute LBP treatment strategy:



1. Start out lying on your back on the floor in the 90/90 position with your legs up on a chair. Stay in this position for about a minute focusing on your breathing. Try to relax as you do so. The reason that this position is useful is that in this posture, the intra-discal pressure is the lowest it can be, and that usually means less pain.


2. In this position, start by dragging your right foot along the chair as you bring your knee toward your chest. Use your hip flexors and abdominal muscles to bring your knee up to your chest as far as you can. Try to move as quickly as you can PAIN FREE. When you achieve the maximum ROM, then push your foot back along the chair and repeat the move with your left leg. Repeat this activity back and forth 30 times with each leg. Remember, move as quickly as you can as far as you can, but drag rather than lift your leg.

3. The next exercise involves you bringing both legs up at the same time. Make sure to spread your knees apart as you do so in order to clear your pelvis. Again try to really curl up by engaging the lower abdominal muscles. Repeat 30 times. Be sure to drag your feet rather than lift them, and make sure the movement is as rapid as possible, but again, PAIN FREE.

4. The next exercise is desigend to engage the trunk in a rotational movement pattern. Wrap both arms around your chest and pick your head up. Keeping your butt on the ground, roll onto your right shoulder, then onto the left shoulder. Repeat 30 times in each direction as quickly as possible, PAIN FREE.

5. OPTIONAL. This exercise I make optional for people. The activity is in sidelying, but you have to roll up a blanket and put it under your ribs. Push it up to the arm pit to reduce the ROM, or further down to increase the ROM. Place the up arm on top of the body, and grab the top shoulder with the bottom arm. Perform 10 reps of side lifts PAIN FREE. Roll over, reposition the blanket and repeat on the other side.

Perform all these exercises 3 times through - it will take about 20 minutes.

The final exerise is key. You need to do this exericse at the conclusion of your previous exericses and again every hour throughout the day, or whenever you LBP irritates you.

6. Half sit on a table with your feet firmly planted on the floor shoulder width apart, your arms wrapped tightly around your chest, one arm above the other. Maintain an erect spine posture, but lean slightly forward at the waist. The exercise is a 5 minute drill of left and right rotation only. The key, as you might already guess, is to move as quickly as possible, PAIN FREE. Gradually increase the ROM as you do the exercise and can tolerate more motion.

Franky, this last exercise is almost magical. Almost everybody with very few exections will benefit from the exercise.

Finally, you need to use ice to inhibit the muscle guarding. In our clinic we have found that crushed ice plus a little water in a plastic bag right on the skin for 30 -40 minutes is the best solution. The reason this is important is that it takes 10 minutes for the ice to penetrate 1cm (about a half inch), and the muscles that are guarding live about 3 cm deep. So prolonged ice inhibits the pain, decreases muscle guarding and reduces edema that might be present.

Add to that 30 minutes of walking and you have a very very very effective acute LBP management program. We call this program Phase 1 LBP Managment.

Good luck

Return to Running after a Lateral Ankle Injury

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Shin Splints

Shin Splints most often are correctly named Medial Tibial Stress Syndrome and occasionally Posterior Tibial Tendinitis. In our clinic, we typically see Medial Tibial Stress Syndrome in active runners and soccer players. The beginning of cross country season and the beginning of track season are the times we typically see this complaint.

Usually, the onset correlates to early training with overuse occurring such that there is shin pain associated with running. Deconditioned people who start training, active people who increase their mileage, lengthen their stride, or start doing jumping drills, or runners who start running further on hard surfaces or down hills are all susceptible to MTTS. The worry is that the leg pain might be a stress fracture or even a compartment syndrome.

Typically, the pain associated with compartment syndrome is early onset and lasting, and seems out of proportion to the amount of effort expended. Compartment syndrome is ultimately diagnosed with Doppler technology, and if you think you have shin splints that do not seem to get better at all ever, then it might be that you have a compartment syndrome and you should get that checked out. The other concern, stress fracture, can usually be ruled out by trying to hop on the injured leg. If you cannot do so, and the pain persists, then you might indeed have a stress fracture. in the case of MTSS, the pain usually resolves quickly after activity.

The best treatment for MTSS is to stop running for a time, PLUS perform ice massage along the injured area, PLUS improve your shoes, PLUS modify the surfaces you are runing on, PLUS use tape or a shin strap when you do return to running.

One good exercise to help you is to sit in a chair with your elbows on your thighs, and while keeping your heels on the floor, rapidly tap your feet one after the other until you are too tired to do more. Allow a time to recover, and repeat.

Return to running gradually and perferably on flat softer surfaces with new shoes. Build your mielage gradually, improve your speed gradually and you will likely overcome this ailment without difficulty.

Fat Metabolism in English

OK, so you want to loose weight. And you are wondering how to go about this in a sane and safe way that is guaranteed to be successful according to scientific principles.

Very simply it is an arithmetic problem. Calories in minus calories out equals calories lost or gained. In order to lose 1# a week, you need to unbalance your metabolism by 500 cal per day. In other words, you need to burn 500 more calories than you take in.

Easier said than done.

So you need to manage both sides of the equation. Eat less and exercise more. How much less and how much more is an interesting question. In our clinic we use Smart Metabolism technology to measure your metabolism, and then we calculate both what you should consider your baseline metabolism, and we calculate your peak fat metabolism heart rate during exercise. Combining this data, we can calculate what you need to do to create that 500 calorie differential.

But lets say you don't really know how to do this, or do not have access to this technology where you are, here is some advice:

• You need to generally eat less than you probably are. Serving sizes here are out of proportion. One way to eat fewer calories is to get a lot of calories from fruits and vegetables rather than empty calories like those found in rice and potatoes. I am a HUGE fan of The Paleo Diet which professes to eat more lean animal protein, and only fruit and vegetables as well as a few nuts. This is a diet program that is not like going on a diet at all. It is more of a change in eating habits to eating only really nourishing food until you are really full.

On the exercise side, there are a couple of considerations:

• Sub maximal exercise, sometimes called aerobic exercise, burns fat. But you need to exercise for a long time since the output is sub maximal in order to burn fat in a meaningful way.
• Interval training from your sub maximal zone to higher heart rates approaching your max heart rate and then recovering to your submaximal heart rate accelerates the process of fat metabolism
• Short bout high intensity exercise (like sprinting) builds your fast twitch muscles (type II) which themselves are preferential in fat metabolism.

What that means is that when you have type II muscle on board, you find it easier to break down stored fat to use as energy. Remember, fat is the primary fuel.

A fit Olympic class athlete THINKS about exercising and starts to metabolize fat (ie turn triglycerides into fatty acids. Fatty acids are fast moving fats that race around the body looking for a muscle to burn them, while triglycerides are usually parked or stored fat. If a fatty acid does not get burned while racing around the body after being released, it can easily be stored again - head fat today, butt fat tomorrow.)

An active person needs to exercise for 5-15 minutes to start to burn fat efficiently. An unfit person will exercise until their sugar stores run out and then sit down again, never burning fat.

We have found in our clinical research that it takes 30 minutes of daily exercise at peak fat metabolism heart rates to stimulate normal fat metabolism mechanics. We have also found that interval training accelerates the fat metabolism on a minute by minute basis (ie more fat calories burned each minute). And we have found that the introduction of short bout high intensity exercise significantly increases calorie out put. In fact in a study we conducted with one person, she burned an extra 1000 cal per day by increasing her output by 6 one minute intervals per day.

Understanding a little more about glycogen use and replenishment will clear up the picture further.

Glycogen is resident in the muscles. We use stored glycogen to operate a muscle. we use fatty acids to help in the process of replenishing glycogen during and after exercise. During sub maximal exercise we use glycogen up and replenish it during exercise and while we use glycogen during max output exercise, we do not replenish it until after exercise in the case of high intensity exercise.

In replenishing glycogen store, we are not exactly sure of the mechanism, but heart muscle replenishes first, and once it is fully restored, then the skeletal muscle replenishes its stores and then once the skeletal muscle is fully recovered, then the liver finally gets its stores replenished. After exercise, a fit person replenishes at the rate of 10% per hour, and an unfit person at the rate of 5% an hour. For this reason, if you are just starting out, then make sure to take a rest day in order to replenish fully. You can also influence your rate of glycogen replenishment because in the first 30-60 minutes after exercise, you can replenish more quickly if you take in sugar (the only time it is OK to do that!)

So to lose weight you need to exercise more an eat less. How much more and how much less can be worked out, and we will be glad to help you figure this out exactly in our clinic. But if you are going to go it alone, then make sure to eat regular healthy meals that have a high protein content (lean animal meats) and low glycemic index carbs (lots of fruit and vegetables), and to exercise both submaximally for 30 minutes a day and also perform interval training while exercising submaximally. And then on top of that add several shourt bouts of high intensity exercise to ensure continued increased metabolism during your recovery after exercise.

And finally, what is "metabolism"? Metabolism is the sum total of energy of all the chemical reactions in your body. to increase your metabolsim, you need to increase the number of chemical reactions in your body. Since we are not very efficient animals, sweating, a response to exercise induced heat, represents an increase in metabolism. In the end, exercise is the best medicine.

Hope this helps!

Neil

My New Love Affair With the Concept 2 ERG

For a little over a month, I have been ERGing...indoor rowing (see the previous blog to see the device).

It has been great to feel my body getting stronger and to watch the quantifiable evidence of that. For instance, during the first week, while I was just getting started, in fact during my first row, I was able to complete 1500m at a pace of 3:21 per 500.

Today, I completed 6000m at a pace of 2:15 per 500. That is four times further, with each 1500 occurring more than 3 minutes faster than I was able to do on day one! This is also a big difference because on the ERG there is a cube effect that means that to improve by 10%, you need to increase your output by 30%. Wow!

I am on the ERG Monday through Friday, and I am trying to complete over 30,000m per week.

I am doing:

• 6000m on Monday and Thursday
• 2x 2000 m on Tuesday
• 500 m on Wednesday with a 2000m cool down
• 10,000 m on Friday

With the warm up I do, I should be able to make my goal each week. Of course, I am complimenting the ERG with a kettlebell routine that really makes me tired and strengthens my legs and shoulders further.

The best news is that I am sleeping great, eating better, feeling fitter and losing weight! Perfect.

Just thought I would share!

Neil