Movement

Power, paths and chains

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I have been thinking about simplifying stretching processes around exercise. Not when trying to repair or prevent injury but as a general mobilisation. Out of this, it is possible to spot a couple of patterns that are easy to follow, cover all the major muscle groups in the body and allow us to achieve the most benefit from our stretching time.

The body has an anterior and posterior chain (originally and well described in the work of Tom Myers), as well as the basic or prime moves.

By combining the basic requirements for movement (flex / extend / rotate) in all joints together with chain connections (it is possible to open up and stretch the whole body very smoothly.

Starting with the spine, we need to create flexion, extension, rotation and sidebending, focused on the articulation of the intravertebral joints rather than faking apparent range of motion with the peripheral limb movements. Hands on opposite shoulders (crossed in front of chest) and turn spine left and right, then flex forward (from the diaphagm) and arch back. Finally sidebending both directions to finish the moves.

For the front chain, step into a open lunge, keep the pelvis neutral (most important), extend the opposite arm as though stretching the chest and turn the upper body in the same direction. You should feel a gentle tension across the whole line. If you are unable to sustain this, it can be split into sections but needs to be considered part of the whole. The sections being kneeling lunge for upper body to pelvis and quad stretch for lower body. Repeat both sides, of course.

For the back line, a sitting figure 4 stretch (foot into opposite knee and lean into straight leg) covers most of the groups.

Finally, lie on your back, pull your knees up so knees and hips are comfortably angled, then let them drop to one side so that the glutes are stretched, together with the back chain. This can be amplified by putting the opposite arm out and stabilising the upper body.

Of course, these are best demonstrated in a clinical situation, so that they can be tuned to your body, however by paying attention to both your attention and intention, then good results can be acheived.

5 easy ways to stop back pain

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Over 70% of adults will suffer from back pain at some point and this number is rising every year. We all use our backs every day without thinking about it until they hurt.

Whether its from acute discs to muscle spasms, trapped nerves to torn ligaments, there are lots of ways for them to go and some easy ones to prevent it, without resorting to pills and surgery. Techniques doctors don’t always have time to tell you but save you time, money and worry.

  1. Move regularly. Your back is often painful if you sit for too long. The muscles go weak, the ligaments holding the bones together stretch and pain is the end result. Instead, walk a bit more, sit a bit less and use those muscles. Exercise doesn’t have to be gyms and furious sweating, simple moves at home will do it.
  2. Lift Properly. Whether it is a bag of shopping, a suitcase out of the car or a small child, we often lift very heavy objects without thinking and without doing it properly. Even if you can only manage a few of these items, they will massively reduce the risk. There is a simple way to remember lifting:
    1. Stop: Stop and think about the lift. Is it too heavy, too bulky?
    2. Face: Move to face the object. Twisting, bending and using the spine is the fastest way to cause lots of damage quickly.
    3. Brace: Pull your tummy muscles in. They are orientated so that they help support the spine safely but we often neglect to use them.
    4. Legs: Bend your knees, back straight and lift by pushing your heels into the ground and driving through your bottom.
  3. Stretch. If we spend too long sitting down, all the muscles at the front of us shorten, all the muscles at the back lengthen and we develop imbalances that cause pain when we try and stand up. Simple stretches can make an enormous difference to how you stand and move.
  4. Lose weight. If you are overweight, every step you take creates excess load on all your joints, even the ones in the spine. Your back has to take more force in the wrong directions, increasing the risk of it hurting.
  5. See an Osteopath. If in doubt, see an expert. Preferably before it starts hurting and you need the emergency appointment. Osteopaths are able to see where it might go and help free you up, allowing you to enjoy life without worrying.

Try these before its too late and you’re laid up.

168 Hours

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There are 168 Hours in a week.

We sleep, on average, for 56 (8 hours a night)

We sit and work for 45 (9 hours a day, 5 days a week)

We sit and commute for 10 (1 hour each way, 5 days a week)

We sit eating, reading or watching TV for 21 (3 hours a day, 7 days a week)

That leaves 36 hours to do other things, mostly at the weekend.

That which we do the most of, we become.

An hours exercise or movement a day really doesn’t seem much to ask does it? And if you recieve treatment for half an hour a week and change nothing else, how can you expect it to work?

Wobbly sticks and string

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Most people have seen a tensegrity model. These are clever constructions of sticks and elastic that use balanced tension and compression to created self supporting shapes.

(Image taken from http://dotensegrity.blogspot.co.uk/2011/01/make-your-own-tensegrity-model.html)

It is possible to consider the body as a tensegrity model, where the bones, muscles and ligaments all act together to support, articulate and move.

Although simplistic and missing huge elements of the effects of fascia, organs, inflammation and so forth, it is a useful analogy to hold, especially when trying to educate patients.

Recently, I have been considering the lumbar spine and the need for good abdominal support around it. The metaphor I use it that of a wobbly stick attempting to link upper and lower halves of the body. The pelvis is a fairly stable, solid object and the thoracic spine is well held with the ribs. This leaves the cervical spine (a wobbly stick with a block on top) and Lumbar spine to do a lot of work. Therefore, we need plenty of active muscles recruited to provide stability, support and movement.

So, no matter how much we may train that six pack and work to get well toned abs, if we cannot recruit them during activity, its fairly pointless.

I have 3 basic exercises I start with for every patient and, if they can do those, move to the next level. These are:

Pelvic control: The patient lies supine, slides one heel up the couch or floor, whilst attempting to maintain a level pelvis, the ASIS not deviating significantly posteriorly. Recruitment of the TA is particularly useful in this.

Cat crunches: On all 4s, the patient pulls their navel towards the spine, attempting to keep everything else still. A count of 5 and release slowly. This helps recruit deep obliques and the thoracolumbar fascia attachments.

Gluteal raises (trendelenburg drops). The patient stands sideways on a step and allows one leg to drop. They raise it back up again, using the opposite glutes, minimising recruitment of QL or lumbar erector spinae if possible.

Once they’ve got these, then the neuromuscular paths are working better and we can progress to more dynamic tests.

No more wobbly stick, less back pain.

Movement

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We need to move, we evolved through movement. Its just that with our current life choices, we don’t move enough. We have cars, internet shopping, sofas, take away food. We no longer need to hunt, track, think or work for dinner. Our survival no longer depends on moving.

If you watch a child, they move naturally and gracefully. No one has taught them to keep a straight spine and bend at the knees when lifting, they just do.

And if we look closer at their movement patterns in comparison to ours, we can see that they initiate their movements from the centre, the torso, long before the limbs are used. This is where they know they have power, not in the shoulders, arms or legs but starting, rooted in the core. As adults, we have learned that our arms and legs are strong and neglect the trunk, the point where it is all connected.

A common set of movements, sometimes known as the primal movement patterns are, in developmental order:

Flex
Twist
Push
Pull
Squat
Lunge
Walk
Run
Play

We should become like children again and do these every day. Only then will we start to find out how we are restricted and what we need to change to get the best from our bodies.

80:20

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There is an idea called the Pareto law. This says that 80% of the work takes 20% of the time. It can be used in almost any situation, from business management to problem solving, personal training to writing a book. I use it to illustrate a patients recovery plan (and will try to cover this in a post soon).
I also think it applies to our area, not just in terms of treatment processes, but in terms of techniques.Far too many people don’t use their training, expertise and experience sufficiently when working with clients. Instead they fall back on what they know works and do the same thing for everybody. (80% of problems can be solved with 20% of our skill). But every body is not the same. Each client is unique and each time we see them they have changed.

From a therapeutic perspective, this means that we need to reassess and reinterpret them each time, not just do the same thing and hope it will work.

When carrying out a fitness program, this also stands. We can draw up a framework for the series of sessions but need to be flexible enough to modify it as necessary. We should and need to concentrate on what they are saying, how they are responding and whether we are achieving their goals. In either mode, we especially need to take into consideration current research and thinking to ensure we are up to date with what the experts are doing. As with every other part of life, we need to remember the loop: observe, think, apply. Only then will we be doing the best for our clients and ourselves.

T4 / Rib 4 Problems

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I have recently been thinking about the connections between the ribcage and shoulder pain. From this, I have noticed a couple of connections.
The main one is dysfunction around rib 4 either side leading to pain in the same side shoulder and arm. This has typically presented as pain next to the scapula, tension in trapezius and radiating pain down the triceps into the forearm. The patient typically has a history of desk based work or driving, with the pain often coming on waking or after coughing / sneezing. Examination shows restricted thoracic spine and tenderness on the ribs, both sternally and on the spine. Having tried to research this, I struggled to uncover much that enlightened me, other than a chiropractic diagnosis of T4 syndrome, which doesn’t really match and often seems rather vague.
My view is that the symptoms are actually caused by fascial tension and pain related muscular spasm, so fascial release, gentle manipulation and soft tissue treatment can have an apparently miraculous effects on some people. I also do some cranial / functional work anteriorly to re-centre and balance the ribs / fascia.
From this, it has been useful to be able to rapidly assess the motion of the spine. Although a detailed examination is always important, it is useful to be able to have a rough guide as to where you should be looking.

Supine, where the patient lies passively and you use their bent knee to create rotation in the spine, blocking at the pelvis, ribs and shoulder to isolate the main sectors. This is following a simple standing active examination, where the patient attempts the main spinal movements of flexion, rotation and sidebending.As an extension of that, I started getting patients to attempt “monkey”. This is an Alexander technique standing posture, which is meant to demonstrate balance within the spine (my perspective). The most important thing to know about Alexander technique (other than it is really rather good and a couple of lessons from a good teacher is worthwhile, I recommend a number of patients to my local teacher) is that it is all about intention and the mind being in charge of the body, so speed is always controlled.To move into a version of monkey posture ask the patient to do the following:

1) Get them to stand comfortably, feet parallel (check, lots externally rotate to minimise loading in the glutes)
2) Bend the knees slightly
3) Bend forward at the waist, spine straight
4) Let the arms hang loose
This is a german video of a man sitting down, but if you stop half way, its monkey.
What I noticed is that most cannot bend solely at the hips without looking down and treating any thoracic restrictions allows them to move much better.
The reason for all of this is to demonstrate treatment further away from the area of complaint and to look for other areas of compromise in their movement patterns. They may also find cervical and lower limb problems start to surface. Once this has been physically demonstrated, it is easier to achieve compliance in terms of future treatments, exercise pescription and general understanding of their body.
And for a positive patient outcome, this can be used as part of their ongoing exercise plan.

Tonight we dance: Lower back pain, tango and movement

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My friends recently bought a wii for their family and watching them play a dancing game, I noticed something that had been slowly dawning on me for a while.

One of them seemed a little more fluid than the other but as they are all very fit and active, at first I couldn’t understand why.

The answer appears to  lie in the lumbar vertebrae and their apparent lordosis. One of them had a slightly more lordotic spine, with more resulting anteriorisation in the pelvis than the other.

From that, the pieces fell into place. Shortening in the quadriceps and psoas had led to a slight increase in the anterior tilt of the pelvis, in turn reducing the available motion in the lumbar spine.

This pattern can commonly be seen in the wider population, especially those presenting clinically. On examination, we will generally find tight glutes, shortened psoas, a slight medial rotation to the thigh, hypertonicity in the superior insertion of quadratis lumborum, an anterior tilt to the pelvis and restriction motion in one or more planes in the lower lumbar spine. If active, they may also report hamstring problems.

Clinically, resolving this can have several approaches, depending on the level you wish to work. Posteriorise the pelvis (one colleague uses MET of the hamstrings, another does it manually side lying), lengthen the quadriceps, stretch or release any psoas restricitons and work on any QL points. Other, more distal, areas can then be incorporated to address the underlying issues that the body was adapting around. This is where it becomes interesting and the individual practitioners preferences come to the fore.

Once treated, this can often be prevented from returning by regular stretching and, interestingly, regular dancing or hoola-hooping! Both of these activities help keep the spine mobile and fluid, encouraging good movement patterns and core integration. And Tango? Particularly for the ladies, this elegant form of dance requires excellent upper body posture, with the ability to stabilise and extend the pelvis and leg smoothly.

As ever, all problems are individual and should be investigated professionally. None of the information above is a diagnosis or treatment plan.

A brief thought on running mechanics and gait

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It is generally thought that there are 4 main phases to the gait cycle when running:

Inital strike, stance, take off and forward swing.

Breaking this down into 2 separate sections, we can firstly look at the strike and stance phases. As the foot makes contact with the ground and rectus femoris (one of the quadriceps group of thigh muscles) proactively fires. As the foot touches the ground, the subtalar joint inverts or everts, the midfoot abducts or adducts and the forefoot plantarflexes or dorsiflexes. All these subtle movements combine to allow a small amount of pronation to occur, maximising the foots ability to dissipate shock.From this, we can see that a tight foot that underpronates limits this ability, which may lead to achillies problems, calf strains, lateral knee pain and illiotibial band issues. Conversely, overpronation can lead to tibial strain, anterior calf injuries and medial knee pain, due to the medial rotation occurring in the tibia. 

Swing phase happens at the same time on the opposite leg. The pelvis rotates forwards, with hip flexion initiated by the iliospoas. The Hamstrings start to lengthen, limiting the extension in the lower leg, caused by the quadriceps.The lower leg decends, hitting the surface as the body accelerates, ideally creating a vertical line between head and toe on impact.

During both phases, the core provides stability for the upper body, allowing the forces to be shared and transferred correctly. As the spine can be considered by some researchers a store and transfer for the energy contained within the running motion, core integration is important and if not present, an indicator and predisposition of other issues that need to be addressed.