Wellbeing App Released

“Would you tell me, please, which way I ought to go from here?”

“That depends a good deal on where you want to get to,” said the Cat.

“I don’t much care where-” said Alice “Then it doesn’t matter which way you go,” said the Cat.

“-so as long as I get somewhere,” Alice added as an explanation.

“Oh, you’re sure to do that,” said the Cat, “if you only walk long enough.”

-Lewis Carroll, Alice’s adventures in wonderland

Imagine traveling without being able to recall where you have been. In order to know where we are going, we need to know where we are coming from and there is no difference when speaking about our wellbeing. For example, if you call me and ask, “how do to I get to Wellington,NZ?”, I will certainly reply, “where are you coming from?”.  We often have a goal but oddly enough we are blind to our progress (or lack thereof). For instance, ask yourself what your mood was yesterday. Now ask yourself how your mood was two weeks ago. I am certain you are slightly foggy on the last one. But what about your mood 3 months ago? 1 year ago? I imagine you truly don’t have a clue- unless it falls on a memorable day good or bad. Not having access to this information can be problematic when tracking progress and measuring outcome.

In practice I identified a problem with asking “on a scale of 1-10, what is your pain today?” The problem was not the question being asked but rather the frequency at which it was being asked. I do not see my patients daily nor do I want to see them daily, I want my patients to recover quickly and efficiently. But identifying progress can be difficult when it is sporadic and spread out over  several weeks. It’s simply better to know how the patient is coping daily.

Before the wellbeing apps creation I took on the tedious job of emailing clients an outcome based spreadsheet. The spreadsheet was simple and it allowed them to enter an 0-10 rating for pain, mood and sleep, everyday of the week. Once the spreadsheet was returned I would graph the data and use it to demonstrate progress to the patient. I found this very effective in unmasking ineffective treatments, demonstrating the harmless nature of flare ups and empowering self-care.

As my clinic grew this system became overly tedious. However what I found during early graphing was exciting. I found that once patients graphically visualized progress, it reinforced their attitude towards improvement. Often patients will forget where they came from (early pain episodes) but simply reminding them with the graph allows them to understand the progress made.

Because I was graphing data on pain, mood and sleep, patients were able to better understand the correlation. This can be simple to understand but also empowering to envisage. When my patients began to see the graphs and realise they were managing their pain, it was a lightbulb moment for them. They knew what was working and what wasn’t. That to me was empowering my patients. Moreover, it was done through powerful visual feed back.

Visual feedback is an invaluable tool. Whether it is EMG, biofeedback or wellbeing, seeing is believing. The primary goal and vision of wellbeing is this,

“empowering the users perspective in regards to health and wellbeing.”

It is a must for anyone wanting to know and see their progress. Wether it be pain, sleep, mood or your own unique category, you are now able to track it easily.

Finally to put the icing on the cake, you are able to overlay and compare graphs. Overlay strength with motivation or strength with impact on others. What ever you can dream up you can monitor. Wellbeing allows you to simply and easily track your progress on a consistent basis. After all how do you know were you are going if you don’t know where you have been?

Buy Here

Summary

1. Wellbeing allows for graphical mapping of your pain, mood, sleep, and motivation.
2. Input your own category to track (i.e. strength and eating behavior)
3. Wellbeing unmasks ineffective treatments and poor progress.
4. Touch screen monitoring. This is simply just cool.
5. Empowers the user to monitor outcomes daily, not at every doctors visit which could be at weeks apart.
6.  Email your graphs directly to your doctor, trainer, or therapist.
7. It costs less than a pizza and is better for your health.
8. Allows the patient understand that hurt doesn’t equal harm.

3 Major Myths Concerning Back Pain

1. The need for an accurate diagnosis
2. The need to rest until pain is gone
3. The pain will lead to chronic disability

The need for accurate diagnosis

The spine is a unique structure and is often subject to debate in various circles of study.  During your lifetime you have about a 70% chance of developing acute lumber pain.  I am sure if you have experienced significant pain in your back, you have had concerns regarding accurate diagnosis of where the pain is coming from.  In fact, many form their own lay mans version of a structural cause, such as the muscles, ligaments or disc.  What is interesting is that research shows that none of these can accurately be diagnosed as a source of pain.  What is even more important is that structural causes need not be identified in 85-90% of back pain patients for a successful outcome to result.  It should put you at ease knowing that serious medical disease resulting in pain is less than 2% of all back pain causes.  What’s more exciting is that the fact that these 2% maybe ruled out through a proper history and simple exam.  So what is causing the pain?

A better question is to ask “what is my pain trying to tell me?”  The perception that pain is a negative sensation is harmful; pain is simply trying to tell you that if you keep doing something (such as lifting improperly a certain way) the tissue may be harmed.  It doesn’t mean you have already harmed the tissue.  In the case of a simple back ache, pain doesn’t equal harm!  Therefore the pain is simply telling you to be more active or aware of your movements.

Need to rest until pain is gone.

The biomedical model has often prescribed bed rest for lower back pain (LBP); however multiple studies have shown bed rest to be more harmful than good.  In fact, 2-3 days bed rest is maximum for acute, simple back aches.  More over this should only be recommended when pain is severe.  Bed rest isn’t treatment for the pain; it is a consequence of the pain.  Even though uncomfortable, being astutely active is the best and most efficient form of treatment. For simple back pain when should you use bed rest?  If the pain is severe (9/10) then consider it, but only for a few days (remember rest isn’t always best).  Excessive bed rest may lead to chronic disability.

People experiencing back pain often become fearful that the pain will cause serious disability.  Such disability is highly unlikely; moreover, people who remain positive, active, and motivated are likely to recover quickly.  People who equate hurt to harm or exaggerate pain tend to become worse.  When a person experiencing back pain stops becoming active, the joints and muscles become inactive, this inactivity leads to de-conditioning and the de-conditioning results and more prolonged pain.  Do you see the downward spiral?  So how do we keep the pain from becoming chronic?

1. Remain active
2. Exercise regularly
3. Remember hurt doesn’t equal harm

If you are fearful, use a quota-based approach, gradually increase your activity in a step wise manner.  Limit activity by quota (set-reps) not pain.  Gradually encounter the things you fear and are safe and low load environment.  You can’t get over the fear of running by sitting on the ground, you get over it one step at a time!

Summary

1. Bed rest may have harmful effects on back pain.
2. The benefit of activity exceeds the risk the rest.  Swimming and walking are great for active recovery
3. Hurt doesn’t equal harm.
4. Flare-ups aren’t a failure they are expected.  Simple movements like a cat crawl or back bridge can immediately reduce symptoms.
5. Exercise is the best way to prevent future back pain; however, 25% of patients fail at sticking to a plan.  What can you do to stay motivated?

Acknowledgements.

Special thanks to Craig Liebenson for valuable insight

Proprioceptive warm-up

In a previous blog I briefly touched on reducing sensory information, in order to improve squatting mechanics. The purpose of this blog is to show a novel approach to modifying a warm-up to compound or Olympic lifts.

In all aspects of movement, such as strength and efficiency, lies the master control; otherwise known as neurological factors. The most notable factors being the sense of kinesthesis and proprioception. It’s important to consider that the joints, through these senses, talk to the brain in two general manners. First, they relay information regarding their individual position in space and time and secondly regarding their relative positions to one another. Moreover, when combined with other senses such as sight, sound and touch we are able to perform movements with incredible accuracy and skill (assuming all are operating efficiently).

In training, improving proprioception, is something that time is hardly devoted to. As a practitioner of manual medicine it is a fundamental piece in the perfection of optimal movement. Any practitioner using PNF techniques or sensory motor training understands and has most likely experienced the positive effects of improving the Proprioceptive system. The results are improved movement patterns, speed and timing of information.

The following is a simple system that I have personally found beneficial in improving proprioception and ultimately perfecting secondary movements and compound lifts. It is both time efficient and easy to monitor improvement. Moreover, this methodology may be used for any movement that may be in need of correction. Usually the person being trained is unaware of errors in movement and believes that the movement is being performed properly. Try using this system to allow the individual to ‘feel’ the errors described by the coach more appropriately.

Step One: Have the client cover their eyes with a soft blindfold or night mask (as used in sleeping).

Step two: Have the client get into the starting position of the lift, without weight or resistance. If the exercise being corrected uses a bar, replace it with a dowel rod or broom stick… Use appropriate touch and verbal cuing to correct any errors. Also, it is important to have them focus on what they are feeling from their feet to their head. They should be aware of both location and balance. Repeat this five to ten times or until satisfactory starting position is naturally achieved.

Step three: Remove the blindfold and allow the client to perform eight to ten reps of the movement in question. Light weights may be used at this time. (I.e. 20% IRM) Afterwards, place the blindfold back on and have the client repeat the movement for another eight to ten steps. As the client becomes proficient at the movement, guidance and correction will diminish. In addition, the movement will become perfected and stable. The client will become more aware of the movements natural feel with eyes open and closed.

In summary, this methodology is a wonderful way to clean up movements. It may be incorporated prior to the warm-up set of any lift or movement pattern. Be creative in how you use it but always be safe. It may be a valuable tool, not only for strength conditioning, but for rehabilitation as well.

Hip Stiffness or Congenital Defect

I realize to some this may be a little elementary,  but I was feeling a bit bored. All in all I think this is still important and relevant to consider.

When assessing hip mobility, it is important to consider all anatomical structures. In the realm of fitness, muscles are commonly assessed as being either stiff or short.

“Stiff muscles respond quickly to PNF stretching techniques whereas short muscles tend to respond better to low amplitude and longer time frames, in regards stretching.”

However, when assessing ROM such as medial and lateral rotation, it is important to not only consider the soft tissues but the actual skeletal architecture as well.When defining structural variations in the hip-joint, we may commonly see two categories.

1. Hip Antetorsion
2. Hip Retrotorsion

Hip Antetorsion is congenital and is defined by the angle of the head of the femur. As the name states, the head of the femur is rotated anteriorly. The by-product of this anterior rotation is

1. Increased Medial Hip Rotation
2. Decreased Lateral Hip Rotation

The best test to determine this insufficiency is Craig’s test. The hip may be considered anteverted when there is more than 15° of anterior rotation relative to the plane of the femoral condyle. Clinically, pain usually is reduced by flexing and medially rotating the hips.

Hip retroversion is a congenital process that is defined by a posteriorly rotated head of the femur. It is also more common in men than it is in women. In this condition, the opposite of hip anteversion is noted.

1. Medial Hip Rotation is limited
2. Lateral Hip Rotation is increased

If the hip is placed into medial rotation for a sustained period, pain will usually result.

Because of habits and anatomical differences, men usually do not experience pain during sitting and sleeping, whereas women will.

Again, the best test to determine is Craig’s test (aside from advanced imaging).

In summary, hip mobility may not always be due to short or stiff muscles (or a tight capsule). Anatomical changes must be considered when assessing a patient / clients ROM of the hip.

Hopefully you found this of use. Or at least a brush up on the basics.

Mastering Your Pain: Self Care

The word pain evokes a plethora of responses from human beings. However, pain is still in many senses elusive. Many different theories have been presented which attempt to describe, label and categorize pain.

Many current theories point to internal factors being the center of pain, processing and  perception. In other words, the nervous system transports and allows for perception of pain.Moreover, misdirected labeling and deceptive medical diagnosis often focus on external sources as an origin of pain.

The argument is that the patient might not have sufficient strength or endurance and as a result may be causing pain. Insufficient strength or endurance may cause improper movement patterns, which are causing tissue irritation, joint stiffness, deconditioning, and pain.

However, how do patients enter into this cycle? Is it a lack of fundamental movement? Perhaps, how about a lack of strength or endurance? perhaps, but what if it’s simply a lack of motivation? You see, I believe that most musculoskeletal pain (MSP) is a motivation problem first and a movement problem second. Of course, there are exceptions to this, but if you look hard enough at the patients’ history, you will find they deal with pain in one of four ways.

1. They avoid it
2. They deny it
3. They compete with it (boom / bust)
4. They accept and learn from it

Once a patient accepts that pain is their friend and not their enemy, they have taken the first step. Most patients will agree that they have been living life below their true standard or simply being lazy. Once they realize that pain is simply a indicator of something potentially underperforming, they can begin to understand why they need to change their approach. 80% is the why, the remaining 20% is the how.

Rename The Pain

Drop the intensity! What do you think of when you hear the word pain? Probably nothing good. But if we look at how we talk to children when they become injured, what do we hear or call the pain? A boo-boo or an ouchy! What if we did the same thing? If you are sitting right now and experiencing acute back pain, stand up and move around, and call your “pain” a boo-boo. It’s hilarious and immediately shifts your focus.

Own it.

Are you able to own and control your pain through thought process? Absolutely.

1. Identify it. Is the pain (boo-boo) truly there?
2. Realize it’s here to help, not harm.
3. Become very curious about your pain.
4. Be confident that you can handle and control it.

Remember, you can avoid it, deny it, go boom or bust, or you can accept and learn how to change it. Don’t live below your true standard. Be honest with yourself. Who are you? Are you a lazy, unmotivated, sedentary human? Of course not! Your habits may be sedentary or lazy, but inside, you know that’s not you nor is it what you intended. If its a lack of movement or lack of life, why are you or why would you harm yourself? Do yourself a favor and realize that you have the same potential that all human beings have. Strength gives birth to movement and movement defines life.

6 Steps to Motivation: Get rid of the pain for good.

1. Decide what you want to feel like and why you aren’t feeling that now.

Write it down, say it out loud, figure it out. Be honest and brutal. Are you sitting at work all day? Are you eating poorly? What do you do after work? Do you watch TV, sit, become and office worker at home? Once you have that figured out, focus on what you want and why.

2. Accountable leverage

Think of something which is part of your regular routine that is causing your pain. It could be anything from sitting too much,  standing to much, or simply not exercising. Whatever it is, connect it to the pain you have been experiencing. Connect even more pain to not changing it NOW. Now connect incredible amounts of pleasure and relief to the idea and action of changing NOW!

3. Interrupt your habits

Anytime you find yourself not behaving or slipping back into an old habit, immediately do something outrageous. This could as be silly as plugging your ears and

making a face. Or it could be as insane as jumping up and down, saying “An apple a day keeps the doctor away!” or “movement all day keeps my pain away!”

4.Own your alternative

What’s your alternative? The exercises your doctor gave you? Perhaps it’s simply getting up more often and taking short easy breaks. Whatever it is, do it and link pleasure to it. When you do perform your alternative, reward yourself. A reward may be smiling, calling a friend or playing a game you enjoy.

5. Make it subconsciously automatic

Habits are formed from repetition. The power that makes a habit breaks a habit. Get into the process of being in control of your habits, your movements, and your life. When you learn a new movement or better posture it will feel awkward. Give it time to become normal.

6. Re-test yourself

After a week or two weeks of honest change, re-think about your pain. Are you still in the same spot ? perhaps you are feeling better? Maybe you are even feeling energized and confident! If not, then go back through the process, be brutally honest with yourself and find out what went wrong.

Remember focus on the why not the how. There is no point in bashing yourself over inconsistency, just simply realize the problem and truly commit to changing it by using the steps above.

Patient Motivation-A minimalist approach.

Imagine a cluttered room, furniture everywhere, books that could fill a library, enough dishes to start a restaurant. T.V.s, Radios and other electronics scattered throughout the room, all of these need wires so plenty of them too. All this leaves little room to negotiate, limits behavior and over time causes more stress.

Now imagine the same apartment or house with only the bare essentials or even nothing at all. Its like a breath of fresh air or the ability to even breath at all. Hence the saying, “Minimize to Maximize”.

I have two approaches when riding the McGill slope to improvement. When looked at from a distance they seem quite simple and minimalistic, perhaps that’s why they work for me.

1. Stack and sway
2. Running the option

The Stack and Sway approach is simply selecting the most relevant exercise to address the patients most current needs. Sometimes this maybe just one stretch and one exercise.

Often I will change the word exercise to something else: an example, Movement Therapy or even Movement.

This at times takes great will power but its important to do the minimum required for the maximum amount of change. After the patient begins this simple routine, I begin to add more to the list one at a time. After 2-4 weeks the patient should be into the swing of their routine. Moreover they didn’t have the cramped list that is often handed to them. If there is no room for slip ups and expectations are high, there will be little room for the patient to maneuver. It also leads to higher levels of disappointment between Doctor and patient if (God forbid) there is a slip up.

Running the option requires some preparation on the Doctors part. Just as running the option in football, the client will be able to do the same. The preparation required is to take a list of commonly used rehab exercises and find a suitable option for each. When you prescribe the patient their movements you also give them their option. This places the patient in the driver’s seat. To make or create more control, add in two or three options. This has been a favorite in the past and was developed through personal discussions with a clinical psychologist.

Anyway that you can change the dynamic, empower the patient, and have fun in the process will be a winner in the patients eyes. Rehab doesn’t need to be boring nor does it need to be overly strict. It should be precise, effective, and simple.

SUMMARY

1. Sound yet Minimal efforts help create breathing space for both doctor and Patient.
2. If something isn’t working, it’s much easier to figure out what when your list is small and systematically built.
3. Remember the stigma and emotion attached to words. What do you think when you hear words such as: Pain treatment, Illness, decay, degeneration, exam and problem?

More over what does your Patient think?

Tactile Pain Management: iPhone Application

Over the past few years I have really wanted a way to be more analytical and technological with monitoring my patients outcome assessment. I have tried everything from standard forms and progress reports to mailing out weekly spreadsheets which patients fill in and return. All of these are time-consuming. Ironically enough, often patients lose motivation as well and do not always complete or return forms properly. Through this I began to develop an iPhone application that would allow for reminders and a tactile surface to measure their daily outcomes. I am happy to announce that I used my concept for the first time as a prototype today and am very excited about the potential of the application.

This may serve as a vital tool for simple, cost-effective, and reliable outcome assessment and patient monitoring.  According to the data, outcome assessment should be valid, reliable, responsive to clinical change, and practical.  I believe this application contains these components on a fundamental level.  Most importantly it is practical.  It is simple to administer, requires little input (if any) from the practitioner.  Moreover, it allows for yes/no or quantitative type responses for the user.  Therefore, this application is time and cost efficient as well as valid, reliable, and responsive.

please note these screenshots are from the prototype and are being sharpened up at the moment.

The application will allow the patient/client to monitor the following areas on a daily basis:

1. Pain and Soreness
2. Energy Levels
3. Quality of Sleep
4. Motivation
5. Impact on Others
6. Willingness to Change
7. Productivity
8. Custom Field (Add in anything you would like here; i.e. Job Satisfaction)

The custom field also allows the individual to place a baseline on the lowest and highest values.  For instance, if we use Job Satisfaction as an example, the lowest value may be labeled as “I Hate My Job” and the highest being “I Cant Believe I Get Paid to do This!”.  It will give freedom over the labels allowing the patient to connect better with their questionnaire.

The application then stores the info and begins to chart the data over time.  This is important for a few reasons:

1. It allows the patient to “SEE” their progress.  Any healthcare practitioner can appreciate the impact this has in demonstrating pain trends.
2. It allows the patient to recall and reflect on their treatment over large periods of time in a matter of seconds.
3. It allows the patient to understand flare ups and how even though they may be having a flare up, their overall trend is improving
4. It allows the patient to monitor their own progress and give a sense of accountability

The graphical input will allow the user and practitioner to see the patients progress over the course of:

1. One Week
2. 6 Months
3. 12 Months
4. Year to Date (YTD)

Furthermore, the user is able to enter in reminders so that the alarm on the phone goes off or vibrates during the day to prompt them to do one or more of the following:

1. Record their Levels
2. Do their exercises/stretches
3. Custom Field (Add in anything you would like here)

Because it is important for the patient to have great and effective communication with their personal practitioner(s) I have included a function that allows them to email the charts and data (on the spot) to their practitioner(s).  I am really excited about this because it puts the accountability in the patients hands and empowers them to understand their pain and talk about their pain in a direct and easy manner.

It will also allow the patient to upload their outcomes to Facebook as a way of showing off their improvement (or perhaps lack of).

The update pathway includes:

1. Secure data (no patient names for security) upload to a server for pain management research
2. Children’s version for child cancer patients
3. Graphical Comparison (look at perhaps pain vs mood)
4. Advanced Statistical Analysis
5. Various Graphical Forms

This application will also be able to be branded to your clinic through our brand-the-app affiliate program.  This will allow your clinic to place all branding and information on the app (such as splash screen, about, and contacts) for sales to your patients.  You will also retain royalties from the sales of the app on iTunes or other supplying stores.

In summary, I am VERY excited about the potential of this application as there is hardly anything of its kind currently available.  Its simple, easy to use, and any patient that has an iPhone will love it.  Plus, it makes something that was bland and boring, actually fun.  The potential for research using this application is also very exciting.  This form of outcome measurement is essential in enhancing doctor-patient communication and improving goal setting and decision-making abilities.  Consider this when thinking of this application:

1. Establishes quicker more reliable report with the doctor and patient
2. Unmasks Ineffective Treatments believed to be Effective
3. Improves Goal Setting and Goal Achieving (are we making our goals?)
4. Improves Decision Making
5. Reduces the “burden” of typical paperwork and progress reports
6. Highly responsive
7. Helps justify treatment outcomes to 3rd party providers

I expect this to be available in the iTunes store by the second week of October and for a very affordable price (especially when compared to the cost of a patients office visit).  I hope you share my joy in this application.

If you have any questions feel free to contact me via comments below or through my website: www.anthonyclose.com

Hamstrings Causing Extension?

According to the web, a paradox is a statement or group of statements that leads to a contradiction or a situation which defies intuition.  Early last week I began to contemplate the idea of hamstring dominance during squatting.  I have know about hamstring dominance for a long time, however, I really never thought too deeply about it.  Lets think about the words “hamstring dominance” for a moment.  The hamstrings primarily flex the knee, so how could it be that during ascension from a squat, they actually help extend the knee?  Seems paradoxical.  The word paradox makes me think of Einstein or back to the future.  As if I meet myself 10 years ago and cause a space-time collapse.  However, this may be the wrong type of paradox.  Instead, I am talking about Lombards Paradox.

Now, I didn’t know the answer to my question about hamstring dominance.  I sought wise counsel and asked about the hamstring dominance.  The answer I received was Lombards Paradox.

Lombards paradox shows that the hamstrings have the ability to create hip extension during gait, cycling, or squatting due to a large moment arm close to the hip, instead of the knee.  It happens with the quads as well.  How does this happen?  Probably from improper joint mechanics (poor form).  However, it may be that Lombards paradox can be a good thing (for walking?) but in squatting you probably don’t want it around.  It seems Lombard was pondering the same idea…

What the Stock-market and Pain have in Common

Lower back pain is often self resolving.  As practitioners or patients, we hear that quite often.  However, what we don’t hear is the future of the pain.  The pain might be self resolving at the moment but what about when it comes back?  Self management has always been a key factor for allowing the patient to manage their pain.  Empowerment over the problem is essential for the patient to regain confidence in themselves.  Pain in itself has deep roots both in traditional medical thinking and more obscure metaphysical (Jedi power) type reasoning.  Either way, it is very real to the patient.  But telling the patient to not think or worry about the pain has little effect.  Below is a more systematic methodology.  This is a short write-up and I have not expanded on many of the aspects I personally use to predict and monitor pain (or trade my personal or clients portfolio) but its a start into the idea.

Buy/Sell or Treat/Prevent?

When we look at pain over a given time we start to see a pattern of troughs and peaks.  Peaks stimulate worry and concern and are often the reason for the patient to seek immediate care.  On the contrary, troughs are when the patient feels like improvement is happening or they are in control of their pain.  The question is how is this monitored?  The simple answer is outcome assessment (OA).  OA is so often overlooked; both in the medical realm but also in the personal training/health coach sectors.  Most practitioners administer their OA at the end of treatment which will usually yield a positive result. However, what about 1 week, 1 month, 6 months, 1 year later?  Is there a return or has it started fluctuating again?

When we look at market trends we see something very similar to pain (especially if your portfolio is bearish).  When I say similar, I mean in a trending sense.  We see peaks and we see troughs.  In the market we have fundamentally driven fluctuations and technical fluctuations.  Fundamentals are news releases, CPI’s, GDP’s, etc; while technicals are geometric patterns or indicators that may result in a group of people buying or selling.  However, there is inverse emotion when comparing pain to the stockmarket.  We see consumer excitement at highs (peaks) and consumer worry at lows (troughs).   While we can not predict where one may go to the exact cent, we do have an idea of the overall trend of a stock or currency.

Empowerment through Reflection

Pain when mapped out over long periods of time shows the client progress.  As humans we tend to be one way in our thinking.  We are able to focus on a vision and aim but we are hardly ever able to reflect and refine.   What I am saying is this.  Clients are able to establish goals and visions but often struggle to see improvement (especially in the short-term) unless properly monitored with outcome assessment. I suggest monitoring your clients in a simple manner.  Have them answer a series of simple questions on a slide or ruler scale (0-10).  Do this every time you see them (I even email my patients now and then to keep tabs).  Overtime trends appear and there is nothing more reassuring than visually seeing the progress.  Visual stimulation with reflection allows them to make the connection so necessary for mental positivity and empowerment.

A simple list for clients, 0 (lowest, i.e. no pain) to 10 (highest, i.e. major pain):

0-10: Pain
0-10:Motivation to Exercise
0-10:Sleep
0-10:Stress
0-10:Custom Category (Select a topic they may be having trouble with. i.e. smoking)

After acquiring this data, spend a short time asking about each.  If the client has selected a lower number than you would have expected don’t focus on why they didn’t choose a higher number, instead focus on why they didn’t choose a lower number.  For instance, if the client has selected a 4 for motivation, DO NOT ASK THEM WHY it wasn’t a 10.  Ask them what kept it from being a 1.  This will elicit their strong points.  Focus on these points for they hold the keys to change.

Pain doesn’t turn on or off.  It fluctuates and it fluctuates with predictability when monitored and analyzed properly.

We have to ask thee specific questions regarding the pain.

1.  What has happened in the past?
2.  What is happening now?
3.  What do we want to happen in the future?

Questions 1 and 2 are important for current history, treatment, and reflection; Question number 3 requires a different response.  For question number 3 you must ask yourself, “how?”  More importantly you need to know what “how” looks like.  Just talking about it here or there isn’t enough for the human mind.  We know it might feel better after a few treatments BUT what if it comes back?  If self-care and prevention techniques are in place, then the peak (or flare up) might not be as intense as the original pain.  If the patient doesn’t have a reference point, then patient perceives the pain as being pain.  The patient simply doesn’t think, “well this hurts but it’s not the pain I had 4 months ago.”  When the health care provider shows the patient their previous highs and they reflect, then the patient is put at ease regarding the severity.  Often when a patient begins to move properly, we see the start of a down trend regarding the pain.

There WILL BE flare ups.  This is guaranteed, we are not perfect, we are creatures of habit.  Changing and re-grooving movements and habits takes time.

However, with proper advice we are able to let the client know a flare will most likely happen and give them ideas on how to manage themselves when or if the flare up happens.  Letting the client know the flare ups will become less frequent and less intense and the good days will outweight the bad days will also put them at ease.  The key is to let them know, you don’t want pain to be a surprise.

In the middle of every difficulty lies opportunity. Albert Einstein

Don’t Panic!  Prevent!

In the stock-market, when stock begin to plummet, we see psychological disturbance.  This causes panic and worry.  This panic and worry has the potential to make things worse.  The same exact thing happens with humans in regards to pain.  Financial traders look at money management and stop-loss structures to reduce the risk.  In other words they cut their losses short or place stops that when triggered close their trade and preventing them from becoming worse.  As humans we need to adopt similar strategies.  Keeping the pain at bay through proper management is key.  Keeping your health portfolio in check is key to success during our time here on earth in regards to pain.  We will all die someday but let’s try to make is pleasurable and pain-free while we are in existence.  Just as successful investors has financial advisors, we as humans should have health advisors and coaches.  Seek people who want to be proactive and help you be prepared for tribulation when it arises.

Just like with stocks, movement and pain is about measuring risk and risk appetite.

In Summary, give the patient something to reflect on and you will be amazed at the response and feeling of relief (given you are doing the right things). That being said, we are also able to use such systems to monitor what is going wrong.  I believe that with detailed monitoring of pain, patients will be better off.  There is nothing more reassuring than knowing that improvement (even though not always rapid) is in fact, happening.  Remember that when things are turning south in regards to your pain, there is hope through empathetic management and reassurance.  Your company (body) is far from worthless.

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Machine Training: Safety Issues

I remember about 7 years ago someone asked me where I thought the fitness industry was going.  At the time I was just finishing up my B.S. in Biology but really had no clue where it was going knowledge wise.  One thing I do remember is saying that the machines would change.  I felt that the machines would be replaced by more complex (technologically) machines or more bodyweight or functional training (remember functional used to be a BIG buzz word, it kind of still is).  Anyways, both have happened although the latter is more apparent; machines are fading away and natural movement is replacing it.  Luckily, for the gym, this means more open floor space.

So Whats Wrong With Machines?

Simply put, when do you use a machine to play your sport?  Unless you are driving robots using levers that are excessively heavy, you are not.  In all seriousness, often people (who don’t know much about anatomy) argue that machines are good for excessively overweight people or handicap individuals.  While this is a decent argument and well intended, it is fundamentally wrong.  It is wrong, in that, if the individual is still able to move their appendage then they are able to train in a free moving manner.  The manner of difficulty arises in the trainers ability to tactile coach (hands on), progress and structure their clients workout(s).  Simply put, the trainer (which may be a doctor/physiotherapist/osteopath/etc) often doesn’t know jack about progressions, structure, and coaching a persons movements.

Remember that often the machines are based on business.  Business means they need to sell it, not selling it means no food, and no food means death.  I know that is dramatic, but it’s also the truth.  Dr. Mel Siff is quoted by saying, “It is commonly believed that gymnasium machines are intrinsically safer than free weights and require far less skill in using them.  This fallacy is one reason why injuries are still regularly sustained by those who rely solely on machines for training.”

One thing is very obvious when considering the spine and sport specific training is the fact that with most machines, the user is seated. When you are seated you remove the entire lower quarter from the kinetic chain.   Yes, you may be able to engage the lower quarter by doing something like, “squeezing the glutes” but does it really mimic what you may be doing in your sport or even in real life situation?  Moreover, It is well-known that when you are seated the amount of compression is elevated 140% (100% based on standing load of 70kgs) when compared to laying flat.  Obviously laying flat is not very sports specific either, so what is the reasonable middle ground?  Standing.   Standing not only reduces total compression ratios once loaded but it also mimics real life situations.  This has been stated over and over again but I want you to think of it as it applies solely to the disc and the spine.  Why do I want you to do this?  Because lumbar disc herniations have the potential to not only ruin an athletes season but to ruin the athletes career.

Alright, Well What Do YOU Suggest Mr. Know It All?

My suggestion is the same across the board, whether its an excessively obese, handicapped, or mentally challenged individual; start simple.

Back to the basics:

1.  Isometrics: Static progressed to oscillatory or rhythmic PNF
2.  Open/Closed Chain (Depends on the issue) Unloaded/Bodyweight

Obviously one must be focusing on building endurance, strength, speed/agility; all built on proper movement.  Moreover, I am not going so far to say “never use machines” but I am going so far to say, I probably won’t use one.  But then again, I don’t need one to make a great athlete or take someone from rehab into doing “typical” gym work.

Machines and Safety Issues
special thanks to late, great: Dr. Mel Siff Ph.D.

Seated Vertical Pressing Machines

Fault: May force the user to hyperextend the spine by leaning forward to “get under” the load.  Also seated exercises are able to exert 90% more compression on the spine than the same exercise in a standing position.

If you have to use the SVPM be sure to keep your feet on the ground, a neutral spine, and a decent brace.  Placing your feet on the foot rest has the potential to destabilize your hips and spine.

Seated Leg Extension Machines

Fault:  One of the major problems with this machine is the unnatural vectors/forces it places on the knee.  The buttressing of the thigh combined with the long lever arm in contact with the shin, imposes a very large and unnatural force along the plane of the knee.  Moreover, the SLEM’s do not provide backrests that support  the lumbar curve.  Again, this can cause flexion thereby increasing the compressive loads already imposed by being seated.

If you have to use the SLPM make sure to lower the weight slowly so that you aren’t forced to round the spine.  I suggest placing a lumbar roll or a half foam roller between your lower back and seat.

Lying Inclined Leg Press Machines

Fault: If the user allows the legs to move all the way to the abdomen, the back will ultimately round (unless their hip mobility is like a ballerina).

Again, I suggest using a half foam roll or lumbar roll to place between you and the back of the seat.  Also if your active SLR is less than 80-90 degrees, stretch your hamstrings!  It’s not rocket science.

Bench Press Machines

Fault: These machines, almost always, make you start in the weakest biomechanical position of the shoulder complex.  What position is this?  With the bar at chest level.  Moreover, according to Siff, you do not begin in a pre-strectch position.  Overcome this by having someone lift the bar up first (if they are man enough).

Seated Torso Twisting (Oblique) Machines

Fault:  These are my favorite to roast.  I am going to digress right now and just say it.  These machines are ridiculously stupid.  Even Dr. Siff is stated saying, “…these [spinal twist machines] are a little more than useless…”  Not only is it possible to flex the spine, while twisting, they often allow you to twist into end ranges of movement with heavy loads.  If you have trouble understanding why this is bad.  Please read my first post on anti-rotational training.  Please just don’t use these, even if you are a discus thrower.

Sit Up Boards

Fault: If the board has grips for the feet or ankles then you can be sure you will be training your hip flexors at the initiation of the movement, which will induce unnecessary compression unless properly monitored.  Whats the problem with training the hip flexors in this manner?  It can limit the hips range of motion and reactivity, thereby reducing the performance of running, jumping, and kicking (to name a few). If you insist on dong this do yourself a favor and stretch your hip flexors.

Hyperextesnion Machines

Fault:  Besides stressing the knee-joint capsule inappropriately, they don’t permit you to change the height of the foot restraint (or the distance between the hips and the ankles).  This causes hyperextension in the knees which equates to improper movement through the spine (by default). Siff recommends moving slowly so that you may avoid damage to the structures of the knee or spine.  Also, individuals with abnormally high or low blood pressure should be careful due to orthostatic blood pressure changes.

The List Goes On and On

But I think you get the point.  In summary, watch your spine and don’t impose “fake” or “forced” trajectories on the joints.  Simply put, “keep it real.”  If you want to know more read “supertraining” in fact, everyone in fitness should read it.  It’s not easy reading but neither was War and Peace.

The last point is, don’t race against the clock unless you are qualified to do so.  This stuff is getting out of control.  Without pointing the finger (saying crossfit, while coughing) please don’t race against the time unless your movements are qualified.  If you haven’t done a press up or pull up in 2 years don’t just go out and try to do 10 reps by 10 rounds in 10 seconds.   That is just ridiculous.  You don’t need to do that to be “fit” or “loose fat”.

All I am saying is be smart, be safe, be sensible.

-Dr. Anthony