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?

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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.

Controversy: Imaging, is it helping your patient or wallet?

Controversy: Imaging, is it helping your patient or wallet?

When diagnosing the culprit of lower back pain, many clinicians rely on diagnostic imaging (i.e.: x-ray, MRI, CT). Lumbar pain is reassuringly benign, 85-90% of the time. Lumbar pain involving nerve compression comprises 10% of lumbar pain patients. Sinister or serious disease make up the remaining 2% of lumbar pain patients. The great news is that these ‘sinister’ conditions are ruled out by a proper history and exam. However, many clinicians still seem to be ordering imaging during the initial exam. The question often raised is

“structural pathology is often evident in images, so why wouldn’t we (the clinician) want to identify such abnormalities?”

While structural pathologies do have there place in medicine, they usually have little to do with lower back pain. In fact, most lumbar pain patients do not have a structural pathology that can be precisely identified as being a cause of their symptoms. McGuirk et-al found that 1.4% of lumbar pain patients had serious causes as a result of their lumbar pain, but they were suspected from the initial exam and history.

What about disc herniation?

Because the false positive rates are so high, in identifying a herniated disc, it makes imaging inappropriate as a screening procedure. Moreover, it can lead to labelling thus allowing the patient to assume a sick role or cause the doctor to prescribe unnecessary treatment. In a study performed by Bonenstein et-al, 67 asymptomatic individuals received MRI’s. The results were staggering, in that, 31% of them showed abnormality of the disc or spinal canal. Moreover, additional studies showed that these abnormalities didn’t predict a greater chance of future problems. Multiple studies have also shown that common “positive” findings are present in 28% to 50% of people with no pain at all! Disc herniations have a tendency to resolve in a natural process without surgery. But, what about the herniations that require surgery? The Danish guidelines show the following as being surgical indicators for herniated discs. 1: No improvement after 4-6 weeks 2: Progressive weakness in the leg 3: Leg symptom remains severe despite treatment and medication 4: There is a positive correlation between clinical findings and imaging reports. What about spinal degeneration (decay)? Again this is a term that instils fear into a patient. Disc degeneration is demonstrated with equal properties between those with and without pain. The prevalence of disc degeneration in people without pain and in their middle ages ranges from 46% to 93%! Therefore there is little correlation between radiological signs of degeneration and clinical symptoms.

When is imaging appropriate?

Most acute lumbar pain patients resolve quickly and with little intervention. In fact, It has been shown time and time again that reassurance, simple pain relief and staying active, is the best strategy for managing active lumbar pain. If there are red flags (sinister conditions) present, they should be picked up during the initial history and exam. Red flags of the serious disease are as follows: Mri of the back 1: Age younger than 20, older than 50 2: Trauma 3: History of cancer 4: Night pain (unremitting) 5: Fevers 6: Weight loss (unexplained)\ 7: IV drug use 8: Cortico steroid use 9: Recent infection 10: Cavda Eqvina 11: Generalised Systemic Disease (diabetes) 12: Saddle Anesthesia 13: Motor weakness of lower limbs 14: Sphincter Disturbance 15: Failure of 4 weeks conservative care Given these guidelines we are able to form a simple strategy. If there are no red flags, consider: 1: Reassuring the patient no serious disease is present 2: Relieve and reduce pain (simple analgesics, manipulation) 3: Reactivation (stay active, no bed rest) If there are red flags present consider the following: 1: Imaging 2: Lab work 3: Referral Informing your patient that you are able to rule out sinister conditions, even though an exact cause of their pain may not be identified, will register as very reassuring news. Craig Leibenson gives a wonderful analogy for simple back pain:

“liken the pain to a common cold or the pain experienced from gardening for the first time after a long winter”.

Conclusion

In a study by Kendrick, patients who received x-rays were likely to report a longer duration and greater severity of pain. Why reinforce a patient’s belief that they are unwell and cause them to limit their activities and in essence promote a more negative outlook? Yes patient satisfaction may be higher but the patient must be educated on why radiography is unable to improve therapy, decision making, or outcomes. If after 4-6 weeks there is no sign of improved function or red flags are identified from the patients history and exam, then consider (imaging or appropriate refferal). But always remember, a picture of a car doesn’t mean its running.

References. Leibenson C, Rehabilitiation of the spine. 2nd edition: 2007 Bonenstein DG, et-al. The value of MRI of the lumbar spine to predict lumbar pain in asymptomatic subjects. J Bone and Joint Surg 2001:83-A:1306-1311. Boden SD, abnormal MRI of the lumbar spine in people without back pain. N engl J med 1994;2:69. Kendrick D, Radiography of the lumber spine in primary care patients with lower back pain: Randomised controlled trial.  BMJ 2001; 322: 400-405. Jaruik JG, the longitudinal assessment of imaging and disability of the back study.  Spine 2001; 26:1158-1166.

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.

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

Five Innovative Ways to Clean Up Your Squat

Now this isn’t a set in stone thing.  Obviously everyone has their own opinion.  This is a simple guideline I use for cleaning up the squat.  I have tried to keep it simple.  If you have questions feel free to email me.  I have an open door policy and with email the door is always open.  That being said, the following are five ideas:

Remove the Hamstrings

Groove the Pattern

Mobilize Blockages

Lengthen Barriers

Refine Proprioception

I once knew a woman who couldn’t pick herself up off the floor.  Her leg muscles were so weak that she couldn’t, physically, lift herself up off the floor.  She didn’t know this was a bad thing.  In all honesty, this woman thought it was normal for her age.  Weakness is NEVER normal, not even at the ripe old age of 38!  You read that correctly, the woman was 38 years of age.  She had no leg strength, no core strength and was in amazement that it wasn’t normal.  It gets better… She didn’t understand how that was causing her knee pain and her hip pain.  A loss of strength is a loss of life.  A person, who is losing their strength, is without a doubt in my mind, losing their life.  Day by day, gravity begins to win.  Once gravity wins, the joints loose and when the joints loose, the pain begins.

That was a hard tangent but a testimony that all my patients hear today.  In fact that woman is now doing lunges with weight on her back.  Her recovery is nothing short of a miracle.  Why do I bring this up?  Because when you begin your battle against gravity, I want you to do it correctly.  Many of you are doing it right.  Many of you are in between and have the potential to do it right.  I trust that this article may give you a small boost in the right direction.  To err is human to squat right is divine.

Let’s start with removing the hamstrings.  The text-book muscles to fire during the ascension phase of the squat are as follows:

Gluteal Group

Quadriceps Group

As many of you know when these are not working properly other muscles like to help out.  The human body is absolutely amazing.  It will find a way.  Just because you are not using your hips correctly does your body stop you, no, it will find a way.  In survival mode this is great; in repetition mode (i.e. the gym) this is bad.  Eventually this leads to wear and tear and micro-trauma.  Ultimately this causes pain and disruption to daily life.  The question is, “what muscles do we use instead?”  More times than not we use the following muscles as compensatory muscles to the above:

Hamstrings

Lumbar Spine

So how do we know if we are using too much hamstring?  Easy, follow the steps below.

Perform a back bridge

Feel you hamstrings during the motion

If they are active throughout the motion then you are hamstring dominant.

Great, I am hamstring dominant.  What do I do next?  I suggest three things.

Learn how to squeeze the gluts all on their own, nothing else should contract.  Easier said than done, just try it.

Perform multiple back bridges with a band around your knees (pulling your knees apart)

Stretch (PNF) the life out of your hamstrings (poor squatting is rarely a by-product of inflexibility, more than not it’s a strength or stability issue).

Double check your back bridge.  Don’t be discouraged if it’s not perfect, it can take a few days or a few weeks to get the gluteal groups firing right.

Re-Groove the Pattern

This is simply through figuring out what to correct (keep it simple) and repeating it over and over and over.  I personally find that I can get someone that isn’t overly weak in stability or overly tight around the hips, to become “re-grooved” in around 1-2 weeks time.  I use the following protocol:

Modified Hip Hinging

Back Bridging Repetition

Sit to Stand

Loaded Sit to Stand

Serious Business (Squatting, Dead lifting, Hip Thrusters, Ect)

Depending on the persons total capacity (their ability NOT to fatigue or feel pain) depends on the reps however I like sticking to a total of 50-75 broken up into multiple sets.  If they are strong in another area we may insert the re-grooving into their program as a transition or superset.   For a simple example:

1A. Press Ups 12 x 3
2A. Standing Rows 12 x 3
3A. Sit to Stand 20 x 3

Another thing that is important to me is avoiding to OVER coach.  Over coaching for me is giving too many cues and too much information.  Give them one command at a time.  Let them master it and then correct the next invasive thing.  Start by correcting the most disastrous or potentially harmful error first then work from there.  For me, it’s usually correcting a large amount of spinal flexion.  If their eyes look glazed over or they are getting frustrated, rethink your strategy.  My approach for fixing spinal flexion is two cues (verbal and tactile).

Verbal: “Keep your chest up and look straight ahead”

Tactile: Pressure on the top of the chest (one or two fingers) and pressure on the lower back (hand).  Guide them into neutrality.

Again, the key is to break habits.  We are creatures of habit and we learn through repetition and mastery.  Empowering the client is so important.  I know that their form looks bad at first but I know what it will look like when we are finished as well.  I find some trainers are particularly good at overstating their assumption of what others are thinking.  For instance, I spoke with a trainer who felt embarrassed when she was training a client who had poor form.   This limited her ability to coach properly and resulted in termination of the exercise or movement in general.  I told her that you can’t expect your client to be perfect all at once.  It takes time, you can’t speed nature up or slow it down but you can improve its efficiency.  Trust what you are doing, don’t worry about anyone else.  She took her client a few steps back and gave the client instruction on why they were going back a few steps.  Two weeks later her client looked better than ever.

Mobilizing Blockages

This is important to complete prior to stretching itself and if you have an irritated joint, you will know why.  Stretching into a barrier with an irritated joint surface is painful.  If the joint is irritated because it’s not moving properly, then fix it prior to stretching.   The muscles and joints talk to the brain and each other.  They tell each other where they are in space.  This allows us to move and be efficient in our environment.  Without this unique communication system we would constantly be in a state of sloppy movement.

Three major areas to look at

Ankles (need around 10-20 degrees of dorsiflexion)

Hips (need around 80-90 degrees of pure flexion and 10-15 of pure extension)

Thoracic Spine (in theory needs 25 degrees extension)

Arm Flexion (should be around 170-180 degrees without back extension)

This is a generalization but should get you thinking.  If you or your client is lacking, have it check or treated.

Lengthening Barriers

What’s stopping you from getting all the way through the movement in a correct manner?  Tight hamstrings, tight hip flexors, poor joint stability?  Now there is a major emphasis put on tight hamstrings causing lower back pain and poor squatting technique but much of this is nothing other than circumstantial evidence.  I have worked with thousands of patients with tight, weak, long, missing, damaged, atrophies, and inconsistent hamstring musculature.  Number one reason is poor neurological skill.  The nervous system isn’t telling them how to co-ordinate the movement.  This goes for the abdomen, hips, knees, you name it.  They are not communicating properly.

The four point test for muscle length:

Modified Thomas Test:  Looks at Hip Flexors, ITB, Quads, Adductors

Leg should drop 10 degrees below horizontal (Hip Flexors)

Leg shouldn’t abduct any more than 15 degrees (ITB)

Leg shouldn’t adduct any more than 15 degrees (Adductors)

Lower Leg should be able to flex 100-105 degrees without hip flexion (Quad)

Active Straight Leg Raise:  Looks at active hamstring flexibility

Hip should reach 90 degrees

No lumbar flexion

No hip tilting

Standard Ankle Stretch

Stretching in Calf before 10-15 degrees (tight calves)

Tightness in front of ankle (under mobile ankle joint)

Thoracic Extension Test

Hands/Thumbs Should Touch Wall/Floor Behind Client

Lumbar spine doesn’t extend (Thoracic or Latissimus Dorsi Tightness)

I find that when any of these muscles are tight it’s usually because something else is weak or overused.  I have tested this concept clinically over the years.  I find that I only need to PFS or PNF stretch during the time strength is returning to the under facilitated muscle.  After that general maintenance is quite easy (dynamic work, static stretching).

Another point to note:

A muscle may be neurologically tight or anatomically tight.  If it is neurologically tight you will see major improvement in muscle length after a MET technique (PIR,PNF,PFS).  However, if it is actually (physically) shortened, it won’t dramatically change after the isometric contraction.  In this case you will need to be more aggressive with the muscle.  You should see a reasonable change in 2 weeks with 6 sessions a week (2-5 minutes each session), 1-2 sets of 2-3 reps of stretching (holding each 15-30 seconds).

Refine Proprioception

This is personally my favourite.  I feel it really give an individual a unique edge to their movement.  We have five primary senses:

Touch

Taste

Smell

Hearing

Sight

I want to use an analogy here.  When your computer is running slow you may hit “alt+ctrl+del” to enter the task manager.  When you are there you usually discover there is a multitude of applications running that you don’t need running.  Closing these unwanted or unnecessary applications thus improves the speed of the computer by freeing up memory.  I want to do the same with my client’s memory and ability.  I want to remove unnecessary input into the brain to be more efficient in my learning.  However, the opposite is true as well.  I want to add what may boost power and performance.  I may add an application to help do that.  If I translate this into my coaching, I get something like so:

Touch:  Try to clean up input from the foot to the brain by removing the shoes.  I suggest changing your mind once you start loading up with weight (for obvious safety reasons).

Taste: Try and reduce this.  Often clients will be chewing gum or eating a mint.  Have them trash it and deal with their bad breath.

Smell: Reduce, No flatulence

Hearing: Try and reduce their auditory input.  Music and other people’s noises are distracting.  Ever try to study in a noisy place?  Libraries are quite for a reason.

Sight: Reduce by having the client close their eyes.  You will immediately see how clear the joints are communicating to the brain.

Now I realize I am being humorous on a few but the truth is removing some of these, will dramatically improve performance.  I save this for last.  Obviously if a person has their ears plugged they won’t hear my coaching.  However, in the clinic, there is no music during training.  I want my client focused on the task at hand.  The client doesn’t mind because saving time (being more efficient) saves money.

I suggest that after things are looking really good, remove sight and hearing.  It’s amazing what starts to surface.  When the eyes are closed and the ears are blocked, its remove heaps of chatter from the brain.  Now the joints will be communicating directly with the brain.  You will see that they have been shouting and yelling, not getting the complete point across.  This incomplete message comes through as wobbling, miscalculating distance, and potentially falling (so be aware of sharp edges).

In summary, I believe that these five points will really help redefine your squat.  If your squat is already perfect (in your mind) try the above anyways, I am sure there is room for improvement.  Like Gray Cook said, “practice doesn’t make perfect, perfect practices makes perfect”.  We are all learning, all the time and while this isn’t ment to be a definitive guide I believe it may help.

-Anthony Close

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…

Anti-Rotational Training

Anti-Rotational Training

So often we look to the core for being the magical fix for the lower back.  Often, even though many won’t admit it, health care professionals are let down.  The core becomes stronger but the pain remains or becomes worse.  There are multiple reasons for this (see the post: why core exercises are not fixing your spine).   Without going out on an already kinetic tangent, I would like to speak about the obliques, their function, and application in training and sport.  One of my favorite topics right now (besides prion research and ipads) is anti-rotation training.

Relevant Anatomy

Touching on the basics, regarding the anatomy of the torso, we know the following to be correct:

1.  The anterior abdominal wall is designed for flexion but also to act as a spring to prevent damaging compressive forces to the spine.
2.  The extensors of the spine are to protect us from heavy anterior shear loads by creating extensor torque.
3.  The lateral abdominal wall is designed to resist us from rotating into extreme ranges.

Let have a ponder regarding each section of the torso and what each section is up to.  A great start is the anterior abdominal wall.  Most text’s state that they are specifically designed to flex the trunk. However, is it the main reason that we have them?  If so why would don’t we have large bands of muscle instead of the six pack (if yours is visible)or  beaded architecture?

The extensors of the lumbar spine may be divided into two general categories.  Ones originating from the thoracic region and those originating from the lumbar region.  The lumbar region extensors have a very small lever arm.  Therefore, they do not act as primary movers for extension, simply because, they don’t have the power.  Instead the act as a support against anterior shear forces by naturally exerting a large posterior shear force.

The obliques are muscles that act to resist movement from side to side and to tie together the protective forces of the front and back.   They distribute the anterior posterior force as well as protect.  The abdominal fascia, which connect laterally to the appernerosis of all three layers of the abdominal region, also connect to the pectoralis major.  Functionally this allows for force during most movement to be transmitted equally through the torso.  In addition, one shouldn’t forget the important role of the QL and psoas in relation to the torso during motion.

This is where is gets controversial.

Lets start with the traditional school of thought on the obliques.  The traditional thought is that we should train them and make them stronger by rotating, side bending, and using various movements and methods.  Traditionally, we have seen several progressions of this over the last 10 years.  Starting with holding a plate on the side of the body and flexing up, to supporting the body at 45 degrees and bending up and down (holding onto weight), rotational machines where the person sits and rotates against resistance, the list goes on and on.  The common ground to all of these exercises: complete rotational ROM with resistance.

The new school of thought is that, this may be incorrect.  The new school is that we should actually be encouraging anti-rotation while still activating the torso and obliques.  Anti rotational exercises don’t have to be isometric but many are by nature.  We see fending drills, one arm walk outs, lateral chops, diagonal chops, pallovs, locked in med ball throwing, the list goes on and on.  The common ground to all of these exercises:  limited ROM held in by a strong brace.

Food for Thought

In the body we find areas similar in design to the obliques, in that, fibers running one way and others running the opposite.   Look at the image below.  You can see that the artist has represented the fibers of the external oblique running in a 45 degree downslope and the fibers of the internal oblique running at a 45 degree upslope.

Where else in the body do we see orientation like this?  One area comes to mind immediately, the disc.  The annulus is designed in the same manner.  Half of the fibers of the disc run at a 45 degree downslope, the other half run at a 45 degree upslope.  The reason?  One half resists rotation to the right, the other half resists rotation to the left.  Being at 45 degrees it essentially acts as a rotational shock absorber.

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So whats up with this 45 degree orientation?  Now I don’t have a degree in physics but it seems that the forty-five degree angle is the perfect angle for both generating and resisting a force in perhaps equal harmony.  Research is showing that side to side twisting (generating a force towards or away from center) is not  as damaging to the spine as previously thought; in regards to disc herniation.  However, the research also shows that such movements will slowly remove the layers of the annulus (de-lamination) over time and repetition.  Therefore, the question must be asked: “why would we evolve muscles that would cause damage to the body?”  The answer is “we didn’t”.  What has happened is mythology and weight room scientists have evolved in their psuedo-understanding at a much faster rate than our true understanding of the body’s architecture and function.  The result is “fantastic” new exercises that “hit” the muscle to give it a great “burn”… or something like that.  The truth is we can train the muscle with as much mean and peak activation (if not more) by using anti-rotational holds and movements.

The Truth

The truth is the core is made to protect the spine.  Those five lumbar vertebra are small and if you have had the pleasure of working on cadavers you can appreciate the amount of stress they go through on a daily basis.  Working one area of the core is about as smart as changing one shock absorber on your car.  They are made to work together as a unit and not only within the core itself but more importantly in sync with the upper and lower quarter.  Moreover, for sport and life the abdominal region needs to be well defined in speed, reaction, and endurance (more than strength).

My Favorite Anti-Rotation Complex

The AC-130:  This is an exercise I started using for rehabilitation, but advanced to a higher level of activation.  The victim kneels on the ground, holding onto a resistance band.  They are instructed to brace (all muscles) and resist movement from all directions and amplitudes over a 130 degree arc.  Major faults to look for is an unlocking of the hips from the shoulders, breaking from the hips, shrugging of the shoulders, and poking of the chin.  Try by holding for :20 seconds in multiple directions for 5 sets.

The Walk-Out (Fending): I originally heard about this exercise from McGill and JC Santana (these guys are like rockstars to me and I have massive respect for their knowledge and passion).  The victim holds a cable handle in one hand and walks away from the cable machine.  The individual may keep the arm in position close or far from the body, the distance determine the lever arm.  The longer the lever arm the more difficult the exercise.  Major faults are unlocking the hips from the shoulders, breaking at the hips, rounding the shoulders, poking out the chin/head.  Try 8-10 walkouts per side.

AR Window Wipers:  This is a modification to the fending drill.  The victim walks out in the same manner as the fending drill but stabilizes at the end (pulling the “floor apart” with the feet to encourage hip activation) and then makes the motion of wiping a window.  Again, the further away from the body the hand goes, the more difficult the exercise becomes.  Major faults are unlocking the hips from the shoulders, breaking at the hips, rounding the shoulders, poking out the chin/head.  Try 2-3 walk outs per side with 5-8 window wipe reps on each walkout.   2-3 sets

Med-Ball Quick Rotaries:  This was an exercise I remember doing years ago but never had a good reason besides getting the heart rate up, my how times change.  The victim holds a medball in front slightly below shoulder height and performs short amplitude, high velocity rotations left and right.  Think of your electric toothbrush when doing this.  Major faults are unlocking the hips from the shoulders, breaking at the hips, rounding the shoulders, poking out the chin/head.  Try by keeping up the rhythmic motion for :20 seconds for 3-5 sets.

AC Pillar Response:  This exercise takes the shoulder bridge and turns it into a anti-rotational exercise.  The victim holds their body up in a press up position with the hands close together, feet shoulder with (or more) apart.  The person quickly touches their hand to the opposite shoulder.  Gravity attempts to pull the side, no longer in contact with the ground, into rotation; a strong brace will extinguish this from happening.  Make this more difficult by elevating the feet and/or bringing the feet closer together.  Try by completing 10 touches (less than 10-15 seconds), 5-8 sets.

In My Thoughts

Thinking of the core as a unit that helps stabilize and protect the spine is important when training the core.  I know this is an overly obvious and repeated statement but it makes me ponder the mechanism of action regarding the muscles of the torso during a protective bout.  Let me explain for a moment.  If the core is made to protect (from an intelligent design point of view), then the muscles would be resisting forces in an isometric or eccentric manner.  Example: opening a door exerts a rotational force on the torso/spine, therefore, to open the door and protect my spine I must resist this rotation either through an isometric or eccentric action. Thus, I want to train these muscles in an isometric or eccentric manner.  However, they are also ment to be dynamic.  This means that I want to train them for speed as well.  Lastley, they are made to hold up all through the day, therefore, I must train them in a manner of endurance.

Confused yet?  Well, we are always learning.  Remember the quote: “be skeptic of those who have found the truth and be confident in those seeking the truth.”