Archives for March 2013

Core, Crunches, & Oversimplification

There is a wealth of information on the core, spinal loads and biomechanics, and appropriate exercise selection. Despite this, there are no perfect, uniform laws of core training. There are some great principles and guidelines, but there are no unbreakable laws. Perhaps in our desire to communicate the ills of repeated, loaded spine flexion some of us have oversimplified this concept.  Such as don’t flex the spine and don’t do crunches.  (I know I may be guilty of this, and in doing so failed to follow one of Einstein’s cautions.  I admit my bias is due to working with a large population of folks with back pain and a great number of athletes/weekend warriors who spend there days in seated flexion during desk work.)  Please note that I am not advocating for or against the crunch, sit up, leg lift, V-up, or any other particular exercise, just a reconsideration of what we know, how we train, and what we say to people about their movements. Perhaps a more complete, reasoned approach is warranted.

Make things as simple as possible, but no simpler.  – Albert Einstein

 

Paraphrasing Stuart McGill, ‘there are no good or bad exercises‘.  We need to find the right exercise for the right person at the right time.  In my opinion this is best done with a constant monitoring: assess, implement training strategy, reassess (within visit and over time).

What does your core training produce? Quality? Capacity? or Both?

I would argue for the novice trainers and clinicians to avoid spine flexion with their patients/clients (particularly loaded or repeated) may be advisable as the yearly and lifetime prevalence of back pain is quite high, 40% and 85% respectively.  However, the more seasoned should take a careful look at the individual, their activities and demands, and then weigh the risks and benefits.  Below are links to an interesting discussion on this, it is 3 parts of a well reasoned, collegial blog conversation.

Side note: I’d like to applaud both authors for stating their points with their own clinical and scientific understanding, reasoned arguments, and interesting perspectives, rather than sinking to the level where some online disagreements tend to go all to quickly..

Side note #2:  The discussion above represent my thoughts and is not intended to summarize the posts below.

Use the links below for a great discussion about appropriate training of youth athletes, the limitations of certain approaches, and finally the multitude of factors that influence appropriate training (particularly in the female athlete). 
Take a moment… read it, think about it, challenge your current understanding…

Post #1: by Julie Wiebe, PT “dear coach”

http://www.juliewiebept.com/alignment/dear-coach/

 

Post #2:  by Greg Lehman BKin, MSc, DC, MScPT  “Dear Julie”

http://www.thebodymechanic.ca/2013/02/14/dear-julie-in-defense-of-the-crunch/

 

Post #3: Response to Lehman’s post by Wiebe “Dear Greg”

http://www.juliewiebept.com/fitness/dear-greg/

 

Things to consider:

  • What factors govern your exercise selection?  Age? Gender? Injury history?  Activity/sport?  Frame size?  Disc shape?  Related mobility (hips/ankles/thoracic)?
  • Are there patients/clients who should avoid spine flexion?
  • Are there folks who should be encouraged to flex?
  • When training flexion how much repetition or load is reasonable?
  • Should training recreate the demands of the sport/activity?
  • Should training prepare someone to resist the loads of their sport/activity?
  • Is core training the same for the male and female athlete?

A bullet list of quality reminders regarding core & pelvic floor.  Once again compliments of Dr. Cubos.

Diastasis: Core Evaluation and Training

 The question was recently posed to me, “What do you do to treat a diastasis recti?”

In short, I’m not an expert in diastasis management.  However, in performing a full body assessment and assessing intraabdominal pressure (IAP) per DNS, this is often a finding in patients who I treat for a variety of conditions.  Diastasis recti is a sign of lack of coordination the abdominals/core that results in a separation at linea alba.  This can appear as a bulge outward or a pulling inward (see below).  Diastasis is ‘normal’ in newborns and typically resolves with development, it is also commonly seen during pregnancy during which time it is not treated.  Post-pregnancy, and when present in the adult population this may be something that warrants further evaluation and treatment.  Appropriate exercise selection is essential to success.

 

 

 

 

 

Evaluating and Training Diastasis:

Some diastasis, such as below, are quite obvious.  Others are more subtle.  Evaluation must occur with careful observation and in a variety of positions that create a challenge to intraabominal pressure.  Check out a DNS course to learn more.  For those who haven’t been exposed to the Prague school methods, perhaps for now consider evaluating in whatever ‘core exercises’ you already do.

I wonder how many of these are overlooked as clinicians focus on the back rather than the front during spine evaluation and as fitness trainers and coaches train the majority of their athletes with shirts on.  Are you assessing for this during your examination or intake screening? 

Are the exercises you’re using appropriate for the patient/client? 
I have heard Craig Liebenson, DC often proclaim to train “the hardest thing they do well”.  I apply this same principle to core training in the presence of diastasis.  I would define ‘well’ in this case as with control of the diastasis.  Below are three images:  1) Core at rest with prominent rib flare.   2) Core activation that is relatively high threshold for this patient; diastasis clearly present.  3) Controlled core activation without diastasis.  I have intentionally narrowed the view so it is unclear what exercises were used in pictures 2 & 3.  Why??? Because it doesn’t matter.  The appropriate level of challenge will differ for each individual, it is your job as a skilled rehab or fitness professional to select the right one.

At times soft tissue mobilization/reduction of fascial restriction can facilitate progress once the appropriate exercise is selected.

I tend to like the control that can be gained in the 3.5-4.5 months supine progression and may use ‘wall bug’ or vertical foam series to challenge the core control.  (See video below.)

At rest

 

With high load exercise

 

Controlled Core Training

 Please note: These photos were taken 1-2 minutes apart.  This does not represent training effect, but should clearly display an appropriate level of training for the individual.  While the goal is to promote function, independence and activity in the individual, the aim regarding the diastasis is that with repeated challenge (training within the functional range) that it becomes smaller, resolves, and/or can handle a greater abdominal challenge. This does typically take time (6-12 months or so).

 

Other diastasis posts:

Dr. Jeff Cubos: Diastasis recti

Dr. Jeff Cubos: Diastasis recti… again

What NOT to do (Thanks to Dr. Oz): http://www.doctoroz.com/pregnancy-videos/baby-belly-workout
The role of rib position/mobility and diaphragm cannot be ignored.  Good video here with training in 3.5-4.5 month position beginning at 3:45, the breathing work before that is valuable as well:

This week’s inspiration

Some things that have brought a smile to my face and renewed enthusiasm to my day.  Very proud that some of these come from R2P, the student arm of the International Society of Clinical Rehab Specialists.  Top notch work by these students.

  1. PT’s vs Chiro’s blog post from From Jas Randhawa & Kyle Balzer (future DC and future PT).  Interesting discussion getting a lot of views.  Look for the upcoming Movement Lecture.
  2. Great Regional Interdependence and R2P intro from Ramez Antoun (future PT from UMass Lowell). first 25 minutes or so are fantastic.
  3. In Sickness and in Movement.  Be prepared to be inspired. 
  4. The difference between winning and succeeding with John Wooden.

 

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