Core, Crunches, & Oversimplification

03/26/2013 by Leave a Comment

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.

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R2P in Daytona: Spine Rehab

02/16/2013 by Leave a Comment

Rehab 2 Performance seminar:

The Cutting Edge: Lumbar Spine Rehab

Principles, Fundamentals, and Putting it into practice.

with Jason Brown, DC
Rehab 2 Performance logo

Date: Sat/Sun April 6-7, 2013

Time: 10-6 Saturday   &  8:00-1:00 Sunday

Cutting Edge: From Occam’s razor to the sharp, crisp blows of Bruce Lee, we see the power of simplicity. Mastery of the basics is essential to exceptional performance.  We will draw from the a variety of contemporary rehab methods (Prague school of rehab [Janda, Lewit, DNS], SFMA, and the works of Liebenson, McGill, Cook, & Butler & Moseley) to help you master the basics of lumbar spine assessment and rehab.

In this mixed lecture, demo, and participation based seminar you will be introduced to the principles behind modern spine care.  During the weekend we expect you to gain an appreciation of contemporary functional assessment, solidify your selection of corrective strategies, and hone your instruction and cueing techniques.  By mastering the basics you will have something usable on Monday morning in the clinic and something that will help you change peoples lives.

Lumbar Spine: Following the principles of the International Society of Clinical Rehab Specialists, we will discuss pertinent biomechanics and load of the lumbar spine, the role of the hips, function of the core, and how breathing fits in.  While discussing one region of the body, the course will focus on global assessment with appreciation for regional interdependence.  Ultimately we will help you understand how it all ties in.

Quality movement is the bridge from rehab to performance.  Improve your eyes and learn to see it.  Enrich your brain and know how to prioritize what you see.  Smooth out your explanation so you can communicate complex concepts concisely to patients and colleagues.

Location:  Daytona Beach Resort
2700 N Atlantic Ave. Daytona Beach, Florida 32118
Phone: (877) 644-3239

Beachfront rehab course = worth the trip.

Cost:

SEATING FOR THIS SEMINAR IS LIMITED and is first come first served.
$249/$329.  Register by paypal below.  (Registration by check can be arranged email: jbrowndc @ gmail.com)


Registration Type
Registrant Name:
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This course is held with the support of the International Society of Clinical Rehab Specialists and Theraband Academy. 

ISCRS logo

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McGill

09/22/2012 by 2 Comments

I had the pleasure of spending a weekend in Saco, ME listening to Stuart McGill.  As you may know, Dr. McGill is a wealth of knowledge, info, research, and clinical insights.  So I don’t become one more in the long line of people to misquote Stu on the web, I’ll let his work speak for itself, you can read his books, review his research, or watch his DVDs to get his opinions and I’ll simply offer a few things I took away from this weekend.  Here’s a few reminders, tips, tricks, concepts, or soundbites I took away from the seminar. 

  • Always look at both sides of an issue.  Make an argument for it and against it.  Almost all tools/methods/systems have strengths and weaknesses.  You need to know this!  I was surprised to see how many exercises, methods, experts Dr. McGill began with I love (Insert method/technique here) it’s great at (insert desirable outcome here), but we’ve also shown that (insert negative impact or side effect).  My translation:  Use all of these great tools, just understand when to use them and when to apply other strategies.
  • Smiling is wonderful, but you can’t lift hard, train hard, or be powerful while you do it.   Concentrate and maintain complete focus until you’ve nailed some quality reps.  Smile after you reach your goal.  
  • Train the nervous system.  The evidence is overwhelming, this is what makes the best athletes.
  • Know the physical demands of the person you’re working with.  Assess their current capacities and then design a program to fill this gap.  For athletes review tape of their competition and break down the movements.  From a fundamental standpoint, what movements are you seeing?  How often? How many times? What duration?  In what combinations?  Write it down and be specific.  Train these fundamental movements.
  • Dissociate.  Proximal stability gives distal mobility and power.  If you can’t separate ball and socket movement from spine movement, stop, peel back and try again.  This is an essential skill.  (Side note great, descriptions in Osar’s book. Osar’s Movement lecture here.)
  • While movement quality  is essential, the fact that speed and load change these unpredictably cannot be ignored.  McGill’s research demonstrated that individual’s patterns changed, in both directions (from ideal to compensated and from compensated to ideal), under load.  Make sure your assessment includes something that matches your patient/athlete’s demands.  Also realize that even though someone passes an initial screen this does not mean the get the ‘green light’ to do anything.  They may have a green light to train, but you need to constantly monitor and assess for quality movement.  Patterns change with speed and load.  (This leads us into the next point.)
  • Assess, assess, assess. Constant assessment and reassessment is performed to titrate the exercise to work at the edge of the patient’s abilities.  It is also necessary to evaluate progress or impact of the intervention.  Assess, reassess, repeat if desired.  (Feel like I’ve seen this pattern somewhere before.)
  • Small things make a huge difference.  As with so many things the difference of good and great, or great and world class are little things.  Don’t overlook the little things that can take your patient to the next level.
  • You need to respect someone’s congenital limitations.  Hip shape is not uniform.  Squat depth and peak abilities will be affected.  Also simple exercise like tolerance for the elliptical trainer, can be dependent on having enough hip motion to spare the spine.  Assess the movement of the ball and sockets. Scour (perhaps daily according to Dr. Cubos).
  • Exercise selection is a risk vs. reward decision.  Stated this way I doubt many will disagree, but when presented more scientifically such as EMG activation vs. joint load, my guess is many will choose to remain in their comfort zone and stick with the exercises ‘that have worked before’.  While EMG studies have their limitations, remember risk vs. reward and that any training capacity you can spare, can be used later.  In those who are injured or at risk, choose exercises judiciously.

Other McGill resources:
Cubos notes from similar course. 

McGill resources from Liebenson

Backfitpro resources

McGill Movement Lecture

Prior post with links to McGill NY times video and article.  Hate sit ups?

 

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Lateral Stabilizers and Transverse Plane Exercise

01/27/2012 by
Quadratus Lumborum

Can you see the stabilizing, connecting architecture.

We know that no muscle works in isolation and the brain thinks in terms of movement, not muscles.  So I think the title of these videos (and articles) may be misleading for those who are not familiar with the paradigm and principles that support it.  Despite calling it QL training, you will notice very quickly that Dr. Liebenson & Chad Waterbury are training patterns and functional whole body exercises, not working to isolate an individual muscle.  Keep in mind our common movement patterns as you review this and realize how neglected that lateral direction or transverse plane can be.  So far today I’ve spent 95+% of my time moving forward on level surfaces.  My activation of the lateral stabilizers has been minimal.  Our modern society and common training exercises necessitate evaluation of this plane and likely incorporation of these exercises into most routines.

A great introduction, now see how it’s done.

Some addition reading: on Dr. Liebenson’s blog  & Chad Waterbury’s blog.
Also a previous post by Dr. Cubos on Gluteus Medius activation which includes the role of the QL.

We must assess all planes and all movements.  Treatment is the applied to the worst, pain-free pattern (treat the abnormal motor control that improves the mechanical sensitivity).

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How do you lift your weights???

11/10/2011 by

While attending a seminar hosted at Peak Performance in NYC, I was impressed by the high level of training offered by Joe Dowdell and his staff.  [visit Peak Performance on facebook] Even as Joe and his staff joined us in the Functional Assessment seminar, workouts continued in the gym with excellent instruction.  The hallmark of quality training is making an exercise ‘challenging’ while maintaining good form, simply making an exercise ‘hard’ (adding weight, doing it faster, performing more reps or sets) is easy to do, but doesn’t produce quality results.  The ‘hard’ way is the hallmark of lesser trainers.  I was impressed by high caliber and ‘challenging’ exercises I saw while at Peak, and I think the contrast with what I saw next is what made it so apparent.

After watching an exceptional set of plank rolls, the athlete stood up, his trainer went to prepare the next exercise, and I watched the athlete bend into complete lumbar flexion with no hip hinge to pick up his water bottle.  Great form and core control in exercise should translate to the same in everyday activities, it clearly did not here.

I saw a similar episode after watching some well done box jumps.  The exercise was performed with quickness, balance, control of a neutral spine, and stability at the hip evident by no medial collapse at the knee or trendelenburg’s sign at the hip.  Upon completing the set, the trainer began to put the box away and the athlete bent over to retie her shoes.  Something like this:

Note extreme lumbar flexion, failure to hinge at the hip. This is not a spine sparing or load sharing strategy.

I was surprised both times this happened. It was clear to me that the athlete understood proper form from the way they performed the exercise. It was clear the trainer understood quality ‘challenging’ exercise from the standard they set for the athlete.  However, there was no translation into activities of daily living.

After thinking about this, I realized that this happens in my office as well.  I spend time training patients in the hip-hinge, proper lunge mechanics, and other spine-sparing strategies so they can continue functioning without aggravating their condition.  In addition to teaching this I explain disc loading (see chart below) and try to follow the teachings of manual medicine pioneer Karl Lewit, MD, “The first treatment is to teach the patient to avoid what harms them.”  However, on occasion that same patient at the end of their visit reaches down to put on their shoes, pick up there purse, or collect their wallet and cell phone and performs the exact movement we just trained with improper form.  I take the opportunity to remind them, they often have a surprised expression, and together we work to repeat the activity with a more spine sparing strategy.

Are you loading your back unnecessarily?

The challenge for the clinicians and the trainers out there… first recognizing improper movement strategies and training good form; second getting good form incorporated into activities of daily living, work duties, and recreational activities through functional training and repetition.  We need our patients and athletes to understand this connection and then we need to work on repetition to myelinate these quality pathways. That which we wish to do with ease, we must first do with frequency.

  1. Teach correct movement patterns. (choose spine sparing, painless, dysfunctional patterns to correct)
  2. Repeat and groove these patterns.
  3. Make movement patterns more complex and add functional challenges.
  4. Add stability.
  5. Build endurance.
  6. Add speed, power, or stability training.

The common thread here is that it is not what we can do it’s what we actually do that determines injury risk.  Much like Professor Stuart McGill’s critique of FMS or similar screens. A simple but brilliant comment. A great analogy is diet and nutrition.  If someone can demonstrate that they can make a healthy, balance, nutritious meal, but they instead choose to eat fried fast food, what is their health risk?

To be truly effective, an athlete or patient’s ability to perform quality movement in the office and/or gym must translate into proper movements during daily activity.

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Hate sit ups??? Perfect, stop doing them….

07/23/2011 by

We’ve been doing sit-ups for decades to strengthen the abs and protect the back. While there is truth to the fact that core strength (and endurance) is protective for the low back, the best way to train this is still debated (or at least not widely adopted).  It is not uncommon to see people in many gyms or even elite athletes doing sit ups and leg lifts.  But commonality does not mean it is correct.  Professor Stuart McGill of the University of Waterloo has taken the effort to quantify the load placed on the lumbar spine and disc during many of these common exercises.  It has become very clear that sit-ups, crunches, leg lifts, and many other common ‘abdominal/core’ exercises have unsafe back loads and are likely more harmful and injurious than they are protective.  We need to move beyond the idea of training the abdominals to simply look good at the beach or pool and start doing better core training.

This is discussed in a NY Times article on Core Myths.  Please read the short article.

The obvious question then becomes what exercises should I be doing, if sit ups and crunches aren’t ideal.  McGill has popularized his Big 3 and has research to support their effectiveness in activating the core as well as showing lower spinal loads during the activity.  The Big 3 include:

  1. Side Bridge
  2. Bird Dog
  3. Curl Up

As with all exercise proper form is essential.  Without proper form the exercise is not as effective and more likely harmful.  If you have questions consult a competent health care or exercise professional.  [Looking for one?  Try searching the ISCRS website]  To view these exercises, and another challenging core stability exercise called ‘Stir the Pot’ view this 3 minute video. McGill- Core Values.

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