The little muscle that could, or why the serratus anterior is important for stabilization

I have come to the realization that I don't like the way anatomy is traditionally taught.  During my undergrad, we went to the medical school at UC Davis, looked at prosections, and learned the muscles of each section- their actions, their origins, and their insertions.  We never looked at how the body as a whole functioned to move, or approached anatomy the way I like to think of it now- these chains of muscles provide postural stability, these chains of muscles provide the strength necessary for movement, and here is how they interact (more anatomy trains-esque, although I am finding that understanding how to walk well is key to athletic performance.  If you aren't walking efficiently, you aren't going to move efficiently during basketball, yoga, Crossfit, or whatever athletic endeavor you pursue).  Prior to starting my graduate studies, I spent a weekend studying yoga with Kino MacGregor.  She talked about "filling in the space between the shoulder blades" and activating the "serratus anterior." I was intrigued, both because it changed the way my plank felt and because it was a muscle I had heard of, but never given much thought to.

Fast forward four years: I have learned the serratus anterior is both critical for walking well, important for shoulder girdle stability, and begins the chain of muscles that stabilizes the core.  The serratus anterior has attachment points on the front side wall of ribs 1-8 and the front surface of the scapula (http://www.anatomyexpert.com/structure_detail/5505/151/).  It shares attachment points with the diaphragm, which has attachments at the xiphoid process, ribs, and lumbar spine.  The diaphragm crura blends with the crura from the transverse abdominis; the diaphragm fascia also intertwines with the fascia from the psoas (Hatley, 2006).  The serratus anterior (SA) protracts the shoulder blades and stabilizes the shoulder girdle and, like the transverse abdominimis, fires before you move to provide stability.  The diaphragm is a muscle of inspiration and aids in postural stabilization.  Its ability to properly dome up is based on the position of the rib cage (Hruska, 2005). This ultimately affects the ability of other muscles of the core to properly function, specifically the internal obliques and transverse abdominus. The transversus abdominus (TrA) is essentially the SA of the lumbar spine.  It creates intraabdominal pressure and provides stability before movement, acting on a feed forward loop.  The psoas flexes the hip and provides lumbar stability. Anteriorly and from a stability perspective, this links the shoulder to the hip in four steps.  The interesting thing about all of these muscles is their ability to properly stabilize is position dependent.  If you have scapula that are retracted in a resting position, your SA isn't in a good position.  This is going to limit the ability of both the diaphragm and the TrA to properly function.  If the scapulae are retracted, chances are high that during rest, the rib cage is in an inspiratory position, which will affect pelvis position.  The ability of the deep stabilizers to work together is necessary for efficient movement mechanics, so while this started as a discussion of the oft forgotten serratus anterior, it's really a discussion of one piece of the deep stabilizing system.

Diaphragm Image

So how do we make sure it is working and why do we care?  We care because if it's not stabilizing the shoulder girdle, something else has to, and usually that something else is the latissimus dorsi, rhomboids, and upper fibers of the trapezius.  These muscles affect resting position of the scapulae, which is problematic if you raise your arms overhead for any reason.  They also affect resting position of the pelvis, with an overactive latissimus tilting the pelvis anteriorly. This can also lead to a "pain in the neck," quite literally.  Breathing should not take place with the shoulders elevating each inhale; when this happens, the upper trapezius and scalenes are going to be working overtime, which can cause overuse.  This also means the diaphragm isn't working properly, which means the lumbar spine isn't being properly stabilized, which means the pelvic girdle isn't in an optimal position.  In order to improve efficiency, the SA needs to be addressed.

The next question is how?  First, we have to inhibit the overactive muscles and improve position, so the SA in a better position to do its job.  If the scapulae are pulling away from the back, the scapulae retractors are working in over time.  To stretch them, we are going to protract the scapulae and bring the rib cage back to meet the shoulder blades. Protraction also fires the SA, so we are killing two birds with one stone.  Once the thoracic spine is less locked up and the scapulae are resting on the back, we can work on position.  The medial borders of the scapula should be parallel to the spine at the level of T2-T7 and flush against the thorax (Osar, 2012).  I use a tactile cue, which is demonstrated in the video below, but the key is to get the sense that the upper back is broad and the scapulae are gently being pulled down and around the back. This will inhibit the upper trapezius and activate both SA and the lower fibers of the trapezius, which relaxes the overactive muscles in the neck in people that are neck breathers.  This needs to be done in order; skipping directly to lower trapezius/SA stability won't fix faulty shoulder position.  The goal of all movement direction and cueing should be efficiency- how can we get the body to move well with the least amount of effort?  This doesn't mean there won't be work; it simply means the body will work more cohesively, and ultimately perform better.

A quick side note- I find it is helpful to remember the shoulder girdle functions like the hip girdle.  If we can relate the function of the muscles in the shoulder girdle to those in the hips, it sometimes makes things a little less foreign.  I will be discussing this in an upcoming post.

Yours in health and wellness,
Jenn

Video link: http://youtu.be/KEqv3V9-htc

Hatley, S., (2006).  Anatomy and Asana: Preventing Yoga Injuries.  Eastland Press: Seattle
Hruska, R., (2005).  ZOA position & mechanical function. Postural Restoration Institute, viii-xi (http://www.posturalrestoration.com/resources/dyn/files/1051512z69443dbe/_fn/ZOA.pdf)
Osar, E., (2012).  Corrective Exercise Solutions to Common Hip and Shoulder Dysfunction.  On Target Publications: Aptos.

Four examples of how I use PRI and DNS during training sessions, plus a plank variation...

I often get asked by other fitness professionals that are studying neuromuscular techniques or are thinking about studying neuromuscular techniques if I use it.  "Yes," I always reply, "all of the time." The inevitable follow up question is how?  How is it implemented into sessions that are supposed to be strength and mobility based?  How do you find the time to test/re-test and actually use some of the correctives when really, our job as trainers is to get people strong? Below are four examples of clients that I use the techniques with often.  The principles of DNS/PRI are utilized in every session I perform; the depth to which I use it depends on both the client's goals and how the client wants to use the session.  I should caveat this with a little about my clientele.  I do not have individuals walk into my studio that have absolutely nothing wrong.  This just doesn't happen.  Even if the person says he has no musculoskeletal issues, after 30 minutes it isn't unusual for there to be references to car accidents, shoulder surgeries, migraines, and my favorite, open heart surgery (while not a musculoskeletal injury, it still seems something worth mentioning to your trainer at the initial intake, but apparently not everyone shares that sentiment).  And, despite what some might think, I do train people under the age of 60.  They have things going on as well (degenerative disc disease at 40?  I am totally your girl).  The take home message is many of my clients have tried traditional exercise programs and have either been injured or had the feeling they were going to get injured if they continued on that path.  And so they end up in my studio, looking to me for guidance, for a safe program that will make them strong and able to do the things they enjoy in the real world.

Kate* is a 70 year old former professional dancer.  She has had chronic neck pain for the last year (diagnosed OA), suffered from a bout of spondololythesis about 16 months ago, and wants to gain functional fitness. She walks regularly and has participated in a variety of fitness programs over the years (her dance career ended in her late 20s).  She is also missing something structural in each foot (fairly certain it is a bone, but not 100 percent).  As a result, she has never been stable standing on one foot.  The very first session, I used DNS techniques to activate her SA (supine and prone 3 month model).  I also taught her how to bring her ribs to her shoulder blades, drop her ribs down, and activate her IOs and TA using PRI breathing techniques.  I did run her through some of the PRI tests, and she has instability issues in her hips.  After we worked on those things, I taught her how to stabilize standing, using her "center." She was able to stand on one foot for the first time in decades without pain or unsteadiness.  We have since progressed to dynamic balance using stepping sequences.  We discussed breathing and I showed her a handful of breathing techniques to help shut off her neck.  I have learned the hard way not to load an overactive upper trapezius.  Bad things happen.  Fast forward 6 weeks.  She walked in for her weekly appointment and said to me, "before we start, I have to understand what we are doing."  "What do you mean?" I asked.  "For the first time in a year, my neck pain has subsided.  You haven't touched my neck.  What are you doing?" This is the power of beginning to understand reciprocal inhibition and facilitation, coupled with the client having the awareness to notice breathing patterns.  She has also told me repeatedly how excited she is to stand on one leg.  It's empowering to be able to do something that has alluded you for most of your life.  We are slowly progressing to a more strength based routine with an emphasis on proper alignment and breathing.

Pete* is a 58 year old executive.  He has been active his entire life and has a bit of a type A personality.  He had low back surgery 16 months ago (disc repair), and, unfortunately, a negative physical therapy experience.  He began seeing me 12 months ago to regain fitness and get back to the activities he enjoys.  We started with working on DNS principles of getting the rib cage more neutral and engaging the SA.  We also worked on the external rotators of the hips and on the integration of the foot and hip using DNS techniques.  We got a bit stuck (he was plateauing, and I wasn't really sure where to go), so a PRI physical therapist assessed him and gave me some ideas.  We had one more set back, involving a very bad adductor drop test that I didn't address at the end of the session and a back spasm the next day (pretty sure it was related to moving furniture, but I didn't tend to my details when I should have, so I placed much of the blame on myself), and are now working towards neutrality by testing at the beginning of the session, repositioning, emphasizing breathing during the core work between the circuits, and re-testing at the end.  He also has breathing homework that he might be doing sometimes (I am not really sure how often, but I know that he is at least more aware of his breathing and knows how to get his ribs down).  He began playing golf 4-6 months after we started working together, walks regularly, and says he is the most fit he has ever been.  He made an interesting comment recently.  He has been working out with trainers off and on for the last 30 years, and he said he noticed that while he got older and his needs changed, the techniques the trainers used stayed the same.  I am the first trainer he has had that approaches things differently.  While I think more and more trainers that are serious about training as a profession are starting to use different techniques, I thought it was a fascinating glimpse into an industry that is slow to adopt new ideas. I am hopeful that in the next 4 months I will be able to help Pete move even more efficiently and enable him to continue doing the things he enjoys.**

Jess* is a 33 year old professional.  She is extremely active and movement keeps her sane.  I have worked her off and on for about 5 years.  We have always done more traditional strength training sessions, using primarily body weight, suspension trainers, and some weights.  She e-mailed me 4 months ago before one of our sessions to ask if we could just spend the hour stretching.  She was experiencing a lot of pain in her mid back, her hips were killing her, and she was sure she was going to have to give up running, which was making her sad.  When she arrived the next morning, I told her I was happy to spend the hour stretching if she thought that's what she needed, but I suggested we try some other, out of the box, things first.  She said that would be okay, so I ran her through some of the PRI tests (which made it pretty apparent why her mid back was bothering her), and we spent the next hour working thoracic mobility with breathing, engaging her IOs and TA, and helping her shut off some the things that were in a state of overactivity.  I told her to not make any declarations regarding running yet; rather, see if she felt better after our session, and see how things went.  She e-mailed to say she felt much better, and over the next 4 months we worked on activation with breath and have recently begun working on balancing out her frontal plane.  She is feeling much better, her mid back pain is gone, her hips only bother her when she does too much and throws herself back into an extension pattern, and she is running pain free (not everyday, but every other day).  We are back to devoting most of our session to strength and mobility work, but spend time in the warm-up on activation/inhibition techniques, and I make sure position is encouraged throughout our workout.

Jenn is a 33 year old personal trainer.  She loves all things movement, and has been active for as long as she can remember.  She runs and bikes (often), swims (a little), practices yoga, and spends some time in the weight room working primarily on body weight drills with a little bit of kettlebell work thrown in.  She pulled her hamstring in the gym 5 years ago and while the pain went away, she never really addressed the root of the problem.  She re-injured it a year ago during a daily yoga regimen that wasn't really that mindful and coincided with running a trail 1/2 marathon.  She began implementing some of the DNS positioning techniques and also began using a regular DNS flow as part of her daily warm-up.  It began to heal, and she noticed things were feeling a little bit better, but than she got a bit stuck.  She began learning PRI and it became obvious that she needed to address some major extension issues if she wanted to continue playing hard.  She began doing PRI every day with DNS as part of her warm-up (about 10 minutes) and implemented some of the PRI exercises during her 3 days/week gym routine.  She utilized the philosophies of both DNS and PRI in her yoga practice, and noticed a change in how she moved and how she felt.  One day, while running herself through some self PRI tests, she discovered she was actually in a state of neutrality.  This made her want to jump for joy, but instead she used it as an opportunity to progress to learning some of the PRI standing exercises.  Her low back no longer feels any sense of compression in back bends, her shoulder blades don't feel a sense of "tightness," and her hamstring feels wonderful.  She strongly believes DNS and PRI together are powerful tools.

Below is a link to a plank sequence I use when I want to activate IOs and TA.  It emphasizes breath to activate the abdominals and focuses on the ribs being in a state of exhalation.
https://www.youtube.com/watch?v=BMqbT_Q2B9k

*All names have been changed except for the last one.  Jenn, as you probably guessed, is me.
**Two days after I published this blog, I received a phone call from Pete's doctor.  He was impressed by Pete's mobility, strength, and overall fitness, and was wondering if he could refer people to me.  He has been looking for a fitness professional that "gets it" and is able to work with more difficult conditions for some time.  I am grateful I found methodologies that make sense to me and have such a profound affect on people's wellbeing.

Yours in health and wellness,
Jenn

Lakshmi, PRI re-positioning, and the brilliance of DNS positions

I was at a yoga workshop last weekend where the teacher discussed some of the Hindu goddesses.  One of the goddesses, Lakshmi, is the goddess of wealth, both internal and external.  As the teacher explained Lakshmi's influence over fortune, she said that part of Lakshmi's power is that she tends to the details.  Tending to the details allows wealth to grow and will result in good fortune, not necessarily in the form of money, but in an internal sense.  It was one of those stories that stayed with me for the week and made me wish I had more patience for the Indian texts (I failed miserably at my one and only attempt at reading the Bhagahavad Gita.  I lasted half a page).

Fast forward 5 days.  I was training a lovely endurance athlete yesterday who has gone from pretty much bullet proof to having some things crop up.  This, unfortunately, happens to endurance athletes, and if they don't get a handle on the root of the problem, they end up spending the next 10 years of their careers "chasing pain" so they can participate in their respective sport.  I have worked with her off and on for a long time (4 years), and I decided yesterday to run her through some of the PRI tests to see what was going on and to give her a more directed, therapeutic program for the off season.  There was only one glaring issue (left AIC), so off to work we went.  After 10 minutes of re-positioning work, I re-tested her, tending to my details, found she was in a much better position, and we moved on with our session.  While we worked on the normal strength training stuff for her upper body, I used several DNS positions for her lower body to try and improve some of her firing patterns.  Her main issue seems to stem from an old ankle injury and her right glute max is taking a pretty intense vacation.  I started her in DNS side lying, couldn't really get any activity there, moved to 3 month supine mode, where I had much better success, and then skipped forward to tripod sit, which is far more developmentally advanced.  She is a crazy endurance athlete after all; I figured I should be able to get some activity going and add some challenge.

While I was moving her through the DNS positions, it occurred to me how brilliant the system really is.  The goal of PRI is reciprocal, alternating movement; DNS addresses movement dysfunction via developmental positions.  The goal of the baby ultimately is walking which is reciprocal, alternating movement.  The higher developmental positions do a wonderful job with pelvic orientation and  addressing strength and mobility needs specific to various stages in the gait cycle.  In many ways, it makes the job of the movement professional easier- make people walk well.  Only then are they going to be able to perform well athletically.  Tend to your details.

At the end of the session, I put her back on the table to re-test her position.  I do this with people when I begin working on improving position.  I want to make sure I am on the right track.  Her left leg didn't drop.  At all.  I had undone her position.  This has never happened to me before- my sessions always address the needs of the individual and I pay attention when there are significant imbalances.  But I had skipped steps.  When she couldn't activate in side lying, I moved her backwards, only to jump forward again.  The neurology wasn't ready for that.  I didn't tend to my details and instead of taking the proper steps, I tried to skip ahead.  I promptly re-positioned her using PRI techniques, re-tested, and she was back to the position I had attained at the beginning of the session.  The take away message: don't rush the process.  Systems exist for a reason and you cannot cheat the system when it is based on neurology.  And don't forget to tend to your details.

Yours in health and wellness,
Jenn

Some quick thoughts on high intensity exercise, breathing, and a potential philosophy shift

Let me start by saying I love hard exercise.  I always have- there is nothing quite like a hard workout, where all of your muscles are fatigued, you feel physically tired, and like you can conquer the world because nothing is quite as challenging as the 40 minutes you just spent killing yourself in the gym.  Whether it's circuit training, spinning, intervals of some sort, or HIIT, there are many different ways to effectively accomplish this, and I think it has a place.  However, what I have come to realize in the last two years is that if we can't shut our sympathetic nervous system off and bring it to a place of calm, we are inevitably setting ourselves up for injury.

We live in a high stress world.  We are always on the go, we multi-task, our brains are constantly being exposed to stimulation.  We don't get outside enough to enjoy our natural surroundings, we don't play enough, and we rarely relax and breathe.  In fact, our breathing often feeds into this inability to calm down.  We breathe into our chests, following a more "fight or flight" type of pattern, with our ribs up and our mouths open.  I ask clients to take a deep breath and I see their chests rise high towards the sky and their bellies not move, or sometimes cave in.  These same clients have upper trap tightness, "tight hips," and low back pain.  There is a general sense of fatigue that follows them, although they aren't sure why.  For these clients, I am going to argue that stimulating their sympathetic nervous more by having them perform high intensity exercise would be a mistake.  It would feed into this pattern of hyperactivity and chronic tightness.  These clients have to learn how to shut their superficial muscles off, find a state of calm, and learn how to breathe.  This is going to benefit them far more than further activating their sympathetic nervous system.  Once they learn how to come down, how to breathe, how to activate their deep stabilizers to keep them upright rather than hold on for dear life with their prime movers, then they can benefit from higher intensity exercise.  However, it is critical to make sure they have returned to a state of calm, with ribs that aren't flared, a sternum that's not lifted, and a breathing pattern that's not feeding into a hyperactive state, both mentally and physically before they walk out the door.  I strongly believe that people should be able to alternate from a state of hard physical work and physical ease seamlessly, with little fanfare.  If you watch the good movers move, you will notice this is what they do.  Watch Ido Portal or Erwan LeCorre, or Kino MacGregor, and you will see an easiness to their movements.  Continue to watch them move and you will see their breath is even, their mediastinum is open, their diaphragm is fully functional.  This is what we should want in our own movement practices and for our clients.  On occasion someone who has been doing lots of high intensity work shows up in my studio.  It could be someone practicing for TacFit, someone participating in Crossfit, or someone who loves HIIT classes at the gym.  All of the individuals want to get back to their respective activity and the one thing they have all had in common is faulty breathing patterns.  I encourage all of these individuals to practice breathing before and after their workouts in an effort to get them out of this pattern that is doing them harm.  I am not suggesting that learning how to breathe will prevent injuries; however, I believe it is a good place to start.

Yours in health and wellness,
Jenn

5 things I have learned studying neurologically based training methods (specifically, DNS and PRI)

Over the last 18 months I have become mildly obsessed with neurologically based training.  My accountant (who is also a client), claims it's because I am bored now that graduate school is finished and I need something to study.  This is partially true- there is something inherently rewarding about studying and implementing concepts that are somewhat challenging to grasp.  I am forced to think, try, and apply until I figure out how (and if) it works.  On a more basic level, neurologically based training simply makes sense to me.  It answers questions about things I have always noticed, but never really understood.  It examines patterns, and it supplies ways to correct patterns that might be inefficient.  It speaks to my yoga background, where I have trained with amazing individuals that have taught me effective techniques, but never fully explained "why" the techniques work.  However, this type of training isn't for everybody, and it definitely isn't the easiest way to approach human movement.  Outlined below are 5 lessons I have taken away during the last year and a half, and I am sure there are many more to come.

1. Breathing is important.  Not just important, paramount to good movement patterns, decreased pain, good shoulder mobility, and good hip function.  If breathing is dysfunctional and isn't corrected, it can be very difficult (if not impossible) to get good quality movement.  I have sat through almost 40 hours of lecture on this topic, and am just beginning to sort of grasp it.
2. Reciprocal inhibition is critical to good movement patterns.  Physical therapist and PRI instructor James Anderson says something along the lines of, "anyone can turn a muscle on.  An expert knows how to turn muscles off."  (This comes from the moykinematics home study course).  Certain things we see over and over again as fitness professionals- tight upper traps, overactive IT band, quad dominance, overactive lats...  The list goes on.  Over the years I have learned to train around things so that I don't flare something up.  A better solution is to turn things off so they aren't active, freeing up the proper stabilizers to do their job.
3. There are many different ways to skin a cat (I think that's the saying.  I have always wondered where that phrase comes from- aren't cats pets?  And who wants to skin one?  But that's a different blog post).  Some people respond well to simply moving more.  Yoga works really well for some, probably because it activates several muscle chains, there is an element of focusing what you are doing and telling your body how to move (neuro training).  Pilates works well for others.  Primal movement, CST, NKT, z-health...  There are several acronyms that are effective at training the neuromuscular system.  DNS and PRI resonated with me.  This doesn't make them the end all, be all.  My clients are making very positive gains and many of my clients are suddenly practicing breathing when they aren't with me, moving better, and feeling better.  This is important to me.  As a result, I will continue to learn these two methodologies, but that doesn't mean I will discount other techniques or be unwilling to listen to experts discuss them.
4. Just because you go to a workshop, you are not an expert in the topic.  These methodologies take time to learn.  And practice.  And a willingness to ask for help.  If you aren't willing to do these things, I recommend learning something else.  I not only do PRI and DNS regularly (it is not unusual to walk by my studio and see me with 2 or 3 manuals out, trying different things, figuring out how it all fits together), I attend workshops, ask questions of more advanced practitioners, and re-read informational material.  I am willing to sit through lectures multiple times in an effort to understand the material better, and am constantly practicing on my clients.  Again, this is hard, and more intensive than other training techniques I have studied.
5. Test/Re-test is invaluable.  I know other methodologies use this philosophy. Prior to PRI in particular, and DNS to a lesser extent, I hadn't fully understood how valuable it is to know whether or not you are on the right track.  Watching someone improve in a matter of minutes is not only exciting to the practitioner; it boosts the client's confidence as well.  I don't test every session, but when someone has something going on or I am working on something specific, it is a good way to test progress.

Learning is a process, and I am hopeful that as I continue to deepen my understanding of human movement, I will be able to have positive impacts on my clients lives and share my knowledge and experiences with others in the human movement field.

"The secret to mastery in any field is to forever be a student." Martin Palmer

Yours in health and wellness,
Jenn

The handstand chronicles

I posted recently on Facebook that I had held my first handstand in the middle of the room.  Clearly, I was excited, slightly overjoyed actually, that I finally accomplished this and felt the need to share.  In the week following, I was surprised how many people asked me about it.  Some people wanted to know “how" I had accomplished this while others wanted to share why they “couldn’t" perform a handstand.

I have been intrigued by handstands for decades.  I used to try them when I was an adolescent, inspired by the gymnasts at the olympics who could lift up with control and hold the position for minutes on end.  I never managed to stay up for longer than a nanosecond, and the ceremonious flop that always resulted never deterred me.  Over and over again I would try, until I became bored and moved on to whatever I deemed more interesting.  Eventually, my interests grew away from handstands, as I moved into running and lifting weights, focusing on more of an external strength rather than an internal one.

When I took up yoga in 2004, my fascination with handstands returned.  I would watch with amazement as women in their 30s, 40s, and 50s would lift up in a controlled manner and hover with their feet in the air.  I was fixated, and after building a consistent practice, I found myself throwing them in on occasion against the wall.  There, I could work on refining the position, feet pressing up while supported, shoulder girdle finding the proper engagement.  

And so this went for years.  About a year ago, Kino MacGregor wrote a blog called “Let her fall," where she discussed her journey with Pincha Mayurasana.  When she began working on that posture, she was weak and fearful.  She realized that to build both the strength needed to conquer the pose and to overcome her fear of falling, she needed to get away from the wall and fall.  For some reason, this resonated with me.  Once a person knows how to fall and has the flexibility to go into a backbend, it’s really not a big deal to fall over.  I had both of these things, and after figuring out how to do pincha mayurasana in the middle of the room, I moved on to handstand.

And fall I did, though not as spectacularly as I expected.  There was frustration, as I figured out how much energy was needed to lift my legs up (I was used to purposely overshooting a little bit because the wall would catch me).  There were the times I ended up in backbend, only to quickly lower myself down and try again.  And then, just like I had always hoped to do, I found myself in it, not shaking, not unstable in any way, just holding.  After five breaths (I didn’t want to press my luck), I slowly lowered down, only to realize my relationship with handstand is a lot like my relationship to life.  Whenever there is a risk of failure, I explore my options at the wall first.  Once I have gained the confidence that I know how to fall and not get hurt, I move to the middle of the room.  Failure is really only a glorified backbend.  As long as I can get back up and try again, it will all be okay.

Hamstring strain, running, and prevention options

Hamstring injuries can be a real pain in the butt (literally).  Hamstring strain is a common injury in all sports that involve running, and in distance runners can be the cause of deep gluteal pain (White, 2011).  This is the one running related injury that shows up in my life occasionally, and I can attest to how irritating it is.  Perhaps more frustrating is the conflicting research showing how to "deal" with it.  Interestingly, the cause of the injury is often forceful eccentric contraction, which occurs during the swing phase of running gait, when the hip is flexed and the knee extended.  If the pelvis is in an anterior tilt, the hamstring is a lengthened position (see image below).  As Panayi (2010) points out, both anterior pelvic tilt and/or pelvic asymmetry puts increased demand on the biceps femoris origin and increases functional demand of the hamstring group because the synergist muscles (glute max) are inhibited.  I have had a number of clients suffer from hamstring strains, all have been female, and all have been prone to excessive anterior pelvic tilt.  The literature shows the best way to treat hamstring strain is using an eccentric approach to improve flexibility and strengthen the musculotendinous junction (White, 2010).  The rationale for this is that eccentric strength training might allow active tension to return to normal by restoring the musculotendon length (Heiderscheit, Sherry, Silder, Chumanov, & Thelen, 2010).  However, by ignoring the lumbo-pelvo-hip complex, the issue of why the hamstring was injured in the first place is being ignored.  Heiderschei et.al, cite a study by Sherry and Best that found a progressive agility and trunk stabilization program emphasizing neuromuscular control was more effective than a progressive stretching and strengthening program at reducing hamstring reinjury risk- after 1 year, 70% of the S&S group had been reinjured, while only 8% of the neuromuscular group had experienced reinjury.  This is more closely related to my experience; eccentrically training my hamstrings when they have been injured doesn't feel good.  I have always felt I needed a different approach to training my hamstrings, I just wasn't sure what it was.

Enter Eric Cressey's blog on hamstring strains and me learning some PRI techniques.  I have already written about how DNS had a positive impact on changing my thoracic position.  PRI takes it a step further and begins to address pelvic position, thoracic position, and thoracic and pelvic asymmetry.  Some of the lower body PRI exercises are specifically designed to integrate hamstring and glute function using a slight posterior pelvic tilt and proper thoracic positioning.  I was learning these when I read Eric's blog here: http://www.ericcressey.com/5-reasons-tight-hamstrings-strain.  Even though he works with baseball players and probably doesn't spend a lot of time assessing runners, I finally felt like someone was giving me permission to avoid end-range movements while trying to improve my hamstring strength and stability.  Up until this point, I was getting ART once every three or four months, which makes my hamstring feel fantastic, but (as is the case with most manual therapy work), wasn't "fixing" the problem.  I was fully aware that my movement patterns were causing the hamstring to flare up again (although to a lesser extent and in a different spot, oddly enough).  It's only been a month, but I can honestly say the hamstring feels like it's healing.  It doesn't bother me after riding (which seemed to be the biggest culprit, although I am sure running wasn't helping), and yoga no longer seems to aggravate it.  I am doing a lot of spinal mobility/breathing/PRI/DNS type work, and throwing in the occasional backwards stair walk.  The strengthening movements I am doing in the gym, such as deadlifts, are performed after some glute/hamstring integration work and no longer feel like they might be doing more harm than good.  The crazy thing is, training the hamstring in a shortened position with a posterior pelvic tilt feels really good- more how you expect something to feel when it is rehabbing an injured area.  I am all for a little mobility, but as Eric states in his blog, you have to assess the individual.  Not every rehab protocol will work for every person.  And sometimes, the research focuses a little too much on the site of pain rather than the source of pain.

Yours in health and wellness,
Jenn



White, K.E., (2011).  High hamstring tendinopathy in 3 female long distance runners.  Journal of Chiropractic Medicine, 10(2), pp. 93-99.
Panayi, S., (2010).  The need for lumbar-pelvic assessment in the resolution of chronic hamstring strain.  Journal of Bodywork and Movement Therapy, 14(3), pp. 294-298.
Heiderscheit, B.C., Sherry, M.A., Silder, A., Chumanov, E.S., Thelen, D.G., (2010).  Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention.

The real reason I can't squat, compliments of the PRI postural respiration workshop

My bodyweight squat leaves something to be desired.  I can squat all of the way down, heels remaining on the floor, and look pretty good once I am down there.  My knees stay straight ahead, my feet stay in good contact with the floor and don't rotate, and my pelvis remains level.  So, where is the problem, you ask?  My torso.  It folds neatly forward, with good alignment in the spine, rather than remaining upright and vertical with my tibia (proper squat form).  It kills me when I do videos of myself squatting because it is the one area I can't seem to improve.  I have elevated my heels on little risers to see if it's an ankle mobility restriction (it's not).  I have worked on my deep intrinsic core muscles, ala NASM's CES protocol, because according to NASM, it's an intrinsic core issue.  I thought maybe my regular DNS work would improve pelvic positioning, thus improving my squat pattern.  All of this has been to no avail.  Still, when I would squat in front of a mirror, I would watch with dismay as my torso folded forward.  The slightly analytical (and perhaps overly compulsive) part of me wanted to be able to squat well.  It's the signature of a good movement pattern, always the first thing people look at when they begin to understand how you move.  I began to feel resigned to the fact that maybe I would never squat well and my movement pattern would forever be less than perfect.

Enter the Postural Restoration Institute Postural Respiration workshop.  I went because a) Eric Cressey mentioned PRI in his blog, b) it was local (this never happens in Monterey) and c) it sounded neurologically based, which seems to resonate with me.  Something that should be understood about these types of workshops is no matter how well you think you move, you are going to discover you have areas you need to work on.  Like most people in the industry who spend oodles of time analyzing others movement patterns and helping them move better, I apply that same overzealousness to my own training and (with the exception of the squat) think I move pretty well.

It turns out, of course, that I was mistaken.  There were all kinds of things wrong with me, most notably my lack of thoracic curve.  When you are a short, athletic female, you spend a lot of time "standing up tall."  Part of that "standing up tall" means pulling the shoulders back and, prior to my DNS training, retracting the scapula.  (I have gotten completely away from that, and have noticed a HUGE improvement in my clients' shoulder function.  I now cringe when I either attend a class that encourage scapular retraction or read a blog/watch a youtube video that encourages this motion).  While scapular retraction is no longer part of my movement pattern, thoracic flexion is something I have never given much thought to, or, more appropriately, my complete lack of thoracic flexion in just about any movement.  I have very good hip flexion (probably to spare my lumbar spine), and because of that bending forward has never been an issue.  However, (and I couldn't find anything online to support this theory), if you take away one of the curves of the spinal column, it only makes sense that the balance of the spine would be thrown off during activities such as hip flexion.  Instead of being able to keep my spine parallel to my tibia during squatting, my lack of thoracic flexion caused me to fold forward to balance the weight of my hips.  In fact, when I hold a medicine ball or kettlebell in front me, I can suddenly stay more upright (again, makes sense.  I am counterbalancing with my upper torso superficially).  Once I realized I lacked sagittal plane mobility in the thoracic spine, I started playing around with things to improve it.  I also tried maintaining a more neutral spine (read: a little bit of thoracic flexion) during my bodyweight squat and low and behold, I could actually squat past 45 degrees with a more upright torso!  Now, I still can't get down to 90, but this has been a huge improvement.  It also led me to think about something that was mentioned during the workshop.  James, the instructor, noted many of us are in an extension dominant pattern,  I thought he was nuts.  With all of the sitting and screen time, how can this be the case?  However, after my squat discovery, I reflected on all of the women I have worked with over the years who have a very similar squat pattern as mine.  They all have a flat thoracic region and, like me, are "stuck" in a more extension dominant pattern.  Restoring flexion in the thoracic spine makes a lot of sense and will further improve lumbar spine and pelvis stability and position.

Yours in health and wellness,
Jenn

MovNat level I- a certification review

Last weekend, I was fortunate enough to attend the MovNat level I certification course in Monrovia, CA.  Kellen Milad and Jeff Kuhland were our coaches and people came from all over the western US to participate in either the certification or the Power & Agility workshop.  While there have been reviews written about the workshop, my goal is to offer a trainer's perspective of the certification portion of the weekend.

I wasn't sure what to expect.  I registered for it because my husband and I did the 4 weeks of MovNat workouts on Breaking Muscle and he wanted to do the workshop, so I figured if I was going to go to the workshop, I might as well get certified (I am a fitness professional, after all).  I had watched the crazy video of Erwan LeCorre moving in this incredibly fluid fashion years ago, after I read the first Outside Magazine article discussing Erwan and his fitness philosophy and was intrigued, to say the least.  I followed the evolution of the company over the years, and this opportunity seemed like a good time to take my curiosity to the next step.

My fellow certification attendees came from extremely varied backgrounds.  One was a successful personal training studio owner with a background in training fitness models.  Another was an acupuncturist with a background in Crossfit and Chinese medicine.  There was a rock climber, a recent college graduate with a genuine interest in bringing outside movement to people in Boulder, and a former chef making a career change.  There were also two people going through the certification simply to help their family and friends.  I work primarily one on one with people and my clientele is generally baby boomers with injuries or endurance athletes, so it was interesting to be in an environment with other fitness professionals that weren't necessarily so corrective exercise based.  Kellen and Jeff did an extremely good job dealing with the varied level of coaching experience and provided a very safe environment for us to learn and help each other.

The workshop portion of the event was physically challenging.  Because MovNat covers so many elements of fitness (strength, power, agility, endurance), it is almost impossible to excel in all areas, although there were a couple of attendees that came close (note to self.  Climbing rocks and trail running seems to improve overall fitness.  The trail running I already do.  The climbing rocks I started this week).  I received the best jump coaching I have ever received and can finally land somewhat quietly, although the height I can jump leaves something to be desired.  Swinging from bars is fun.  So is learning how to climb trees, which has become a small area of fixation (performing a handstand in the middle of the room is a slightly larger area of fixation.  Both should be accomplished by the end of the summer).  The lifting and throwing techniques were taught well, and the different crawls and rolls were fun to execute- however, I felt maybe a little more attention could have been given to bad crawling technique.  Maybe it's just my clientele, but it is not unusual for me to put a new client in a quadraped position and see scapular winging and an increase in spinal lordosis, which would have to be addressed before adding locomotion.  The highlight of the workshop came on Sunday, when we created our own combos in small groups and played outside for 3 hours.  Both activities cultivated a team environment and allowed us to put the skills learned over the weekend to use.

The certification portion of the weekend meant we started an hour earlier and ended an hour later than the workshop participants.  During that time, we discussed coaching and programming, were assessed on our proficiency in the movements, took a written exam, and were asked to design a small group program for participants of varying levels.  I was grateful I had been practicing some of the movements since early January (things like tuck swings can tear apart your hands if you don't have blisters), and I didn't find any one aspect overly challenging.  I actually enjoyed the practical portions of the certification- I have a number of certifications and with the exception of ACSM over a decade ago, I have never been asked to actually teach a movement and prove I have any level of coaching competency.  Jeff and Kellen gave excellent feedback, and they did a nice job with the diversity of professionals in attendance.

While I don't know if I will go on and get my level II and III certification, I definitely enjoyed the experience and would recommend it to anyone looking to have a more diverse movement background.  One of the things I really like about philosophies such as MovNat is they are fun; you get to lift some things, throw some things, maybe dynamically balance and swing from things, in a much less regimented way than most training.  If you work with the general population, performing these types of movements well are more functional than most open chained activities.  Overall, a very positive experience.

Yours in health and wellness,

Jenn

Golf balls and the feet- a quick update

In August, I became fascinated with using golf balls to release the fascia in my feet.  I discussed it in my blog here.  I have been using a small ball on my foot every evening, and can officially say it has definitely improved the way my feet feel.  They aren't tender at all, the intrinsic muscles seem to engage more easily during movement, and, considering that I am on my feet for hours every day, they feel great.  More interestingly, however, is how this has affected my clients' movement patterns.

Before I get too far ahead of myself, it is worthwhile to note some of the discussions that are taking place in the movement/rehabilitation world, specifically in regard to trigger point therapy.  In a fascinating blog by Diane Jacobs, she theorizes trigger points are actually neural in nature, rather than a structural issue, either fascial or muscular.  As a result, trigger points provide temporary relief via the CNS, but it's short lived.  I can get behind all of this.  We aren't changing or lengthening the fascia when we perform SMR or trigger point work.  We are providing a short moment of neurological change.  During this window, I would argue it's possible to invoke potentially more permanent change if the trigger point is biomechanical in nature, not the result of an internal issue such as a cyst or tumor.  If, for instance, we do trigger point work on our foot, mobilize the ankle, and begin working on short foot and better movement patterns in the lower limb, I don't think the trigger point will repeatedly return, especially if we are diligent with our training.  This is the general theory behind the NASM CES course which, while it has its flaws, in my opinion has some merit.

Now, back to my clients.  I have a client I have been working with for years who has trouble with back spasms.  Her hamstrings and foot complex have always been incredibly tight, no matter what I tried (and I tried it all.  Hamstring SMR, activating the tibialis anterior to release the calves, PNF on the hamstrings, etc).  I began using the "golf ball trick," in addition to short foot activation, single leg stance  with short foot activation, and diaphragmatic breathing.  Supine leg flexion is close to 90 degrees and her foot is incredibly normal, not internally rotated and slightly plantar flexed like it has been.  You might argue this was related to the breathing, and I think that played a role, but she says the trigger points in her foot are almost completely gone.  She actually looks forward to our barefoot work,and sometimes requests it at the beginning of our sessions.  I have another client who had low back surgery 11 months ago for a disc repair.  He has had trouble with tightness in his calves and hamstrings since prior to the surgery.  Again, I utilized a variety of techniques to improve mobility and function, but it wasn't until we added the trigger point work to his feet that he noticed substantial improvement in hip flexion and mobility while walking and jogging.  Maybe these are outliers, or maybe other factors are at play, but I will continue to use the golf ball trick on clients with trigger points in their feet.  Even if relief is short term in nature, the more tools I have to help people move better, the more likely they are to move more.

Yours in health and wellness,
Jenn

Mastery, boredom, and how to accomplish proficiency

I am completely fascinated by the subjects of mastery and expertise, both what it takes to become a master of a given movement or craft and how one becomes an expert in coaching/teaching the movement or craft.  The former is mysterious to me; I get bored relatively easily and wonder if I will ever truly master anything.  The latter, of course, is my profession and the more I learn, the more I realize how little I know.

When it comes to what it actually takes to become an expert at one thing, the research seems to be pretty clear.  Ericsoon, Krampe, and Tesch Romer (1993) established that expertise occurs after 10 years of intense practice or 10,000 hours, whichever comes first (Magill, 2011).  Intense practice consists of practice that is deliberate, or designed by a coach or teacher to address aspects of performance through repetition and refinement.  This is very different than simply going through the motions and is done in a mindful way.  All of this practice and refinement allows experts to process information differently.  Experts of specific skills recognize patterns more quickly.  This allows them to anticipate and act more quickly than non-experts.  Daniel Coyle discusses the concept of focused practice in his book "Talent Code."  Deliberate practice, or deep practice, as he refers to it, is focused.  This is accomplished by performing practice where mistakes are made, tending to the mistakes, and practicing again until it is performed correctly.  This, of course, means working slightly outside of one's comfort zone and perfecting something before moving on (interestingly, Ashtanga Yoga works much this way.  It is traditionally taught so that the teacher only gives the student one pose at a time.  The student doesn't receive the next posture, or asana, until the current asana is perfected.  The founder of Ashtanga, Pattahbi Jois, is known for saying it takes 7 years to perfect the first series.  This would be approximately 4000 hours of practice, not including immersion weekends, weeks, or months where more deep practice typically occurs.  I understand many of the martial arts are taught the same way, with black belt status usually taking about 10 years to complete).  This also requires the person performing the deep practice to be passionate about the skill.  Last summer, during a graduate school presentation by legendary running coach Dr. Jack Daniels, he said the hardest athletes to coach were the ones with the most talent and low internal drive.  Because things come easily to these athletes, they don't feel the need to participate in deep practice, relying instead on their innate talent.  This, of course, eventually leads to a person "not reaching his potential," with the less talented person participating in much more deep practice, analyzing his mistakes, and eventually realizing a more favorable outcome.

Research also shows that how the practice is performed can affect the outcome of learning.  Massed practice, or practice with little rest between sessions or trials, is less effective than distributed practice, or practice that is much shorter in length.  This prevents both physical and cognitive fatigue, leading to faster acquisition of the skill.  I use this often when I train; I introduce a movement that is challenging for someone at the beginning of the session.  The person inevitably struggles because it is new and more complex than what we had previously been doing.  We perform one set and move on to something else, coming back to it 10 minutes later after doing other movements or exercises.  The second set is almost always better than the first, and it's always fun to watch the surprise on the client's face when he realizes he is more successful the second time around.  Usually, after 2-3 weeks of interspersing the difficult movement into the routine, the movement is no longer intimidating or threatening for the client and progression can occur, in terms of load/reps/sets.  Grooving a movement pattern is a rewarding feeling, both for the client and for the trainer.

Movement is something we should all want to master.  This doesn't mean performing complex gymnastics routines or being an elite level athlete.  It simply means having a sense of mastery over what our bodies can do and regularly challenging it to perform in ways that require focus and practice.  As I mentioned earlier, I am prone to boredom.  As a result, I will probably never be an expert at any one yoga practice, or any one movement system, for that matter.  I have been running for 17 years, more than half of my life, and I certainly don't feel like an expert runner.  I am, however, in tune with my body.  I regularly challenge it to do things that are hard, and I practice until I can perform these things with some level of ease.  I am currently training for the MovNat level I certification.  One of the requirements involves hanging from a bar and pulling the body up using a leg, elbows, and arms.  Two months ago, hanging from a bar for longer than 15 seconds was really challenging for me, let along actually performing the movement.  I began practicing the movement 4 times a week, sporadically throughout the day, about 10 minutes each day.  Now, I can get up easily with my right leg; my left leg isn't quite as smooth, but considering I couldn't get up using my left leg at all 8 weeks ago, I am pleased with the progress.  I think we are generally scared of things we can't do physically and instead of picking small challenges and working on them in a focused manner, we practice avoidance.  Instead of masters of our bodies, we are merely inhabiting them, allowing them to dictate what we "can" and "can't" do.  In order to maintain function and ability, we have to change the way we look at physical challenges and aspire to a sense of physical expertise.  Rather than shy away from physical challenges, we should embrace them, remembering that with deep practice, what is a physical challenge today won't be in a month.  And even if it still is in a month, that doesn't mean that one day, with focus and determination, it won't be accomplished.

Yours in health and wellness,
Jenn

Magill, R.A., (2011).  Motor Learning and Control, ninth edition.  McGraw-Hill: New York.
Coyle, D., (2009).  The Talent Code.  Bantam: New York.