A balanced hip: Part I

The hip is a neatly designed joint, organized in a way to allow functional mobility, but still has proper constraints in place to maintain stability, including 3 ligaments (Nam et.al, 2011). These three ligaments are the ischiofemoral ligament, pubofemoral ligament, and iliofemoral ligament.

There are 6 deep muscles that stabilize the hip in the socket, followed by several layers of muscle that move the joint a variety of different directions, culminating with the gluteus maximus muscle which not only generates power and propels the body forward, but is also believed to be the point of load transfer from lower extremity to torso via the thoracolumbar fascia (Barker et.al. 2014). Directly opposing the lateral hip is the “groin” area. This area connects the abdomen and the lower limbs via the inguinal region, consisting of abdominal muscles (internal and external oblique, transverse abdominis, rectus abdominis, and the pyramidalis), the inguinal canal, and the femoral triangle (Valent et.al, 2012). During movement, the pubis symphysis is stabilized synergistically by the abdominals and the erector spinae, and the adductor muscles work in an opposing manner to provide stability to the area during load transfer. In the front of the hip are your “hip flexors,” which flex the femur in the sagittal plane. One of these muscles, the psoas, has attachment points on the lumbar vertebrae and is believed to play an important role in lumbar spine stability in an upright stance (Penning, 2000). It also shares fascial connections to the diaphragm and some believe it may play a role in overall trunk stability, along with the diaphragm, transverse abdominis, multifidus, and pelvis floor (Sajko & Stuber, 2009). A variety of issues can occur in and around the hip joint, including minor issues, such as tendon snapping, and more serious pathologies such as femoral acetabular impingement syndrome (Byrd, 2007). Interestingly, hip pathologies usually present as a “pain in the groin,” rather than pain in the more centralized hip joint area. Obviously, the cause for these pathologies are multi-faceted in nature, and it is worthwhile to note that the hip receives innervation from branches of L2-S1, with the L3 dermatome innervating much of the medial thigh, so if you or someone you work with has chronic groin pain, refer to an M.D. to rule out serious hip or lumbar spine pathology and make sure exercise is cleared.

Clearly, the hip and the muscles surrounding the hip play an important role in movement. It can be unclear how to train this area (do I focus on hip internal rotation or external rotation? Do I stretch the hip flexor or instead think about glute activation?) Each person is unique and what works for some might not work for all; however, hopefully we can begin to examine ways to move the body and integrate the hip in a balanced way. It is important to first bring awareness to the area and see if the hips are balanced, or if any asymmetries exist. An easy way to check this is to lie down on your back and begin noticing the weight of the pelvis on floor. As you begin thinking about this area, ask yourself if the weight of the pelvis on the floor feels even or if it feels unbalanced. If it feels unbalanced, ask yourself which side feels heavier against the floor. (If you have a difficult time identifying the contact of the pelvis with the floor, I strongly encourage you to work on some breathing exercises and learn how to engage your core using your breath. It is possible that by simply focusing on the sensation of your exhale, you will begin to feel a stronger sense of weight of the pelvis). If your pelvis feels like it isn’t quite balanced, chances are this asymmetry will be present during movement. Consider that your muscles are designed to work in a specific manner depending on their length-tension relationships. If you have a pelvic asymmetry, muscles on one side of the pelvis will be in a different position than the muscles on the other side of the pelvis. Unless you begin to correct the imbalance, your muscles will be working differently on the two sides. Now that you have assessed your pelvic position in a supine position, sit down on a bench or chair with your feet flat on the ground. Glance down at your feet. How did you naturally sit? Is one foot slightly in front of the other, or are your feet even? If your feet aren’t even, can you pull the hip of the foot that is forward back a touch to even out the feet? Now, notice the contact of your sitting bones on the bench. Are they both rooted evenly, or is one in better contact than the other? If you can’t find or feel either sitting bone, I highly recommend some breathing work with an emphasis on core integration (you might begin to notice a theme). If you feel one better than the other, can you begin to root the sitting bone that you can’t feel and then relax back to what feels “normal?” Do this a few times and relax. See if there is a difference. Now, come into a standing position. Once you are in a position that feels comfortable for you, glance down at your feet and see if they are even. If they aren’t, can you move the foot back that is forward with your hip? Now, take your hands on your hips and look down and see if one finger appears to be slightly forward or higher than the other, or if they look balanced. Observe the contact of your feet with the floor. Are your feet balanced on the floor, or are you standing more in your heels or toes? Where is your weight more loaded? Is it more on your left foot or your right, or is it even? Find balance. What happens when you spread your toes and lift your arch? Do your feel any activity in your hips? If you have a high arch, what happens when you engage the center of the foot and press the arch towards the floor? Do you feel any activity in your hips?

Before training the hips, it is important to understand there can be imbalances and asymmetries in our pelvis. This influences how we perform movements and which muscles are activated during movement. Bringing awareness to the area is often the first step in recognizing asymmetries that might exist. Asymmetries also affect the body’s ability to move in an efficient manner. Part II will focus more on actually training the hips and integrating the movement with the rest of the body.

Nam, D., Osabahr, D.C., Choi, D., Ranwat, A.S., Kelly, B.T., & Coleman, S.H., (2011). Defining the origins of the iliofemoral ischiofemoral, and pubofemoral ligaments of the hip capsuloligamentous complex utilizing computer navigation. HSS Journa, 7(3), 239-243.
Barker, P.J., Hapuarachchu, K.S., Ross, J.A., Sambaiew, S., Ranger, T.A., & Briggs, C.A., (2014). Anatomy and biomechanics of gluteus maximus and the thoracolumbar fascia at the sacroiliac joint. Clinical Anatomy, 27(2), pp. 234-240.
Valent, A., Frizziero, A., Bressan, S., Zanella, E., Giannotti, S., & Masiero, S., (2012). Insertional tendinopathy of the adductors and rectus abdominis in athletes: a review. Muscles, Ligaments and Tendons Journal, 2(2), 142-148.
Penning, L., (2000). Psoas muscle and lumbar spine stability: a concept uniting existing controversies. Critical review and hypothesis. European Spine Journal, 9(6), 577-585.
Sajko, S., & Stuber, K., (2009). Psoas Major: a case report and review of its anatomy, biomechanics, and clinical implication. Journal of Canadian Chiropractic Association, 53(4), 311-318.
Byrd, J.W.T., (2007). Evaluation of the hip: history and physical examination. North American Journal of Sports Physical Therapy 2(4), 231-240.

Meditation and exercise

Meditation has been showing up in my world a lot lately. It could be argued that as a yoga practitioner, meditation should show up daily, but it is easy to put that portion of the practice on hold for the physicality of asana. It could also be argued that yoga is moving meditation, and I definitely think that it can be, but first a brief explanation of what meditation actually is and how it can be applied to all realms of exercise, not just asana.

Lately, I have been a bit dissatisfied with the fitness industry, or more accurately, the air of negativity and self righteousness that permeates the online scene. Perhaps this is the downside of social media- often the ones with the loudest voices are also the ones with the strongest opinions. I study a variety of systems in an effort to find the most effective way to get people moving well, get them strong, and prepare them for the demands of life. The systems I study all provide aha moments, but I find them incomplete. Each one is missing something and so I am constantly searching for the answer, the one system that will help all of my clients lead pain free lives. I find many people in my profession like to make absolute claims regarding movement, (“Distance running will kill you!” “Yoga will make you weak!” "Kettlebells cure everything!") all while claiming a specific system/methodology/philosophy is the solution to movement dysfunction. This frustration led me to run away to a yoga festival in Boulder and study with several well respected teachers and turn off my phone. Meditation came up in two of the classes, and I found the teachers saying things that made sense. Jason Crandall said that meditation is really the observation of thoughts without judgement, and Maty Ezraty said her cues (which were given while we were shaking in deceptively simple postures) were meant to help focus our thoughts and move us towards a more meditative state. 

According to Wikipedia, “meditation is a practice in which an individual trains the mind or induces a mode of consciousness, either to realize some benefit or as an end in itself.” A meta-analysis performed by Morgan, et.al, (2014) found mind-body therapies are effective at reducing markers of inflammation, and it is well-accepted that meditation can be an effective way to reduce blood pressure, reduce anxiety, and decrease cortisol. The term meditation can indicate several different techniques. A fascinating paper Debarnot et.al (2014) examines the influence meditation can have on expertise (if you have any sort of interest in mastery, this is well-worth the read. The link can be found below). They categorized meditation into two different groups: focused attention and open monitoring. Focused attention is the concentration of a particular external stimulus while ignoring all other input. This was the type of meditative practice Maty was hoping we would achieve by listening to her cues rather than fixating on what our bodies were feeling or thoughts of “this is too hard.” This type of practice can develop sustained attention and enables the practitioner to redirect attention to the desired object, in my example, Maty’s voice. On the opposite end of the spectrum is open monitoring, which aims to enlarge focus to all incoming sensations, emotions, or thoughts without any judgement. This was what Jason was emphasizing during his arm balance class. He wanted us to notice what we felt and observe the thoughts associated with the asana without judging them (harder than it seems if you are at all type A). This type of practice is believed to develop awareness, and improve executive attention. John Ratey, Richard Manning, and David Perimutter point out in their book “Go Wild” there is a belief that meditation is about relaxation and bliss when it is actually about hyper attention and focus. From an evolution perspective, this makes sense. Hunter gatherers needed to use this hyper focus and awareness to both stalk their prey and perceive danger. This requires both focused attention and open monitoring, and the beauty of understanding meditation in this way is that it can be applied to several areas of motor learning and performance.

The easiest way to begin improving awareness is by leaving the cell phone at home or in the car prior to engaging in physical activity. This was one of the things I appreciated about my timel in Boulder. I am not someone that is necessarily tied to the phone; however leaving it at the hotel while I participated in 6 hours of yoga was freeing and allowed me to focus, not just on the yoga, but on my surroundings. While much of the technology built into the cell phones is great for data collection, I will argue that leaving the cell phone when one hikes or runs is a way to increase both open monitoring and focused attention. The ability to observe our surroundings and  thoughts without technology is powerful, and actually focusing on body sensing during movement allows us to recognize unnecessary tension and ease of movement (Danny Dreyer discusses this in depth in his book, “Chi Running”). What “mind-body” disciplines all have in common is they require the practitioner to focus on what is going on, a sort of focused attention to the task at hand. Not using electronics, minimizing music, and choosing movements that require focus are all ways to ensure a movement meditation. While this type of training is harder for the teacher or trainer, the mental benefits could be significant, and perhaps improve our overall health. I frequently cue clients to think about  the breath during “regular” exercise movements in an attempt to keep them focused on the task at hand and ask clients to notice how one part of the body responds when another is moving. Instead of viewing meditation as a separate activity, if we try and incorporate it into our everyday lives and particularly into our movement regimens, we might find an increase in performance, attention, empathy, and health.

Yours in health and wellness.

Jenn

Morgan. N., Irwin, M.R., Chung, M., & Wang, C., (2014). The effects of mind-body therapies on the immune system: a meta-analysis. PLoS One, 9(7). 

Debarnot, U., Sperduti, M., Di Rienzo, F., & Guillot, A., (2014). Experts bodies, experts minds: how physical and mental training shape the brain. Frontier of Human Neuroscience, 8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4019873/

The stiff neck dilema

A large survey of 353,000 Americans revealed 31% of Americans reported experiencing chronic neck or back pain in 2011 (Brown, 2012). Interestingly, rates of individuals experiencing chronic pain increases until the late 50s, when numbers level out and slightly drop, possibly because of morbidity. I began working with a 15 year old basketball player 5 weeks ago specifically because of nagging neck pain. His neck had been an issue for months, and a running drill the team did with their hands overhead for 7 minutes caused a spasm that left him with discomfort in the following weeks.  He rested, avoided movements that bothered it, and asked his mom if he could see me so he could get strong without getting hurt. A quick assessment revealed asymmetries in his thorax and pelvis, as well as a tendency towards inefficient breathing. Research performed by Wirth et.al, suggests improving neck flexor muscle endurance, thoracic spine mobility, chest mobility, and respiratory muscle endurance training for individuals with chronic neck pain. Further, Dimitriadis et.al, compared respiratory strength in 45 individuals with chronic neck pain compared with 45 controls. The researchers found the chronic neck pain group had a statistically significant difference in their respiratory muscle strength and concluded this weakness impaired global and local muscle systems in the neck.

When you look at the anatomy, this makes sense. The primary muscles of inspiration are the intercostals and the diaphragm; the accessory muscles are the sternocleidomastoid, scalenes, and serratus posterior superior and inferior. During respiratory distress, the levator scapulae, pectoralis major and minor, rhomboids, serratus anterior, and latissimus dorsi are also involved (an easy to read chart can be found here: http://share.ehs.uen.org/system/files/0720024.pdf). If you glance at the picture above, you will see all of the accessory muscles of inspiration are have attachments at the neck and many of the muscles used during respiratory distress do as well. This, of course, might lead one to wonder if a breathing disorder is causing chronic neck pain or if the chronic neck pain is leading to inefficient breathings patterns? It depends on the person, and individuals that are referred to me because of chronic neck pain fall in the "cleared to exercise, everything else has been checked and is a non-issue" category. In the presence of breathing disorders such as asthma, it is useful to understand the effect this has on stabilization and potential increased activity in the accessory muscles of inspiration. This affects rib cage position and will lead to a decrease in overall stability. When clients are experiencing an increase in asthmatic symptoms because of weather or allergens, I am careful about position and load. Anecdotally, clients that have asthma have reported a decrease in symptoms after 4-6 weeks of regularly implementing breathing exercises into their program. I am not suggesting asthma can be cured by mindful, diaphragmatic breathing, but in my experience, it seems to help the severity of it. 

What I did with the basketball player consisted of three parts. I taught him how to breathe in a more parasympathetic (read, diaphragmatic) manner. This went hand in hand with improving his overall core stability with breathing exercises and bodyweight exercises done in an efficient position. I also made him aware of his shoulder position. He is preparing to participate in a pre-season strength and conditioning program involving olympic lifts. His natural, resting tendency is to have his shoulders up by his ears, which doesn't lead to efficient lifts. This pattern seems to be common in individuals with neck pain and goes along with anteriorly rotated shoulders (which he had). I taught him some techniques to notice where his shoulders were located, and I asked him to "make his neck as long as possible" in a variety of positions. When we first started, he consistently used the strategy of trying to find a way to use his neck to make his neck long. Once he because aware that his shoulder position influenced the length of his neck, he became better able to alter neck position with shoulder position. He was able to bring this increased awareness with him during his daily activities, and I can happily report he is currently participating in all of his pre-season activities (including hours each day of basketball), pain free. Many times, what we do outside the gym matters far more than what we do in the gym.

Yours in health and wellness,
Jenn

Brown, A., 2012. Chronic pain rates shoot up until Americans reach late 50s. Gallup Well-Being; http://www.gallup.com/poll/154169/chronic-pain-rates-shoot-until-americans-reach-late-50s.aspx

Wirth, B., Amstalden, M., Boutellier, U., & Humphries, B.K., (2014). Respiratory dysfunction in patients with chronic neck pain-influence of thoracic spine and chest mobility. Manual Therapy, [Epub ahead of print].
Dimitriadis, Z., Kapreli, E., Strimpakos, N., & Oldham, J., (2013). Respiratory weakness in patients with chronic pain. Manual Therapy, 18(3), pp. 248-53.

Calcaneus neutral- and why the ankle bone really is connected to the hip bone

If you read this blog on a somewhat regular basis, you are aware that I am fascinated by how the body works. This includes an interest with feet and how they impact our movement. Our feet are the first part of our body to receive feedback from the ground. As a result, they are full of mechanoreceptors which send feedback to the brain regarding body position with respect to supporting surface (Kennedy & Inglis, 2002). The ankles and knees provide proprioceptive feedback to the brain which are thought to provide information about joint angle relative to the trunk, linking what happens at the foot and ankle joint to what is happening in our body's center. Interestingly, reduced plantar support (position of the foot) appears to affect stepping reactions to postural perturbations (basically, how you respond to losing your balance). This matters because one of the jobs of the deep core musculature is to maintain stability during walking; this includes making sure the system can recover from large and small perturbations during gait (Stanek et.al, 2011). If our first line of contact with the ground isn't in a position to properly respond to disturbances, how can we expect our deep stability muscles to stabilize when needed? The reverse could also be stated: if the core stability muscles aren't in a good position to do their job, the foot isn't going to be able to do its job. Walking is important, and before we can perform well or move well, we have to be able to walk well and recover from slight changes in the environment that throw off our balance.

The first line of defense is a good offense (or so I'm told) so training the body in a position that addresses foot position is important. First and foremost, I think it is critical to have a spine that is well-organized/neutral/has proper rib cage to pelvis position. This gives the deep intrinsic muscles of the core a chance to do their job reflexively, without conscious activation (and this is what we want. If you miss a step, you do not want to have to actively think, "shoot! Fire transverse abdominis, internal and external obliques, serratus anterior, gluteus maximus!" By then, you will be neatly crumpled on the ground). Further, Moon et.al (2014) point out postural control is automatic and the balance of the body depends on how the center of gravity is maintained by the body's support base; this means small alterations in foot position can change the postural control of the entire body, indicating foot position is important. After the spine position is addressed, a good foot position can be established. I like to spend a little bit of time working with people barefoot, but it isn't necessary. Being barefoot helps a person more readily identify what a neutral position is because of the feedback from the floor, but this can be done in shoes as well. The first thing I like to do is have the person figure out where the center of the foot is located. This means observing normal standing position, rocking forward and back to feel the extremes a few times, and then settling on what feels like the center of the foot to that person. I also have the person rock from left to right and find what feels like 50 percent of the weight in the right foot and 50 percent of the weight in the left foot. This begins to move the person towards a more neutral calcaneus, which simply means the calcaneus on visual inspection will appear centered and you will be able to draw a straight line from the calcaneus up to the back of the knee. This position will allow the arch of the foot to gently lift (if the person has pronated feet) and/or the big toe to begin to engage with floor more actively. It is important to keep the tibialis anterior (the muscle in the front of the shin) relaxed and keep the toes from clawing at the ground. I find it useful to have the person observe how his hips felt in his "normal" standing position and observe any increase or decrease in awareness of the hips in the "new" position. If the person is having a really difficult time with both feet, I frequently use the 1/2 kneeling position demonstrated below to bring awareness to foot position. Doing 5 minutes of standing exercises helps reinforce the position and sensation of the foot and the hip working together. Once in a while, I am unable to improve foot position despite trying a variety of things; when this happens, I refer the client to someone specializing in foot mechanics, such as a podiatrist, for further evaluation. More often than not, I observe improvement in balance and core stability when I incorporate this type of training, and as stated above, walking efficiently is the first step I can take in getting my clients to move well.

Yours in health and wellness,
Jenn

Video Link: https://www.youtube.com/watch?v=hjVYmzPYv0I
P.S.- For more information about barefoot training, I highly recommend checking out www.evidencebasedfitnessacademy.com

Stanek, J.M., McLoda, T.A., Csiszer, V.J., & Hansen, A.J., (2011). Hip- and trunk-muscle activation patterns during perturbed gait. Journal of Sports Rehabilitation, 20(3), pp. 287-295.
Kennedy, P.M., & Inglis, J.T., (2002). Distribution and behavior of glabrous cutaneous receptors in the human foot sole. The Journal of Physiology, 538, pp. 995-1002

Goal setting for mindful movement and the asana in progress project

One of the things that I love about movement is there is always something to work on. Regardless of one's physical endeavors, there is always room for increased efficiency, improved performance, or simply moving to the next level. Over the years, I have had many different goals, some extremely specific ("I will run up this 2.5 mile hill without stopping to walk in the next month," "I will learn how to do the Turkish Get-up,"), others specific to what I viewed as weakness ("I will learn to fire my lateral hip stabilizers on my right side during single leg squats," "I will learn to use my adductors while arm balancing"). Perhaps the most challenging change in my movement that I implemented was last year when I realized my deep core stability as it related to my breathing was not just less than optimal- it was non-existent. I spent three months re-training my neurological system and did so much diaphragmatic breathing that I bruised a little muscle under my sternum called the triangularis sterni. I get bored easily, and setting a goal keeps me interested and moving towards something.

In my quest to learn about movement, I spend time on Youtube watching people move really well. There are the yogis, that float gracefully from one pose to another, the Ido Portals of the world, that could seemingly spend hours in handstand variations, and the Scott Sonnons and Erwan LeCorres that move seamlessly, fluidly, as though there is no effort required at all to lift a giant log or swing a club bell. This is wonderful, inspiring, and can be a great learning tool; however, it never showcases all of the work it takes to get there. I truly believe that almost anyone can achieve whatever movement task they desire, as long as they work mindfully and intelligently on that task. The task will not come overnight; it takes months, sometimes years to accomplish a movement task that poses a large challenge to an individual, and often requires addressing a specific weakness, looking at the task from several different angles, or dedicating specific time to practice the task daily. The way I finally made it up the 2.5 mile hill, for instance, was running it in the dark. Because I couldn't see how much longer I had, I was able to trick myself and just keep running.  In a world where movement tasks such as climbing trees for fruit, hunting down large prey for food, and carrying heavy logs to build shelter are no longer necessary, it is important to set movement goals periodically to keep the mind and body engaged and working together. The mind/body disconnect and lack of movement efficiency that exists in western society isn't healthy for our overall well-being. So, I invite you to join me. Pick a movement goal. It doesn't matter what it is, as long as it is something that you can't do currently. Examine it, practice it, figure out your sticking point, and get creative about moving past the sticking point. To measure your progress, once a month, either film yourself, time yourself, or have someone assess you, depending on what your goal is. My goal, as you will see below, it to link together some of these postures together on my yoga mat. I filmed myself in the middle of my practice, which is eventually where the task should be performed with ease. I will work on these tasks in a variety of ways, by performing some of my sticking points in isolation, in the gym after a strong core session, and in a less fatigued state. However, since the task is to be done during yoga, each month, I will film during a yoga practice and examine my progress. I am giving myself 12 months, and if I complete the task before then, I have two other asanas I am working on that I will devote my attention to. When I was debating graduate school, a client pointed out that in 24 months, I would be two years in the future, with or without the knowledge a master's degree would provide. Which version of myself did I want to be? The same is true with any challenge. Twelve months will pass regardless of whether I decide to improve my strength and mobility. I want to be a stronger me, and I hope you do too.

Yours in health and wellness,
Jenn

https://www.youtube.com/watch?v=es90vm7y8kU

Training the unstable client

I began training Amy* 8 years ago. She came to me because she wanted to build strength and prevent her osteoporosis from getting any worse. I was a much greener trainer at that point, and did my best to challenge Amy with heavier weight, dynamic movements, and body weight exercises. This didn’t go so well, and it became obvious that Amy was unable to support heavier weights, particularly in her upper body. Her shoulders were sloppy, and she didn’t have the ability to perform the movements in a technically proficient way. She also had some instability in her hips, and would occasionally get hip pain. 

My first three years with her was a lot of trial and error to figure out what wouldn’t bother her shoulders and her hips, but would still give her strength (some of my clients are amazingly patient people. Why she stuck with me, I will never know). It wasn’t until I began studying joint position and mechanics and actually understanding how that impacted function that I was able to help her. Instability is rampant in the yoga world; to be good at many of the advanced postures requires quite a bit of mobility. While this should be balanced with an equal amount of strength, it is not unusual for people that already possess a large amount of mobility to gravitate towards the practice. Unless they spend time focusing on finding strength in each asana, this can be detrimental and lead to a lack of cohesive movement. The body will move in a way that lacks underlying support- it’s like removing the foundation of the house and hoping that the beams are strong enough to hold up the roof.

To understand the importance of joint stability, it is important to have a brief understanding of how the nervous system works. When we want to lift our arm, for example, the brain sends information via motor neurons to the appropriate muscles required to both stabilize the body for the action and to the muscles that lift the arm. Inside the joints are sensory nerve fibers that provide information to the brain about forces exerted on the joint tissues, joint position, and whether or not the joint is moving (Grubb, 2004). The nerve fibers that provide this information are called proprioceptors, and are located in the joint ligaments. This poses a problem when a person has joint laxity, or ligaments that are overstretched. In the shoulder, for instance, it is believed dynamic ligament tension is involved in signaling how much force the rotator cuff muscles need to exert on the humeral head (Kelly, 2002). If the ligaments lack tension, this would alter the activity of the 4 muscles of the rotator cuff, as well as decrease the stability of the joint simply because the ligaments aren’t doing a very good job keeping the shoulder in the socket. In a healthy joint, full range of motion should be pain free, the person should know where his arm (or hip, or ankle) is in relation to his body, and there should not be a fear that something is going to “slip” or “fall out,” common descriptors when you work with hyper mobile clients. It has been my experience that when someone falls into the category of hyper-mobility, it is important to change the training strategy to give stability on the deepest level.

In the case of Amy, she returned one summer from travel with shoulders that were not in a very good position. They were painful, her neck was overactive, and she said she couldn’t figure out “where they [the shoulders] are supposed to be.” At this point, I suggested we back off the weights for a while and try and a different approach. She agreed, and while it was frustrating at times, (“why is this so hard? I am not doing anything”), we progressed slowly and steadily. I gave her things to be aware of when she wasn’t with me, such as how to move from the scapula rather than the shoulder to reach for things. We worked on other things as well, such as breathing and improving her thorax/pelvis integration, and eventually we got back to weights, though I don’t have her go very heavy (she is 64, and I find it is better to train smart with older clients, rather than harder). She said to me last week, “thank you. My shoulders haven’t given me trouble in a very long time, and I feel way more stable.” Sometimes, people need mobility, sometimes they need strength, and often they need a combination of the two. We tend to avoid the things we aren’t good at; these are frequently the things we need the most. Having a little patience and an overall plan can go a long way in improving function and well-being.

Yours in health and wellness,

Jenn

P.S.- For a glimpse of some of the things I use to enhance shoulder stability, view the link here: https://www.youtube.com/watch?v=pmY8J2EVxuM

Grubb, B.D., (2004). Activation of sensory neurons in the arthritic joint. Novartic Found Symposium, 260, pp. 28-36.

Kelly, I. The Loose Shoulder, Maitrise Orthopedique, 111.

The Integrated Systems Model, and evidence based practice

I recently listened to Diane Lee's lecture on the Integrated Systems Model, which she uses to classify her treatment strategy (more information can be found on her website here: http://dianelee.ca/the-classroom.php). I am quite fond of her presentation style- she has a good sense of humor, doesn't seem to take herself too seriously, and is passionate about her subject matter. If she allowed personal trainers to take her courses, I would figure out a way to get up to Canada and attend one of her 4 day workshops. She made a number of points in this particular lecture that resonated with me, and one thing she discussed rather extensively was evidence based practice.

Evidence based practice (EBP) has become a bit of a buzz word in the last 5 years. Practitioners want credibility, so they search out evidence (i.e., research) that demonstrates they are on the right path, while consumers want proof that what they are doing will help them become healthier/fitter/stronger/better. This is fair; the profession of exercise or movement science is quite young, and for every person that claims exercise helped, another says that exercise caused pain. It is muddy, and unclear, and everyone has an opinion. The term "evidence based medicine" was coined by Dr. David Sackett in 1996. He wrote, "...evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients," (http://en.wikipedia.org/wiki/Evidence-based_medicine). According to Ms. Lee, there are 3 components associated with this. The first (and the one most people attach to) is the research. For the research to be high quality, it should be a random control trial. Here is the thing with research when it comes to exercise- you can find a study supporting almost any view you want to take. In graduate school, I noticed over and over again during class discussions that people could take completely opposing views on something and there would be research to support both sides. By the time I was in my second year, I began to realize that sample sizes of things I was interested in were typically extremely small, the studies weren't always designed in a way that mimicked actual performance (who runs solely on a treadmill?), and not very much research on functional exercise or performance actually existed. I read through several studies last weekend examining deep core stabilization and how the intrinsic muscles of the core affect function. What I found was dismal. Saunders, Roth, and Hodges state, "despite the importance of the deep intrinsic spinal muscles for core control, few studies have investigated their activity during human locomotion or how this may change with speed and more of locomotion." This was in 2004, and not much has been done in the last decade to improve upon this.

The next component to the evidence based model is expertise. Experience comes from learning the material, practicing the material, and figuring out how to apply it. In the ISM, having a variety of tools is encouraged; the key is knowing when to apply those tools. It took me a while, but I eventually realized I am happiest in my career when I am learning. I find that what works best for me is learning a system fairly well, integrating it fully into my own workout/movement practice, and then using it with my clients. At this point, my tool box is diverse, and I feel comfortable using what I know. When I first learn something, I tend to use it on everyone; as the material becomes less foreign to me, I am able to more readily identify which tools fit best with each client. This is the final component to an evidence based model. The sample size that ultimately matters is when n=1. Not every modality works for every person. Some people respond really well to certain things, while others need a completely different approach. Working solely in an exercise setting, I can genuinely say I have experienced situations where 90 percent of clients do really well with one particular movement, while for the other 10 percent, that movement doesn't work at all. Experience comes largely into play, and over the years, I find I am able to figure out the best course of action with people a little more quickly.

Another note about EBP is a lot of the techniques that are out there are seriously lacking in research. Anecdotally, people will tell you "system x/y/z changed my life." Again, the sample size of n=1 is what matters. The beauty of this is that there is something out there that will work for everyone. It might take a while to find it, but patience and an open mind are key. From a consumer's perspective, I recommend trying something 4-6 times. This is enough time to let you know whether you a) hate it, b) don't really mind it, but aren't sure it's doing something for you, c) notice a little bit of difference, but maybe that's attributed to the 5 other things you changed at the same time or d) you know in your heart this is it. It's changing your life. As a practitioner, it is extremely important to learn things that resonate with you on some level. Maybe it's the material, maybe it's the teacher, but whatever it is, it needs to move you to learn it well and apply it in a manner that your passion for the material can be conveyed. This means that maybe not every workshop you go to will work for you, and maybe some things will work for you for a while, but then you might stumble upon something else that works a little better. Or maybe one specific system is your thing and you want to study that intensively for years. Find what works for you. Personally, I find that each system/teacher has strengths (and obviously, I haven't studied every system that is out there); the flip side, is they all have weaknesses. This is why I immerse my body into whatever it is I am learning about. I try it on, see how it fits, see how it makes me feel. Studying anatomy and physiology and reading a bit about the brain also allows me to better understand why things work (and I am very much a "why" person). Keeping an open mind when it comes to movement techniques and searching out quality, passionate instructors will help individuals find movement that they both enjoy and enhances their lives.

Yours in health and wellness,
Jenn