The case of the “sore” hip

My left hip has been sore. For months. More accurately, the front of my left hip felt like it needed to be stretched, and while it felt good when I stretched it during yoga, the sensation of tightness remained. I thought it was just something I would have to live with, and since there wasn’t any pain and I could do everything I enjoyed, I didn’t really devote much thought or attention to it. I should qualify this by saying I could do everything I enjoyed except backbends. (Not that I have ever truly loved backbends, but they are part of my yoga practice and many, many years ago backbends taught me how to use my lower traps and get rid of neck pain, so they hold a special place in my life as something that helped heal). My backbends were downright awful. They didn’t hurt, I was able to disperse the load in my spine, I just couldn’t lift up into any sort of arc shape. This was a new thing. I used to be somewhat good at backbends, though for a long time they didn’t feel good. Now they felt fine and looked awful.

3 weeks ago I went to DNS Movement Skills down in Carlsbad. I had a great time, and would definitely recommend it to people that study DNS and enjoy the exercise component. I had a really good partner for most of the course named Jonathon. At the end of the first day, we were working on the deadlift using DNS principles and despite a fairly good understanding of how to move my body, I couldn’t finish the lift. It was as though my brain didn’t understand how to move my femurs back and my hips forward. Jonathon told me I needed to learn how to use the posterior third fibers of my gluteus maximus or I was going to end up with a shortened gait cycle (chiropractors and physical therapists work with so many dysfunctional movement patterns, I think they tend to catastrophize a little bit, but that’s a personal opinion). Martina, the instructor, came over at one point when Jonathon was struggling with getting me to go into full hip extension. “You need to work on moving your femurs back."

Learning to use the posterior third of my gluteus maximus and moving my femurs back made sense. I began learning PRI about 18 months ago. I fit the worst pattern, and designed a restoration program for myself, both for personal gain and to understand how PRI worked. The PRI viewpoint is that the patterns are like an onion. At the deepest layer is PRI “neutral” which means a balanced pelvis in the sagittal, frontal, and transverse plane along with a balanced ribcage and shoulder girdle region. Layers add, starting with a transverse plane femur pattern, working all of the way up to complete lack of sagittal plane control, or “superior T4 syndrome,” which was me. PRI, like chiropractors and physical therapists, uses verbiage that can be a little disconcerting. Knowing I had a “syndrome” that could potentially lead to all of these awful things definitely prompted me to be a little obsessive about being “syndrome free.” Over the span of 4 months, I peeled away the layers from superior T4, to right BC, to patho PEC (yes, patho is short for pathological. Counseling may be required if your PRI professional tells you the names of some of these things), to L AIC until finally, I became “neutral.” Now, neutral didn’t solve all of my problems, but it did improve the efficiency of my movement. A lot. And it eliminated tightness in the mid back, improved mobility, and allowed access to muscles I hadn’t really been using. It also left me with a sore left hip.

If we look at the anatomy, it is pretty easy to see why. Let’s say the first layer of the onion developed when I was 13 (that is probably being generous. There is a good chance it was earlier than that because I was a high strung child, but I am giving young me the benefit of the doubt). The first layer of the onion involves my left pelvis living forward of my right pelvis in all situations. There are several muscles that cross the hip joint and attach and flex the hip, including the psoas major, the iliacus, the rectus femoris, and the sartorius. Now, imagine the left pelvis has been tipped forward for two decades, altering the length tension relationship of those muscles with the gluteus maximus. If you buy into the whole PRI thing (and I must say, for those of us that fit the patterns it can be hard to ignore), I had not had access to full hip extension with the pelvis in a neutral position on that side for 20 years. I was using the part of the muscle I knew how to use, and I definitely wasn’t using those lower fibers of gluteus maximus. That area had been in a lengthened position. I didn’t have the ability to use that part of the muscle for a very long time, and my brain didn’t know how to access that part of my body. (It is worthwhile to note I had the same problem on the right side as well, just not as severe, and I didn’t have any sense of chronic soreness on the right side. From a PRI perspective, this makes sense. The right side hadn’t been that way for as long).

The solution was surprisingly simply. I needed to learn to extend my hip. And so with the same tenacity I used when changing my “syndrome,” I taught my femurs how to extend. I used the supported lunge position, I used the finishing position of the deadlift, I discovered a very cool way to do this in a doorway. (Face doorway. Come into 1/2 kneeling position with back knee pressing into doorway to give you feedback. Exhale, allow ribs to come into expiratory position, inhale begin pressing thigh into doorway to create space between pelvis and femur and focus on moving femur back engaging the glute. The doorway keeps you honest and prevents your from cheating with your back). I began using the range of motion I had access to, which meant my hip soreness went away. Almost completely. It’s only been 3 weeks, but the fact that something that was there for at least 6 months has decreased 90 percent makes me pretty sure I can take care of the last lingering 10 percent of sensation in the next 2-3 weeks. More importantly, now that I understand how to extend my hips with my new range of motion, my backbends are dramatically improving, and since yoga is all about how pretty the asana looks, this makes me very happy. When people complain of things like tightness, it can be ease to assume it's a tissue quality problem (stretch more!) when sometimes, tightness is simply a motor control issue.

Yours in health and wellness,
Jenn

Self-perception

I was standing in line at Starbuck's the other day, looking around at nothing in particular. I noticed a woman waiting for her drink with an adolescent daughter or niece. "Wow," I caught myself thinking, "it's hard to believe adults can really be so little." As I paid and went over to the same counter to wait, I realized she and I were the same size. If anything, she may have been a touch taller.

Self-perception is a funny thing. I noticed early in my training career that when I asked some of my female clients to place their feet hip distance apart, they would set up with their feet wider than their hips. Their perception of their hips and the reality were different (I have also had the opposite happen, with people setting up more narrow than their actual hips). Becofsky et.al, found in 401 individuals with osteoarthritis, perception of disability was more strongly correlated with depression than actual reduction of physical functioning; those with reduced functioning that didn't view their condition as a disability were actually in a better place psychologically than those with less reduced functioning, demonstrating that perception can affect both our physical and mental health. Our perception of our physical selves and abilities can be our biggest barrier (or our most powerful aid) in attaining our athletic potential. I often wonder how we get so out of touch with our physical bodies. Is it because we don't use them very much? Or that we are inundated with press about knee replacements, arthritis medication, and the obesity epidemic? Many of my clients that come to me as new exercisers don't trust their bodies to be strong. They wait for something to go wrong, assuming their bodies will fail them. It is my job to teach them their bodies are capable, and if they are patient, their body will perform feats far greater than they expected. The reverse is also true. Sometimes there is an expectation that "I should be able to do x because I could 30 years ago." While "x" might still be an attainable goal, if a person's body is different than it was 30 years ago, "x" might have to be achieved in a different way or on a different time schedule. A yoga teacher once said what we think we look like we while we are practicing yoga and what we actually look like are two different things. There are times where I think I must be in the deepest backbend ever, only to find my hands and my feet are miles apart. As a result, my perception of my ability to backbend is that I am not "good" at it and probably won't ever be able to do poses that require a lot of back mobility. This is in contrast with my perception of my ability to handstand. I know I can handstand in the middle of the room (I have accomplished this on several occasions, just not consistently); as a result, my perception is that eventually I will be able to always handstand in the middle of the room. My perception for handstands translates to confidence, while my perception of back bending borders on self deprecation ("I cannot currently backbend; therefore, I will never be able to backbend").

Perception also affects how people with chronic pain move and and their ability to perceive where their body actually is in space. Wand et.al, found 50 out of 51 patients with chronic low back pain endorsed items on a questionnaire suggesting distorted body perception. (Body-perception distortion was found to be infrequent in the healthy control group). Recently, I trained a gentleman that had suffered from bilateral sciatica in the past year. While he was feeling better, he still suffered from a bit of pain, particularly walking up and down stairs. The first time I had him come into a supine position with his knees bent and feet flat on the massage table, I noticed his right pelvis was pressing heavily into the bed while his left pelvis was barely in contact with the surface. "Which side of your pelvis feels like it is most in contact with the bed?" I asked, assuming he would say his right. "My left," he responded with certainty. "My right feels like it's barely touching it." Though I learned a long time ago not to assume anything about how a person feels or experiences movement, I was a little bit shocked that his perception of his body and the reality were so different. His perception wasn't wrong; it simply didn't resemble what my eyes saw, further demonstrating the importance of asking rather than assuming what a person is feeling or experiencing.

Something that I find interesting about self-perception is the ease with which it can change. The new exerciser that perceives movement as a potential threat to injury with the right guidance can begin to view her body as strong and able. Using imagery and focused attention over time has allowed my client with low back pain to begin to perceive both sides of his back and where they are in space. I doubt I will look at a person while waiting in line again and think about how little she is, knowing now that that is a more accurate representation of me. While I think about movement and how my body moves a bit obsessively, I don't think much else of my physical self. If someone asked about my self-perception, I would describe myself as strong, not short or little, though I would probably qualify it with, "stronger than average, but there are many that are stronger than I am." If asked about my flexibility, I would quickly say my flexibility leaves something to be desired. Perception is relative and largely depends on one's frame of reference. Watching women regularly perform incredible feats of athleticism on the yoga mat and in the weight room (thank you, Youtube) gives me a different frame of reference of strength and flexibility, leading me to feel that compared to my peers, both could be improved upon. However, it could probably be argued that my strength and flexibility are above average when compared to the normal population. It is impossible to know a person's frame of reference and one's perception of his physical self. The client who has always been told her hips are bigger than her torso will probably regularly set up with her feet a little too wide, while the client that has been told she is frail might balk if given heavy weights too soon. The value of asking, "how does that feel," shouldn't be overlooked, either as a trainer, or as self-reflective question. Conversely, our experience of proprioception and how we move might be impacted by pain, our movement vocabulary (how much or how little time we spend thinking about movement), or our current psychological state. Connecting with our physical selves and beginning to paint an accurate picture of our body in space can improve athletic performance, self-confidence, and overall well-being.

Yours in health and wellness,
Jenn






Becofsky, K., Baruth, M., & Wilcox, S., (2013). Physical functioning, perceived disability, and depressive symtoms in adults with arthritis. Arthritis, 2013.
Wand, B.M., James, M., Abbaszadeh, S., George, P.J., Formby, P.M., Smith, A.J., & O'Connell, N.E., (2014). Assessing self-perception in patients with chronic low back pain: development of a back-specific, body-perception questionnaire. Journal of Back and Musculoskeletal Rehabilitation.

What personal trainers could learn from mind body practices

I am taking an online yoga training right now on "The Art of Sequencing." The instructor, Jason Crandall, teaches in a clear, concise manner. Part of the course is to take themed yoga classes taught by him. The interesting thing that he does, which is very similar to how I train, is he takes an area, brings awareness to that area, and then threads that awareness through the class in different postures. What happens when classes are taught like this is when the class is over, the student is more in tune with holding patterns in that area and how that area responds and is affected by other movements. This is similar to some of the Feldenkrais ATM lessons- the participant is taken through a series of movements with an emphasis on a specific region of the body and how that region responds to a variety of conditions. It heightens the participant's awareness and in Feldenkrais lessons, usually results in a substantial increase in mobility due to improved motor control and better neuromuscular organization.

There are, of course, multiple ways to coach and many ways to cue exercises. I am not going to discuss word choice for cueing, though much has been written about this topic. Sam Leahy wrote a great blog reviewing the research and discussing the application of how to cue which can be found here: http://samleahey.com/science-of-coaching-cues/.  What I find works best for my clients is if I pick an area to emphasize during the warm-up, I start asking general association cues regarding that area, and I bring awareness to that area throughout the session. For instance, I am currently training a gentleman I will call Jim. Jim had significant sciatica in the past, and has done quite a bit of physical therapy. He is 69 and wants to be able to walk and play with his grandchildren. I quickly realized (after both assessing some general things and watching him move) that he was disconnected from a sense of center and I decided to start with improving his awareness of his inner thigh connection to the pelvis and abdominals. All of his warm-up activities included holding a foam block between his thighs, which I instructed him to imagine he was holding with his pelvis. I had him do some isometric adductor squeezes, just to bring a little more awareness to the area, and we moved on to standing exercises. For the remainder of the session, whenever he would set up for an exercise, I would ask him to pretend like he was holding the block with his pelvis. We had established what that meant earlier, giving him a movement vocabulary for that action. As the session progressed, I asked him to notice what the sensation of holding the block did to his abdominals (made him feel them) and what it did to his feet (made them less duck footed). Because this was foreign for Jim, I cued it often, though I always gave him the opportunity to set up before I said anything. About 30 minutes into his session, he was paying much more attention to foot placement and inner thigh engagement without feedback from me. The next time I saw him, he commented that he was much more aware of his general tendencies towards external rotation, and he was practicing keeping his knees straight ahead when he sat down. Jim had learned something during our session, done a little bit of homework and his own, and this allowed us to move forward to connecting the hip to the weight of the foot, which is where I went next.

People like Jim are a fairly common occurrence in my practice, though occasionally I get someone like Kate*. Kate danced when she was in college and is a Pilates teacher. Kate has a very large movement vocabulary, and if I help her make an association once, she will retain the cue and implement it without me asking. Kate has a strong bias towards internal rotation, which sometimes leads to stress underneath her knee. I started with teaching her how to engage her glutes and not let her thighs fall into internal rotation in various kneeling and 1/2 kneeling positions. When we moved into standing work, I found she had a difficult time maintaining a neutral calcaneus with hip external rotation. We have been working on keeping a neutral foot and a balanced hip in every exercise. She has a difficult time dissociating the hip from the foot, though as we explore it in a variety of ways, it is improving. She tells me she thinks about glute engagement during barre class, and she thinks about her position when she is demonstrating exercises on the reformer. Like Jim, she was able to make an association about how her body moves and is applying that general awareness to activities performed outside the gym.

Training in this way is powerful because it empowers the client and allows him to take ownership of movement patterns. Experienced yoga teachers do this naturally, though their emphasis is usually on improvement on a specific posture. However, the principles are the same. I am regularly told by clients that they leave sessions feeling like they learned something. I strongly believe that if I want to improve movement ability and increase everyday activity in my clients, it is necessary for them to begin to understand how their bodies work and how they have control over their movements.  I do think part of my job as a trainer is to educate and improve body awareness, one association at a time.

Yours in health and wellness,
Jenn

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