How DNS changed my yoga practice (and my running)

In November, I had the opportunity to take the second part of the DNS sport course.  I reviewed DNS I in an earlier post, and was thrilled to have the opportunity to not only learn from Zuzana again, but to take a private with her.  I was coming off of a self imposed 30 days of yoga, 1/2 marathon training, with some biking and weight training thrown in for good measure.  An old hamstring injury flared up in the midst of all of this and I was hoping Zuzana could provide some insight into changing my mechanics.  I, of course, thought I was in pretty good shape with perhaps some minor tweaking needed. During our private session, my tendency towards an inspiratory breathing pattern became quite apparent, along with my lack of lateral hip stability.  Both of these things were negatively affecting my spinal position during physical activity.  Over the course of the weekend, proper breathing patterns were continually emphasized during higher level positions, as well as eccentrically working the gluteus medius and integrating it with proper foot function (i.e. maintaining a short foot).  A video of Zuzana explaining proper breathing technique can be found here: http://www.youtube.com/watch?v=-7UJPm1hBEo

The fascinating thing about all of this was how much an inspiratory breathing position can affect spinal position and how much that affects pelvic position during movement.  Not only is spinal position impacted by breathing, the muscles of respiration, including the serratus anterior and transverse abdominis, are also important spinal stabilizers.  Blandine Calais-Germain points out in her book "Anatomy of Breathing" the serratus anterior is a powerful inspiratory muscle that does not involve the neck.  Rather, it has a strong rib cage posture which serves as the base for the neck region.  It is also an extremely important stabilizer of the scapula.  One of the rationales behind maintaining a good breathing position is this allows proper shoulder blade positioning and therefore proper shoulder stabilization.  Another important aspect of proper breathing which has strongly influenced how I move is the relationship between the diaphragm and the psoas.  In a review by Buchholz (1995), Elsa Gindler's work on the function of the diaphragm is discussed, including the fact that the diaphragm properly lowers only if both the psoas major and minor and the hip joints allow free leg-movement and low back flexibility.  Additionally, Page, Frank, and Lardnor (2010) point out spinal stabilization occurs if the transverse abdomens, multifidus, diaphragm, and pelvic floor co-activate for both trunk stability and force transmission.  Weakness in the pelvic chain can lead to dysfunction elsewhere, including low back pain, IT band syndrome, anterior knee pain, ACL tears, and ankle sprains.

So what does this all have to do with running gait and hamstring injuries?  By using primarily a chest breathing pattern, I was not properly stabilizing my pelvis.  To compensate for my lack of spinal stability, I learned to accomplish hip extension by anteriorly tilting my pelvis.  This, of course, shortened my psoas, turned off my poor gluteus maximus, and caused the rest of my posterior chain (calves and hamstrings) to go into overdrive leading to the appearance of the old hamstring injury.  Two fascinating things have happened since I have adopted a better breathing strategy.  The first is that my running stride has improved.  When I catch sight of myself in windows, I am no longer arching my back.  I am able to breathe into my belly as I run and my posture is much better.  The combination of better breathing, improved spine position, and active release therapy on my hamstring has resulted in no more hamstring pain.  The second thing that has happened is I no longer feel any lumbar spine compression when I practice yoga.  I have always had too much mobility in my lumbar spine.  My solution has always been to draw my belly button in to activate my transverse abdominis.  It turns out drawing in the naval doesn't activate the TrA, but breathing diaphragmatically does.  This has made a huge difference in how my back bends feel and I suddenly understand why the inhale always happens while moving away from the earth- to stabilize the spine.  Mark Stephens wrote a really interesting blog that discusses engagement of Uddiyana Bandha which can be found here: http://www.markstephensyoga.com/blog/mula-bandha-uddiyana-bandha.  He essentially says we want a relaxed belly during practice, not a contracted one.  While it has been really hard for me to throw out years of "engage Uddiyana Bandha.  Pull the navel towards the spine," the elimination of discomfort in the lower back and the improvement in my thoracic extension has been rather extraordinary.

One last note is much of the positioning of the spine and ribcage comes not from a pelvic tilt, but from a dropping of the ribcage.  This can be difficult to understand at first and, while it is a subtle distinction, it is an important one.  Dropping the ribs flattens the lumbar curve by using thoracic mobility, not lumbar mobility.  This allows spinal stabilization to occur and does not compress the lumbar vertebrae.  I do think this is what has made a huge difference in how my backbends feel and present themselves.  It is also what I focus on while running to maintain a proper pelvic positioning.  Years ago, when I read Chi Running by Danny Dryer, I couldn't figure out why he wanted people to pretend like they were hugging a big ball before they began running.  In retrospect, I see it accomplishes the same spinal position in a different way.

If you are interested in more reading on this topic, "Anatomy of Breathing" does a really nice job explaining the breath in a not overly technical way.  Sue Falsone's Movement Lecture on the thoracic spine also does an excellent job explaining the role of breathing in spinal stability.

Yours in health and wellness,
Jenn

Calais-Germain, B., (2006).  Anatomy of Breathing, Eastland Press: Seattle.
Buccholz, I., (1994).  Breathing, voice, and movement therapy: applications to breathing disorders.  Biofeedback Self Regulation, 19(2), pp. 141-153.
Page, P., Frank, C.C., & Lardner, R., (2010).  Assessment and Treatment of Muscle Imbalance.  Human Kinetics: Illinois.

V-Core instructor training and why runners should do things barefoot

Last week, I had the privilege of taking a V-Core certification class with Dr. Emily Splichal. Dr. Emily is a podiatrist in NY who introduced me to the golf ball technique I discussed here and whose guest blog can be found here.  She advocates barefoot training as a way to improve foot stability, mobility, and integrate hip and foot function.  She believes in an evidence based approach to programming and selects exercises based on their proven effectiveness, rather than simply because it "looks" cool.  She is an excellent teacher and a thorough lecturer.  By the end of the 6 hour workshop when we were reviewing anatomy, I found myself thinking, "of course the gastrocnemius and the peroneals concentrically evert and plantarflex while the soleus and its best friend the posterior tibialis plantar flex and invert and it only makes sense that at initial contact the foot is rigid, becomes flexible (pronates) and then becomes rigid ago for toe off.  Why didn't anyone else ever explain it this way?"  The workout was challenging, and by the second workout, I noticed some other participants fighting fatigue (lack of gluteus medius control during dynamic balance exercises, difficulty balancing as effectively), but that's to be expected at the end of a long day.  The sequencing was well thought out.  I found myself repeatedly thinking how good this style of training would be for runners.  Not only was the workout performed barefoot without socks to optimize feedback from the ground, the movements are sequenced so that there is a gradual build in difficulty without some of the masochism often found in a group exercise setting (the "we will do this until we are all dying" approach).  If I were teaching this to runners, I would integrate diaphragmatic breath with an emphasis on neutral pelvic alignment to bring a little more awareness to the LPHC, but this was a foot workshop focusing on foot mechanics, so that is simply a personal preference.

There is this fascinating thing that runners do when they take up exercise programs.  They exercise with shoes on and they often choose exercises that are done in a seated position or on 2 legs.  Running, of course, is an activity that takes place entirely while standing and on one leg; as a result, I have always felt it is important for runners to incorporate single leg training into their routines.  An interesting journal article by Barr and Harrast (2005) points out 40-50% of all running injuries take place below the knee and foot problems are the most common injuries reported by marathon runners.  What this says to me is that runners need to strengthen the foot and ankle complex as part of their movement regimen.  Performing exercises while maintaining a short foot, for example, is a great way to begin to re-establish the neuromuscular control necessary for proper gait mechanics.  This, along with improving ankle dorsiflexion, can begin to combat the risk of plantar fasciitis; Barr and Harrast state runners with ankle dorsiflexion of 6-10 degrees have a 2.9 odds ratio of developing plantar fasciitis while runners who had 0 degrees or less of ankle dorsiflexion have an odds ratio of 23.3.  This is a substantial difference, and one that should be considered when developing strength and mobility programs for runners.  Further up the kinetic chain, these factors can contribute to anterior pelvic tilt, lack of hip control, and excessive knee movement in the frontal plane.  Runners need to perform movements that integrate foot and hip function and emphasize proper mechanics all of the way up into the pelvis and lumbar spine.  Another point Dr. Emily made during the V-Core workshop which also applies to running gait is there needs to be a focus on eccentric control, rather than simply focusing on concentric contraction.  Functionally, decelerating motion is critical for proper stabilization patterns during gait mechanics.  This is why things such as hopping can be so good for runners- proper landing technique requires eccentric control of the lower limb muscles.  She integrated some single leg hops and plie hops that were low impact and felt safe, even in a group setting.  Runners would benefit greatly from integrating some of these gentle plyometrics into their programs.

I would highly recommend taking one of Dr. Emily's workshops if you are at all interested in gait mechanics, integrated barefoot training, and understanding the impact of the foot on the rest of the kinetic chain.  If you are a runner and there is a V-Core class near you, it would be highly worth your time to incorporate this into your training program.  I strongly believe that runners need to do more than just run (especially if they are sitting most of the day) to maintain joint mobility and prevent injury.  If there isn't a V-Core class near you, take your shoes off and, if you are without an arch, try to activate the muscles that lift the arch of the foot away from the floor.  Try to perform some exercises in this position, such as lunging, single leg squats, single leg deadlifts, etc.  Notice how this makes your hips feel and focus on using perfect form with each repetition.  Your running stride will thank you for it.

Yours in health and wellness,
Jenn

Barr, K. P., & Harrast, M.A., (2005).  Evidence-based treatment of foot and ankle injuries in runners.  Physical Medicine and and Rehabilitation Clinics in North America, 16, pp. 779-799.

Running, hip mobility, and the importance of stabilization

One aspect of running gait which has been getting quite a bit of attention lately is the hips, specifically what role they play in sending a person forward.  There are many muscles in the hip, a mobile joint designed to move in the sagittal, frontal, and transverse planes.  The hip and shoulder are designed to function similarly (internally and externally rotate, flex and extend) and the anatomy of the two joints is also similar.  The hip has 6 muscles that function much like the rotator cuff.  The deep 6 muscles of the hip (piriformis, gemellus superior, gemellus inferior, obturator internus, obturator externus, and quadratus femoris) are considered part of the local muscle system, which stabilizes the hip in the femoracetabular joint (Osar, 2012).  The psoas major, minor, pelvic floor, and deep fibers of the gluteus maximus also contribute to hip stabilization, although the deep 6 function primarily to maintain joint centration during rotation.  As we move superficially, the global muscle system, or the muscles that are primarily responsible for movement, can be found.  These include the superficial fibers of the gluteus maximus, gluteus medius, hamstring complex, quadriceps, TFL, adductor complex, and sartorius.  The fibers from the TFL and gluteus maximus joint together to form the IT band, which assists in abduction and internal rotation (Behnke, 2006).  While we consider the hip joint a "mobile" joint, a lot has to happen to maintain stability and throughout movement and gait mechanics.  For instance, if the gluteus medius, which functionally controls hip adduction, isn't firing properly during gait mechanics, the IT band picks up the slack.  This leads to increased knee adduction during running gait and can be a source of knee pain.  In a study performed by Wilson, Kernozek, Arndt, Reznichek, and Straker (2011), the running gait of 20 females without patellofemoral pain (PFP) was compared to the running gait of 20 females with patellofemoral pain (PFP).    EMG analysis revealed gluteus medius activation was delayed and shorter in the PFP group.  Late gluteus medius and maximus onset also correlated to increased hip adduction and internal rotation.  Runners with tight hip flexors have an extremely difficult time extending the hip with a neutral back (Dicharry, 2012).  This not only limits hip mobility, it leads to inhibition of the gluteus maximus which, as seen above can lead to knee instability.

So, what does all of this mean and what can we do about it?  Designing a focused strength and mobility program that emphasizes maintaining knee control during movement in multiple planes and hip mobility while strengthening the hip external rotators and gluteus maximus is a great place to start.  When designing a program, either for yourself or someone, it is important to look at the person's current form during movement, then choose movements to improve function where there is dysfunction, and finally, make sure the movement is executed with quality.  These three things, form, function, and quality, are the pillars of improving moving patterns and enhancing movement function.

Below is a sequence I frequently use to work hip mobility and strength.  If you try it, focus on maintaining proper knee alignment by not letting it collapse.  Also, think about maintaining a neutral spine and letting all of the movement come from the hips.  I usually do 10 per side and switch.  It's a great dynamic primer for more complex movements.

Yours in health and wellness,
Jenn

Osar, E., (2012).  Corrective Exercise Solutions to Common Hip and Shoulder Dysfunction.  On Target Publications: Santa Cruz.
Behnke, R.S., (2006).  Kinetic Anatomy, Second Edition.  Human Kinetics: Champaign.
Wilson, J.D., Kernozek, T.W., Arndt, R.L., Reznichek, D.A., Straker, S., (2011).  Gluteal muscle activation in females with and without patellofemoral pain syndrome.  Clinical Biomechanics, 26(7), pp. 735-740.
Dicharry, J., (2012).  Anatomy for Runners.  Skyhorse Publishing: New York.

Foot Function & Kinetic Transfer- a guest blog by Dr. Emily Splichal

I am excited to share that this week's post is written by educator, podiatrist, and founder of the Evidence Based Fitness Academy (EBFA) Dr. Emily Splichal.  Dr. Emily is also the creator of both the internationally recognized Barefoot Training Specialist Certification and the V-Core certification, a barefoot training workout that emphasizes functionally training the core with specific exercises.  To find out more about Dr. Emily or to check out some of her workshops, visit her website at http://evidencebasedfitnessacademy.com.  Enjoy!

Foot Function & Kinetic Transfer:

With foot fitness and barefoot training concepts at the forefront of athletic performance and fitness programming – how often do you assess your client’s feet?   

One of the most important roles the human foot plays in human movement is in the transfer or unloading of kinetic energy and power!   

The secret to the unleashing of this kinetic energy and power – is supination & pronation. 

When it comes to foot function – or shall I say dysfunction – over-pronation gets the most attention.  Excess mobility or lack of foot strength can lead to excess strain on tendons and ligaments of the foot, knees and hips, leading to over-recruitment of large global muscles to stabilize.   

Let’s take a moment and look at the opposite – lack of foot mobility or over-supination.

Can this be just as harmful?  

If a foot has a limited ability to pronate (or load) how does this impact kinetic transfer and power output?

To fully understand kinetic transfer in the foot, we must also understand that the foot is greatly influenced by the hips – and therefore we cannot address foot dysfunction without integrating hip mobilization!

How is the foot influenced by the hip?

Formed by the femur proximally, the movements of the hip that impact the foot the greatest are in the transverse plane – these are internal rotation & external rotation.   

These transverse plane movements of the hip are transferred distally through the tibia which will influence the foot in the frontal plane.   Tibial movements are able to influence the foot through its direct contact with the talus.  

Talar movements are then translated plantarly to the heel bone (calcaneus) and distally to the midfoot (navicular), causing the foot to either supinate or pronate.   When assessing for integrated foot mechanics, just remember that hip internal rotation is associated with foot pronation – and hip external rotation is associated with footsupination.  

Hip mobility and foot function

If you have a client or athlete with an over-supinated or inverted foot type, you will want to assess their ability to internally rotate the hips.   Often times, I find athletes with a history of stress fractures, plantar fasciitis and tendonitis have restricted hip mobility.   

If this is the case, hip mobilization is key to achieving optimal foot function, foot mobilization and kinetic transfer with each step!   I integrate piriformis, glutes, TFL, lateral hamstrings, and adductor stretces in all planes.  

Empowered YOUth- a book review

I was contacted recently by the Youth Wellness Network to review a book written by its founder, Michael Eisen, and his father, Jeffrey Eisen.  While I feel strongly about youth wellness, it's not my normal area of expertise.  After reading about the organization and Michael, I decided it would both be fun and potentially informative (more information about the Youth Wellness Network can be found here: http://youthwellnessnetwork.ca).  I was pleasantly surprised by a book that, while written primarily for young adults and their parents, should be read by anyone wanting to make changes in their lives.

Empowered YOUth tells the story of two very different individuals.  Jeffrey was born in the 1950s and desperately sought his father's approval.  He was driven, closed off emotionally, and goal oriented.  The stress he placed on himself to succeed led to anxiety, GI issues, and pent up emotions.  As he began to achieve major successes in the business world, he focused solely on his next major accomplishment, never appreciating what he had already achieved or being present for his three children.  This lead to physical problems (he continued to suffer from both GI problems as well as Crohn's disease), and a tumultuous relationship with his youngest son, Michael.

Michael, unlike his father, was an extremely sensitive child who was rather uninterested in pleasing the adults in his life.  As a young child, he earned the reputation of being "spirited" and "challenging."  He never really fit in as an adolescent until he discovered his love of basketball could also be a way to be accepted by others.  However, rather than continuing to enjoy the sense of being in the moment basketball originally gave him, he became fixated on earning the most points each game and proving his prowess on the court.  This eventually takes away from the magic the game once held for him and results in the game becoming a goal oriented, rather than process oriented, endeavor.  One of the themes that runs throughout Michael's first 20 years of life is his need to blame others for things that happened to him, instead of focusing on how he chose to respond to difficult situations.

When Jeffrey is in his mid-fifties, he realized his business successes weren't fulfilling him.  He felt something was missing, and stumbled upon life coaching as a way to both give back and improve himself.  During this time, Michael floundered at University, attempting to figure out his path.  Through the suggestion of Allan, Michael's older brother, Michael began to be coached by his dad.  As their previously strained relationship begins to improve, both Michael and Jeffrey experience important changes in their outlooks, goals, and attitudes towards life.

One of the themes that ran continuously throughout the book as a way to become empowered was the concept of mindfulness.  Mindfulness, as defined by www.psychologytoday.com, is "a state of active, open attention on the present.  When you're mindful, you observe your thoughts and feelings from a distance, without judging them good or bad."  This is an extremely valuable tool and one which can be difficult as a young person to grasp.  When I was an adolescent, one of the adults in my life (I can't remember which one) gave me the copy of a speech entitled "Attitude."  I read it often and while I couldn't always fully grasp the meaning behind the author's words, the last line impacted me greatly.  It stated, "I am convinced that life is 10% what happens to me and 90% how I react to it.  And so it is with you...we are in charge of our attitudes," (Charles Swindoll).  Though I didn't realize it at the time, this tool of simply recognizing my reactions helped me deal in a much more positive way with difficult issues in my life.  Being a teenager is a very self absorbed time, where everything that happens is viewed from the eyes of "how does this impact me."  That tends to be the place we react from, which leads to much more emotional responses as a young person than is necessary.  Those who learn to internalize their responses often end up sick, as represented by Jeffrey in the book.  Being in the moment and understanding the control we have over how we respond enables us to both deal with the difficult situation at hand and not over react.  One of the things that helps tremendously with this is exercise.  Sports is such a wonderful outlet for emotion and allows us to be calmer in the moment.  Dr. John Ratey's book "Spark" does an excellent job explaining the psychological benefits of exercise, particularly on mood.  One point he makes which is also made by the Eisens, is that exercise should be mindful.  We need to be present while we exercise, aware of what we are doing, focused on how we are feeling in that instant, rather than putting on headphones, watching TV, and going through the motions.  Viewing exercise as a skill is helpful with this, and finding a type of exercise that one actually enjoys is also helpful, rather than perceiving it as a chore, a drudgery that must be done because it is "good for me."  Yoga, martial arts, learning a sport, powerlifting, running, a well designed complex functional training program, all of these are movement skills that can and should be performed with a level of mindfulness and attention that have benefits reaching far beyond just the physical.

I would highly recommend Empowered Youth not just to adolescents and young adults, but to their parents, teachers, and people who want a better understanding of how their actions impact themselves and others.  Empowered Youth can be purchased at Amazon (follow link here).

Yours in health and wellness,
Jenn

Bridging, hamstring dominance, and how to find your glutes

Bridging is one of those movements that shows up in multiple systems, with multiple variations, for differing reasons.  There is the post rehabilitation bridge, designed specifically to work hip extension, the yoga bridge, which emphasizes opening up the front of the body, and the Pilates bridge, which focuses on vertebral segmentation.  There is the Cook hip lift, the handstand to bridge in yoga, and the interesting CST bridge involving arm reaches and rotation, which I have only been exposed to once and in no way have mastered.  All of these movements share the basic premise of hip extension and, when done incorrectly, can lead to either compression of the lumbar vertebrae or hamstring cramping/discomfort due to moving from the wrong place.  Today, I am focusing on the latter, although I would argue that learning how to activate the gluteal musculature not only takes pressure off the hamstrings, but also allows the lumbar region to stay stable during hip extension.

The two main muscles involved in hip extension are the gluteus maximus (GM) and the hamstrings muscle group, specifically the long head of the biceps femoris (BF) and the semimembranosis (SM) (Ono, Higashihara, and Fukubayashi, 2011).  In an ideal world, the gluteus maximus would be the prime mover, or main muscle used, and the BF and SM would be synergists, or muscles that help the gluteus maximus do its job.  Unfortunately, what happens often in a culture where we spend a lot of time sitting and is these muscles become, in the words of the wise Sarah Young, "lazy."  As a result, the BF and the SM pick up the slack, and take over as the prime mover.  Why is this bad?  Unlike the gluteus maximus, the BF and the SM aren't designed to generate large amounts of force.  In a case study of a 42 year old triathlete complaining of hamstring cramping, EMG analysis showed excessive hamstring activation during hip extension and GM weakness (Wagner, Behnia, Ancheta, Shen, Farrokhi, and Powers, 2010).  A hip strengthening program focusing on GM activation got rid of the cramping and increased GM strength.  I would argue that an even greater issue with the hamstrings becoming the prime mover is an increased risk of hamstring avulsion.  If the BF and SM are responsible for generating force repeatedly throughout the day, during standing up from a chair, running, and walking up stairs, eventually the wear and tear on the muscle will take its toll.  Research needs to be done in this area to support this hypothesis, but I know I can think of three people off the top of my head who have either strained their hamstrings or experienced a rupture.

What does this have to do with bridging?  It is important when learning how to bridge and teaching bridging to make sure the hip extension is initiated with the gluteus maximus.  For the sake of this blog, I am going to focus on a post-rehabilitation bridge with the ultimate goal being something like the Cook hip lift or some other version of the single leg bridge, although both yoga and Pilates have their own tricks for ensuring proper activation patterns.  I find having the person perform the exercise barefoot helps with GM activation.  There has been surprisingly little (or no) research done on the effects of barefoot training versus shod training on GM activation, so this is purely anecdotal.  The feedback from the floor and the focus on big toe activation seems to help the person find the right area.  Another part of neuromuscular retraining which I find useful is visualization.  Livesay and Samaras (1998) reported a significant increase in forearm EMG activity in subjects who were asked to visualize squeezing a ball with their dominant forearm.  I have individuals focus on planting the foot firmly and evenly into the ground, using the big toe, pinkie toe, and heel to evenly distribute the weight.  Then, I have the person imagine the GM, or butt, is doing the work to lift the hips on the ground.  I have the person think about this while taking 3-5 deep, diaphragmatic breaths, maintaining that sense of grounding with the feet.  After breathing and visualizing, I ask the person to lift up, extending (not squeezing) at the hips.  I am looking for a straight line between the knees, hips, and shoulders.  I make sure there is no compression at the cervical spine and that the lumbar spine stays in a neutral position, not arching.  The person holds for a count of 5 and lowers down, repeating 10-15 times.  Once the person has mastered this, it is time to progress to alternating bridges, which involves moving the feet all of the way together, placing the hands on the hip bones to make sure they stay even, and picking up one foot, and then the other.  There should be no hip rotation and, if the foot and GM are integrated properly, there should be no cramping in the hamstring.  The final progression is the single leg bridge, which can be done by starting in the same position and lifting the right leg off of the ground, the Michael Boyle version, which involves putting a tennis ball between in the hip flexor crevice of the right hip flexor and holding it there, or the Gray Cook way, which involves placing the hands around the shin of the right leg while lifting up.  Everything else remains the same, and it is extremely important to maintain good contact with the ground with the left foot, focusing on extension of the left hip.

And, for the final question, why do we work on bridging?  Hypothetically, if we can master hip extension in a supine position, it should make it easier to transfer the concept of hip extension while standing during movements such as squatting, walking, running, and stepping.  These movements should be initiated with the GM and assisted by the BF and the SM, not the other way around.  Remember: maintaining proper movement patterns allows you to move better and hopefully move more.

Yours in health and wellness,
Jenn


Ono, T., Higashihara, A., & Fukubayashi, T., (2011).  Hamstring functions during hip-extension exercise assessed with electromyography and magnetic resonance imaging.  Research in Sports Medicine, 19(1), pp. 42-52.
Wagner, T., Behnia, N., Ancheta, W.K., Shen, R., Farrokhi, S., & Powers, C.M., (2010).  Strengthening and neuromuscular reeducation of the gluteus maximus in a triathlete with exercise-associated cramping of the hamstrings.  Journal of Orthopedic and Sports Physical Therapy, 40(2), pp. 112-119.
Livesay, J.R., & Samaras, M.R., (1998).  Covert neuromuscular activity of the dominant forearm during visualization of a motor task.  Perceptual Motor Skills, 86(2), pp. 371-374.

The 2030 report and why exercise professionals have to work together

There were several topics I considered writing about in this month's blog (pain and how it impacts movement, gluteal versus hamstring dominance and how it affects bridging), but after reading "F as in Fat," a report released by Trust for America's Health, I decided those other posts could wait.  "F as in Fat" paints a rather dark picture of the potential state of America's obesity problem (to read the full report, click here: http://healthyamericans.org/assets/files/TFAH2012FasInFat18.pdf).  The good news is that some progress is being made.  In Mississippi, for instance, the rate of overweight and obesity in public school elementary students dropped from 43% in 2005 to 37.3% in 2011.  That is a substantial difference, and one that should be applauded.  However, over 35% of adults are considered obese (BMI of 30 or greater) and 19.6% of children between the ages 6-11 were considered obese in 2008.  This is tragic, not only from a healthcare cost aspect, but because of the negative impact obesity has on wellbeing.  Obesity has many causes and can be looked at from many different angles, but from a fitness professional's standpoint, increasing physical activity is paramount, both in our children and in our adults.  In California, one of the fitter states with 23.8% of the adult population obese, 19.1% of adults reported they participated in no physical activity in the last 30 days.  And in Colorado (the fittest state, at 20.7% obese), only 29.2% of high school students were physically active for 60 minutes, 7 days a week.

In all fairness, as an exercise professional and one who reads the trending news bits in popular media, it is easy to see how daunting exercise can be.  "How much?"  "What type?"  "Is one better than the other?"  "This fitness professional is showing me the best movement to tone my behind, but I tried to bend like she did and strained my back.  What should I do now?"  "And how come some people say high intensity is the only way to go?"  This, coupled with some of the bootcamp style exercise programs popularized by shows like "The Biggest Loser," is enough to make a person's head spin.  Top that off with the fact that industry experts can't even agree (Running is bad!  Crossfit is bad!  Yoga will hurt you!  You should be doing short burst for 4 minutes a day!  Personal training is a waste of money!  People should be self motivated!) and it's overwhelming, to say the least.  When people come to me and ask me what type of exercise program they should embark on, my first question is always, "well, what do you like?"  Dr. Stuart Brown points out in his book "Play" that often we can reflect on what type of play we enjoyed in our childhood and turn that into a hobby as an adult.  I personally think that the words "exercise" and "workout" conjure up images of drudgery.  As Dr. Brown states in regards to running, "Sometimes running is play, and sometimes it is not.  What is the difference between the two?...Play is a state of mind, rather than an activity," (2009).  As exercise professionals, this should really be the first thing we embrace when encouraging physical activity.  As a result, we should stop focusing on the fact that one type of movement/activity/exercise is better than another and embrace a person's individual motivation for increasing movement.  If someone derives motivation and a sense of play from participating in a Crossfit class, despite the fact it is not my personal movement of choice, I am not going to talk him out of it (although I am going to strongly encourage finding an experienced and educated coach).  And every time I see negative comments by fellow professionals crop up about running or yoga (two of my favorite movement choices), I remind myself that no one but me has to approve of my exercise selection.  But I am an educated, knowledgeable professional in the area.  Think of how this must appear to someone who decides he wants to begin integrating exercise into his life and, when reading multiple blogs on the internet, he learns that fitness professionals have an extremely difficult time agreeing what the "right" type of movement is.  People should be encouraged to try a variety of things until they find something that they enjoy, that makes them lose themselves in the moment the way play does.  Instead of arguing over whose method is right, let's work together.  It never bothers me when I realize I can't provide the type of training or the type of movement a person needs.  I simply point the person in the direction of a professional specializing in that type of movement that I trust and holds a similar philosophy of quality over quantity.  If we want to change the course of America's plunge into a nation of osteoarthritis, diabetes type II, coronary heart disease, we have to start working together and embracing all types of movement as valid and good.  Our country deserves it.

Yours in health and wellness,
Jenn

Brown, S.B., (2009).  Play, Penguin Group: New York.

Training the foot (and what happens when you do trigger point work daily)

At the beginning of August, I went to Arizona to attend lectures and meet some of my classmates I have been virtually conversing with for the last two years.  One of the women I met, Emily, is a podiatrist who believes in treating the foot like any other body part and strengthening it to withstand everyday use.  Her website is here: http://evidencebasedfitnessacademy.com/index.html.  I am hoping to attend one of her workshops when she comes back out west, but I started to think about this concept of training the feet and how ignored this body part often is.  Charlie Weingroff refers to the "short foot" in his DVD "Training=Rehab" and Dr. Evan Osar discusses forming a tripod by engaging the big toe, pinkie toe, and heel while standing in his book "Corrective Exercise Solutions to Common Hip and Shoulder Dysfunctions."  When we think of the foot, we often think of the plantar fascia, a sheath of fascia that wraps underneath the foot and attaches near the proximal metatarsalphalanges (Bhenke, 2006).  Beneath the plantar fascia are four layers of muscles that control the motion of the foot when static and during locomotion.  When these deep intrinsic muscles are not as strong as they should be, the plantar fascia becomes the primary mechanism for preventing foot collapse; while the posterior tibialis functions primarily to prevent foot collapse and prevent excessive tension on the plantar fascia, other muscles, such as the flexor digitorum longus, flexor hallucis longus, peroneus longus, Achilles tendon, gluteus medius, gluteus minimis, and TFL all work together to control foot motion and shock absorption (Bolgla & Malone, 2004).  Clearly, as with training any other body part, it is important to focus on strengthening the entire kinetic chain during dynamic motion to gain muscular synchronicity and efficiency.  The short foot is an easy way to begin to bring awareness to the deep stabilizers of the feet.  Two small studies, one performed by Jung, Kim, Koh, Kwon, Cynn, and Lee (2011) and the other performed by Lynn, Padilla, and Tsang (2012) suggest performing short foot exercises were more effective than toe curl exercises at improving height of the medial longitudinal arch (MLA) and decreasing center of pressure.  This makes sense; rarely in regular life do we curl our toes.  However, if we can teach our MLA to not collapse during everyday movement, especially if we are on our feet often (runners, factory workers, hairstylists), we should hypothetically be able to reduce the tension on our plantar fascia.  I find Dr. Osar's cueing useful when teaching a short foot.  I have also seen practitioners physically lift the medial arch and cue the person to feel the activation of the foot muscles with the arch lifted.  (As a side note, I find people prone to supination have a different problem with being able to engage their big toes during movement.  The muscles of the feet lack the flexibility needed to perform pronation, which is a natural movement that occurs during locomotion).  Another important aspect of the foot is maintaining toe mobility so the toes can perform properly during toe-off.  This is particularly important during running gait, when the intrinsic muscles of the foot contract to stabilize the transverse tarsal joint, absorb ground reaction forces and propel the body forward (Dhugan and Bhat, 2005).  If these muscles are not working properly, one risks placing more stress on the surrounding ligaments and joints.  Gaining a sense of awareness of how your foot feels while in contact with the ground and beginning to train some of these deeper, stability muscles can lead to a better sense of alignment all the way up the kinetic chain.

While I was chatting with Emily about her philosophy and experience with feet, she mentioned she recommends everyone stand with a golf ball under each foot at the end of the day.  "Stand on it, don't roll," was her advise.  Trigger points, or areas which are sore when pressure is applied, can occur where ever there is fascia.  The feet, which are used all day, are susceptible to trigger points in the plantar fascia and in some of the deeper layers.  Me, being the slightly compulsive person that I am, decided to stand on a little tennis ball I have that is about the size of a golf ball both in the morning and in the evening (if once is good, twice must be better, right?).  When I started, it was difficult to apply much pressure at all.  I start with the ball right in front of my heel and every 30 seconds, move it forward just a little bit.  After 3 weeks of diligent use, the trigger points in my feet have lessened significantly.  I will save the science behind soft tissue work for a different day, but if you have trigger points anywhere, know that the pain will greatly be reduced if you perform self soft tissue work regularly.  This reduces overactivity in the muscles with trigger points and allows other muscles to begin working.  Even better, see a talented massage therapist at least twice a month and perform soft tissue work on yourself daily.  Your body will thank you.

Yours in health and wellness,
Jenn
www.bewellpt.com



Osar, E., (2012).  Corrective Exercise Solutiojns to Common Hip and Shoulder Dysfunction.  On Target Publications: Santa Cruz.
Bhenke, R.S., (2006).  Kinetic Anatomy: The Essentials of Human Anatomy, Second Edition, Human Kinetics.
Bolgla, L.A., & Malone, T.R., (2004).  Fasciitis and the windlass mechanism: a biomechanical link to clinical practice.  Journal of Athletic Training, 39(1), pp. 77-82.
Jung, D.Y., Kim, M.H., Koh, E.K., Kwon, O.Y., Cynn, H.S., & Lee, W.H., (2011).  A comparison in the muscle activity of the abductor hallucis and the medial longitudinal arch during toe curl and short foot exercise.  Physical Therapy of Sport, 12(1), pp. 30-35.
Lynn, S.K., Padilla, R.A., & Tsang, K.K.W., (2012).  Differences in static and dynamic balance task performance following four weeks of intrinsic foot muscle training: the short foot vs. the the towel curl exercise.  Journal of Sport Rehabilitation, [Epub ahead of print].
Dhugan, S.A., & Bhat, K.P., (2005).  Biomechanics and analysis of running gait.  Physical Medicine and Rehab Clinics of North America, 16, pp. 603-621.

Dynamic Neuromuscular Stabilization- A workshop review

It's all about the breath.  That is the basis of dynamic neuromuscular stabilization, or DNS, a movement philosophy based on Pavel Kolar's work as a physiotherapist with a PhD in pediatrics (more info on Dr. Kolar can be found here: http://www.rehabps.com/REHABILITATION/Kolar.html).  DNS focuses on reestablishing proper breathing patterns using the entire diaphragm to create intra-abdominal pressure (IAP).  Once IAP is established and joint centration has occurred, movement can take place (joint centration refers to the proper position of the bone in the socket).  Movement patterns that are grooved use a developmental kinesiology approach, i.e. legs in the air, diaphragmatic breath, a caudal rib positioning, similar to a 3 month old baby, with the arms and legs then moving in various patterns while maintaining IAP.  This is far harder than it sounds and was a bit eye opening for those who consider ourselves strong (and there were a few of us in there).  Our instructor, a physiotherapist from Prague named Zusana, was fantastic- patient, with an obvious mastery in the information she was conveying.  The class consisted of people from all over the US (Baton Rouge was the furthest anyone had travelled) and diverse backgrounds.  Some of the people in attendance were a Pilates instructor, ATC from a physical therapy clinic, Stanford athletics ATC, Feldenkrais practitioner, ortho bionomy practitioner, Football strength and conditioning coach, and massage therapist.  I felt the content had wide reaching application and I appreciated Zusana's approach to the material.  When someone asked her "how" to sequence an exercise program, her response was, "there is no cookbook approach.  You all do what you do.  The goal is to incorporate some of the principles into your approaches."  She wasn't trying to change how any of us do things; rather, the goal was to simply get us to think about things a little bit differently and give us more tools so we could do our jobs a little more effectively.

I was familiar with the principles of DNS, thanks to listening to webinars with Charlie Weingroff and reading/watching presentations by Dr. Evan Osar, both of whom have a more integrated approach than many strength and conditioning coaches.  One of the hardest things for me within the personal training field is there are so many different ways of doing things and no "expert" has resonated with me enough for me to want to "study" with him.  This is different than yoga, for instance.  There are many different types of yoga.  Once you find a style that speaks to you, you can take workshops or classes with senior teachers.  I have learned a ton of both practical and conceptual aspects of Ashtanga by attending workshops with a number of senior teachers and it has always made me a bit sad there is nothing like this in the personal training world.  The DNS approach feels like what has been missing, at least for me.  It is a fundamental concept I can thread through my sessions that makes sense.  I will take Sports Course part II in November if Zusana comes back to SF (there were rumors she will come up to the bay area after teaching in Phoenix), and from there, I might consider moving into the Basic Courses.  While I am unable to do soft tissue work, the better understanding I have of how the body works, the better trainer I will be.  I feel like many trainers get stuck.  They learn how to move, figure out what works for them, and never really expand past that to learn more techniques and apply new principles.  This doesn't always address some of the more basic stability problems and often allows individuals to continue adopting efficient compensation patterns.  I strive to help people move better and move more, and I think DNS might help me do that.

Yours in health and wellness,
Jenn
www.bewelllpt.com

Adapting Ashtanga

As some of you are aware, I am an Ashtanga yoga pseudo-junkie.  I love everything about it- the breath, the poses, the way it is sequenced, the challenge of it.  However, some of the very things I love (the poses, the sequence) conflict strongly with the philosophy I take with my clients.  I feel movement should be individualized to enhance and correct a person's posture and improve movement, two things Ashtanga doesn't always provide (at least in my opinion).  At times, I find myself conflicted, particularly when a client wants to begin a yoga practice and wants me to be the guide.  Many of my clients have or have had injuries and/or pain and are in their 50s and 60s.  They trust me to help them move better and the clients who end up asking me to teach them yoga do so after we have been working together awhile and they trust me not to hurt them.  Currently, I am teaching yoga to a wonderful woman I will call Kay.  Kay is in her early 60s, practiced a yoga program designed for her by someone 30 years ago for decades, has had hip replacement, needs the other hip replaced, has experienced bouts of vertigo with headstand, has scoliosis, and was injured in the last guided yoga class she took.  Kay strength trains with me twice a week.  We emphasize good hip mechanics, strength, and core stability.  I do not feel Kay is a good candidate for the Ashtanga primary series for a variety of reasons; however, I think elements of first and second series with a strong attention to mindfulness and movement with breath will benefit her posture and her current physical condition tremendously.  We are currently working on Ujjayi breath, slow sun salutations, some of the standing postures (we are skipping revolved side angle because it is difficult for her to hold the hip firmly in the socket during rotation and move from the thoracic spine rather than the lumbar), some of the seated postures (not always with vinyasa between but always with breath), some modified postures from second to improve thoracic mobility, and a modified closing sequence.  Sometimes, I feel a bit fraudulent (this isn't Ashtanga!  I am not being true to lineage!), but I return to ahimsa, which is my guide as a personal trainer and yoga teacher.  To practice ahimsa, I must do what I think is right for the client or student and help, rather than hurt.  While this isn't necessarily "true" Ashtanga, it is Ashtanga that has been adapted to the individual's needs.  Sometimes, I think it is important to practice flexibility in teaching to provide the greatest benefit.  Kay is thoroughly enjoying our yoga practice, and has recently added another day.  She might not be standing on her head anytime soon, but I am confident that she will progress from modified cobra to upward facing dog without pain.  The greatest sense of success as a teacher often comes from what an outsider might view as a simple improvement.

Yours in health and wellness,
Jenn
www.bewellpt.com

Hip extension, running, and the importance of dynamic hip mobility

Running is a dynamic, repetitive movement pattern.  The trouble with these types of activities is if you lack a good, basic movement and you perform a version that is slightly off over and over again, things don't work as well.  It's kind of like a door that is on a hinge slightly crooked.  You don't notice that the hinge is rubbing wrong at first, and the door opens fine the first 50, 100 times.  After a while, the door doesn't swing as well and eventually, the hinge wears down and the door, while it might still open, doesn't function well.  Your body functions much the same way.  You can get away with certain faulty movement patterns for a while, but after enough times, something's gotta give.  In the case of running, the poor knee (which should move forward and back, not side to side) is stuck between two joints that are supposed to be quite mobile (the ankle and the hip).  The movements we perform in our every day lives do not favor ankle and hip mobility; as a result, the knee often loses some of its stability.  Running with hips and ankles that lack mobility is setting that knee up to function like the crooked door hinge.

Hip extension is critical to good running mechanics.  Our society is extremely forward in nature.  We sit, hips flexed, at desks with our heads jutting forward.  This shortens everything in the front of the body and reduces our ability to properly use the muscles in the back of the body.  Schache, Blanch, and Murphy (2000) found a correlation between limited hip extension flexibility and increased anterior tilt during running.  While there is little in the literature that discusses the importance of hip mobility as it relates to running stride, Saunders, Pyne, Telford, and Hawley (2004) point out a strong correlation between running economy and distance running performance; further, muscular stiffness and efficient mechanics are thought to decrease the amount of energy wasted on braking forces and vertical oscillation.  If you do not have good hip mobility, you are going to be unable to extend your hip, leading to a more forward dominant running stride.  This often leads to a running pattern that involves more hip flexion, causing the foot and knee to land more forward.  As a result, the ground and the foot collide each time the foot lands, resulting in more braking forces.  Couple this with poor ankle mobility, and there are more than likely going to be problems.  One way to work on hip extension is to implement a corrective exercise program that emphasizes hip extension and mobility.  Exercises such as squats, lunges, and bridging are great ways to begin to activate the hip area.  More advanced and complex moves such as McGill's airplane, the Cook hip lift, and Bulgarian split squats can reinforce proper hip mechanics and gluteal activation if performed properly.  It is also important to not neglect the ankle area.  Implementing simple drills, such as seated ankle dorsiflexion, ankle circles, and inverserion/eversion, can dramatically increase ankle mobility.  Remember, when implementing a strength and conditioning program, understand your goals and know what movement patterns and mechanics are necessary for success in your chosen sport.  This, coupled with your current static and dynamic posture, should dictate the exercises you choose, not necessarily the exercises "everyone else is doing."  Move well and move often.

Yours in health and wellness,

Jenn

Schache, A.G., Blanch, P.D., & Murphy, A.T., (2000).  Relation of anterior pelvic tilt during running to clinical and kinematic measures of hip extension.  British Journal of Sports Medicine, 34(4), pp. 279-283.

Saunders, P.U., Pyne, D.B., Telford, R.D., & Hawley, J.A. (2004).  Factors affecting running economy in trained distance runners.  Sports Medicine, 34(7), pp. 465-485. 

Monthly goal setting and the importance of mindfulness

This year, I decided to set monthly goals rather than the typical New Year's resolutions.  I diligently wrote out 6 months worth of goals in January, which I re-visit at the beginning of each month to make adjustments and add to, given on how well I accomplished the previous month's goals and to account for the unpredictability of life.  Included are personal and business goals, and it has proven to be an extremely effective way for me to stay on track, personally and professionally.  As March ended, I dutifully pulled it off the refrigerator, revealing a sheet with my plan for my April.  I took it down and began reading through when my eyes came to rest on something that was a bit of a surprise: "Practice second series for 8 weeks."

I was a bit taken aback.  Maintaining a high level of physical activity is not something I struggle with, and while I had placed a handful of physical goals on my monthly goal sheets (I completed a half marathon in March, for instance), I hadn't given much thought to my yoga practice, probably since I had written the goal way back in January.  "Huh," I thought to myself.  "I guess it's time to step up my yoga."

Here is the funny thing about writing a goal down like that.  You feel compelled to do it.  Or, more accurately, you feel compelled to do it if you're me.  I could easily have crossed it off, or placed it somewhere else.  But that would have been failing.  Who, you might ask?  Well, me I guess. I would have known I hadn't done this thing that in January seemed like a good idea.  And it would eat at me, because that is how I am.

So, in the middle of my last quarter of graduate school, buying my first house with my husband, fulfilling my Maid of Honor duties for my sister, and running my business, I began adding second series postures into my three day a week practice.  It's worthwhile to note that while I have been practicing Ashtanga yoga for years, I rarely have the opportunity to practice with a teacher.  In addition, I have been stuck in primary series purgatory (psp) for a very long time.  I go through periods where I begin second series, but then something unforeseen happens, such as riding my bike into a moving car (it was the garbage truck's fault), which makes me step back and return to psp.  In all fairness, I am unable to do some of the key postures that indicate one is ready for second series, such as supta kurmasana; however, the redundancy of the primary series has led to things like handstands after navasana and tripod headstand after bakasana after utkatasana.  As a result, it would seem second series would be a welcome opportunity to mix things up.

A month into it, I can genuinely say it has been a welcome distraction from real life.  It gives me an opportunity to focus and challenge myself in ways I had been avoiding.  It can be difficult to push beyond one's comfort level.  My handwritten goal on the refrigerator has forced me to step out of the familiar and into slightly hard, which can be a little bit scary.  I have 4 weeks left, and am happily practicing pincha mayurasana in the middle of the room.  Who knows what the next four weeks will bring?

Something that has been brought to my attention lately is the importance of performing complex movement patterns.  This benefits not just the body, but the brain as well, leading to increased attention, higher levels of learning, and perhaps even a less anxious state.  This is different than simply plodding away on a treadmill or exercise bike, although I would argue that I am mindful while running and cycling outside, constantly making minor adjustments to improve efficiency.  Yoga certainly falls into this category, as does dance, tennis, and anything else that requires focus.  Dr. Ratey's book "Spark" does an excellent job delving into the psychological benefits of movement.  One of the critical ways to accomplish a higher level of mindfulness during movement is to turn off screens, focus on what you are doing and how you are feeling, and get outside.  The fresh air can be a wonderful way to be more present in the moment and identify how your body feels.

Yours in health and wellness,
Jenn

Scapular stabilization and why we assess

My last blog addressed scapular winging and the importance of serratus anterior activation.  Below is a circuit I often use with clients when I want them to focus on proper scapular alignment and strengthening of the SA.

1. Begin in a plank position, as noted in picture A.  Your wrists should be under your shoulders, your feet should be about hip width apart, and your ears should be aligned with your shoulders, chin slightly tucked.  Resist the floor with your hands, filling in the space between the shoulder blades (if the person isn't getting this cue, I place my hand gently between the shoulder blades and encourage the person to press into my hand).  Hold for 10 seconds or 5 breaths.
2. Lift the hips up and back into down dog, as in picture B.  Press firmly into the index fingers and gently externally rotate the humerus.  Notice how the shoulder blades feel, as though they are gently wrapping around the ribs without elevating.  Hold for 10 seconds or 5 breaths.
3. Lower on to your forearms for dolphin (picture C).  Resist the floor firmly with your forearms.  Make sure the shoulders don't elevate to the ears and keep the neck long.  Again, note how the shoulder blades feel.  Hold for 10 seconds or 5 breaths.  
4. Flatten back into a forearm plank position.  Continue resisting the floor with the forearms and be sure the space between the shoulder blades is still filled in.  The back of the neck should be long, and the chin slightly tucked.  Hold for 10 seconds or 5 breaths.

Rest for 5 seconds, and repeat the circuit 1-3 more times, depending on the person's endurance.  This brings awareness to the shoulder blade area and encourages healthy spinal alignment.

I am excited to announce I will be holding a static and dynamic assessment workshop Saturday, May 19 (for more info, www.bewellpt.com or www.montereyyogashala.com).  Static posture assessment and dynamic movement assessment allow a human movement professional to identify muscular imbalances and potential injury risk.  While the accuracy of movement assessment and how it applies to injury is still being studied, it has been my experience that identifying impaired movement patterns and employing a corrective approach restores movement efficiency, and often reduces pain the individual is experiencing.  The ability to move freely and without restraint is something that is often taken for granted; assessments enable a human movement professional to establish a baseline and improve freedom of movement, both as it relates to everyday function and physical goals.  Assessments enable the professional to design programs that will help an athlete move better, the yogi or dancer improve stability, and the parent perform activities with his child without injury.  I am looking forward to sharing my passion about this topic with others, and hope to see you there!

Yours in health and wellness,

Jenn

Scapular Winging

Something that has shown up repeatedly while researching shoulder dysfunction for graduate school is scapular winging.  This occurs when the scapula collapse back and out, causing the bone to look like a wing, rather than lying flat against the back.  While there can be a number of reasons scapular winging occurs, in a gym setting, one of the main causes is serratus anterior weakness.  The serratus anterior is a muscle originates at the ribs and inserts on the medial border of the scapula.  One of it's primary jobs is to stabilize the scapula.  Lack of scapular stability can be problematic for a number of reasons.  Using the joint by joint theory, the scapulothoracic joint (SC joint) should be a stable joint.  If there is too much mobility in the SC joint, the mobile joints surrounding it, namely the glenohumeral joint and the thoracic vertebrae, are likely to become more stable than they should be.  This can cause a variety of problems, due to less efficiency of movement in the shoulder, which increases risk of injury in the shoulder joint and upper back area (Escamilla, Yamashiro, Paulos, and Andrews, 2009).

Not everyone has scapular winging while standing.  I most often see it when clients attempt to perform a push-up, or in yoga, when students move from plank to chatarangua (something which is often glossed over, at least in the Ashtanga practice).  To correct for this, I first focus on plank position.  I encourage clients to press firmly into their hands, sliding their shoulders away from their ears and maintaining a neutral spine.  From their, I ask them to "fill in the space between their shoulder blades."  If that doesn't work, I place my hand between their shoulder blades and ask them to press into my hand.  I have them hold for 10 seconds, relax, and repeat 3 or 4 more times.  Once we have established a good base there, we work on lowering into a push-up without collapsing the scapula.  As time goes on, people are able to lower themselves down while maintaining good scapular control.  While the scapula retracts during the motion, it shouldn't collapse ahead of the chest lowering down; rather, it should all move as a unit.  With so many people spending hours on end at computers and desks, it is extremely important to pay attention to the cervical and thoracic region, emphasizing proper alignment and good biomechanics at the glenohumeral and SC joints.

Yours in health and wellness,
Jenn
www.bewellpt.com

Escamilla, R.F., Yamashiro, K., Paulos, L., & Andrews, J.R., (2009).  Shoulder muscle activity and function in common shoulder rehabilitation exercises.  Sports Medicine, 39(8), pp. 663-685.
Picture taken from http://www.trihardist.com/2008/06/stop-slouching-winged-scapula.html.  She does a nice job explaining scapular winging and how it impacts sports performance.  She also has come great exercises to begin to correct this issue.