I’ve been working out with fitness anywhere’s TRX system lately. I had read about it and heard rave reviews from some of my fellow fitness and sports med professionals. The TRX is a portable suspension exercise system that delivers as easy or intense as exercise session as you want. Because the design uses your own body weight, you can modify the exercises from easy to ridiculously hard…all while dialing in your core musculature. I already do metabolic and strength circuits, but was impressed at metabolic demands and intensity of workout that was available with this system. From my first use of this system I could see some good rehab application. Sure enough, they are launching their sports medicine & rehabilitation stream to their system. Click below to see a quick clip about how the TRX works.
5-time Leadville 100 runner, Brian Costilow getting K-taped by Lindsey Fitch, DPT prior to going for number 6!
Good luck Brian!
The Leadville 100, America's highest 100 mile race is this weekend. Dr. Joel, 
Own own Adam Plummer gets top spot and a great inside spread in Trail Runner magazine this Summer!
I was in Brighton, CO this past weekend for theFunctional Momvement Systems seminar withBehnad Honarbakhsh.
The background and rational for the Functional Movement Screen and associated corrective exercises are excellent. Despite being the only chiropractor there, the functional movement analysis created by physical therapist Gray Cook fits seamlessly into my problem solving approach to injury and dysfunction. In the few days back at the office since the seminar, I have already started looking at patients differently and changing how I address their problems.
The Functional Movement Screen (FMS) and Selective Functional Movement Analysis (SFMA) uses challenging movements that are meant to exaggerate deficits and asymmetry in the body. If the fundamental movement patterns in the body are altered, then any strength, power or sport specific training may be built upon a shaky foundation which at best will prevent optimal performance, and at worst reinforce imbalances leading to greater chance of injury.
Check out the video here:markjpitcher.com/wordpress/?p=125
Mark
A Big Welcome to Lindsey FitchWe are very pleased to welcome Lindsey Fitch to our team! Lindsey completed her Master and Doctorate Degrees in Physical Therapy from San Francisco State University/University of California, San Francisco. She has worked in the outpatient orthopeadic setting focusing largely on sports injuries. Lindsey has completed specialized training in running analysis and routinely assesses and treats running related imbalances and injuries. Lindsey will be practicing in our Vail and Edwards locations.
Please call 970-926-4600 to schedule an appointment.
Learn more about Lindsey here
Mark Pitcher DC, MSc
chiropractor, exercise physiologist
Dr. Pitcher works in the Vail, Edwards and Eagle offices. To make an appointment call, 926-4600. If you have questions for Dr. Pitcher, you can email him at drpitcher@vailhealth.com
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This might seem like an odd rallying call in this day and age. After all, it seems like there is healthy and nutritious food available in every grocery store. However, if you've ever read a book by Michael Pollan, watched "Fresh", "Food, Inc.", or seen Jaime Oliver's Food Revolution on tv, you may be wondering if your food is really healthy beneath the surface. Over the years there have been product recalls ranging from spinach to frozen meat and peanut butter that have shaken our trust in the large agribusiness and food processing companies. Why are we so scared of our food? And what can we do to ensure that we don't have to be?
My grandmother used to tell me that food didn’t have flavor any more. I was 10, and I thought that my grandmother was just old and experiencing what happens when you get old. As I grew up I saw an explosion of processed foods, convenience foods and fast foods that seemed to be huge steps forward until I was out in an organic garden. I plucked a ripe tomato and bit into it; all of the sudden I understood what my grandmother had meant all those years ago. My grandmother was raised on a farm in Mississippi over 90 years ago where they grew a few cash crops to support the family’s finances along with their own vegetables and raised their own livestock. This was a prototypical small family farm that helped provide for the family and the wider community. As the world changed and industrialization started to become the norm these very small farms faded quickly. After World War Two industrialization spread like wildfire, making many farms impossible to sustain.
We live in a world that surrounds us with cheap food. My grandmother spent a full 25% of her income on food. The average modern family only spends 10%. Subsidies of commodity crops and the extensive use of chemical fertilizers, pesticides and herbicides allow us to grow a lot of cheap calories. Add convenience foods full of empty calories and fat to this equation, and you can see how our food culture has changed.
Thankfully we are experiencing a renaissance of food that has more flavor, nutrition and vitality than anything we have seen in decades. As people found organic foods and demanded more, the industry listened and organic products flourished. Even more importantly, we now understand that even organic food has high costs and risks associated with long distance shipping. As a result, we are seeing a resurgence in gardening, community gardens, farmers markets, farm stands and community supported agriculture.
The relocalization of our food system is a vibrant movement that can change the food landscape all over our state and the country. The challenge in the high country is that we have such a short growing season, ranging from 39 days in Summit County to 59 days in western Eagle county and Routt county. Colorado Mountain Communities are blessed to have growing regions on the Front Range and Western Slope that can feed us through their much longer growing season.
Community Supported Agriculture (CSA) is a way to connect you and your family to a local farm. In a CSA program people become members of the farm and purchase a full season of vegetables that are grown for you on the farm. This direct relationship allows you to know who is growing your food and dramatically reduces the miles your food travels to get to you. Unlike grocery store produce, your farmer grows food for you that is allowed to fully ripen in the field so that you can eat food that is full of flavor, nutrition and healthy for you. CSA’s will normally deliver your produce to your town once a week throughout the growing season. Even in the high country it’s easy to eat farm fresh produce.
To learn more about Community Supported Agriculture and how you can eat better this year call 970-328-1200 or 970-846-6233
http://www.grantfarms.com/home.php
ESPN article explains PGA Tour medical staff treatments. Dr Joel has been part of the PGA Tour medical staff since 2009. Enjoy!!
This is a great interview with Dr. Stuart McGill about how his laboratory research propelled him (Albeit reluctantly at first) into clinical evaluation of patients. He talks about his approach and addresses many rehab myths surrounding lower back pain. Its a long, but extremely interesting interview. Click here and have a listen and you'll see why I am a big fan of Dr. McGill's no nonsense scientific approach to evaluating and treating low back pain.
If you have picked up a health, fitness or training magazine recently, you can not avoid reading about the importance of “core stability”. Core stability is touted as paramount to maintaining a healthy back, however the idea of what “core” actually means, what muscles are involved and what exercises are best vary greatly depending on who you talk to. When you think of the core, the abdominal muscles inevitably come to mind. But that is only part of the picture.
Many of today’s popular ideas of spinal stability originate from research out of the Australian physical therapy group back in the 1990s. The research showed that the transverse abdominis (TA), a deep abdominal wall muscle and the multifidus, a series of spinal muscles, thickest across the lowest part of the lumbar spine, had unique behavior when injured. The transverse abdominis was shown to have a feed forward ability, meaning it turned on before other muscles did during a task that required stability. 1,2. Further it was shown to have altered activity when there was a lower back injury, sometimes turning on late or not at all. The multifidus was shown to decrease in size and have increased fat content after injury local to the site of injury. 3 This deficit did not recover spontaneously, even if the pain went away and it was found specific exercise was needed to rehabilitate the area. 4 Therapists began to use very focused rehabilitative exercises to activate the multifidus and deep abdominal musculature.
The research became popularized, spilling over beyond physical therapy and other health disciplines to personal training and popular fitness culture. The rehabilitative concepts, while useful for addressing specific muscular deficits, grew beyond its scope shaping personal training and core conditioning programs. This may have led to an overemphasis of the deep musculature.
Researchers such as world renowned biomechanist Stuart McGill found that exercises used to activate many abdominal exercises particularly those that repetitively flex and extend the back, offer unhealthy loading of the spine and only work very specific muscles. Further he argues that emphasis on deep musculature can actually destabilize the spine (More on this next time). McGill’’s live and biomechanical modeling also showed that there are not necessarily muscles that were more important than others. All the muscles in the trunk are important at different times, with different loads, under different circustances.5 Movements in the body are almost never a result of one specific muscle, but a result of coordination of many muscles, or muscle systems. Muscles that are further away from the center of rotation (the spine) offer better mechanical advantage than deeper muscles. McGill’s approach is to take a broader stroke, training the movement, not an individual muscle. He developed exercises to address the trunk musculature more comprehensively, focusing on exercises that create adequate muscular challenge across a number of muscle systems while putting the least compressive load on the back.
These exercises are often distilled down to what is often referred to as the “Big Three”. (See the related article on our blog) These basic exercises are commonly used initially in lumbar spine rehabilitation. These exercises are also becoming popularized beyond clinical practice as well. (See the NY Times video here: http://video.nytimes.com/video/2009/06/17/magazine/1194841000095/core-values.html?scp=1&sq=core%20values&st=cse)
All patients are different and what is appropriate for one person may not be appropriate for another. But generally McGill’s basic spine sparing core exercises can be used across many patient populations. Clinically I typically pull from more than one school of thought. If there problems with joint mechanics or muscle adhesions, they are addressed with manipulative and soft tissue techniques. I may also look to identify overt muscular deficits such as multifidus or transverse abdominis issues. If present, muscular deficits are addressed and some basic motor control exercises are taught. However, I will usually progress quickly to include a broader and more balanced approach using various spine sparing exercises based on McGill’s research and concepts.
In our next newsletter, we will continue exploring spinal stability
References:
1. Cresswell, A.G, Thorstensson A. (1994) “Changes in intraabdominal pressure, trunk muscle activation and force during isokinetic lifting and lower. Eur J Appl Physio Occup Physiol. 68: 315-21
2. Hodges, P. W., Richardson C. A. (1997) “Feedforward contraction of transversus abdominis is not influenced by the direction of arm movement.” Experimental Brain Research 114 (2): 362-370
3. Hides, J.A., Stokes, M.J. et al. (1994) “Evidence of lumbar multifidus wasting ipsilatreal to symptoms in patients with acute/subacute low back pain.” Spine 19(2) 165-72
4. Hides, J.A. , Richardson, C.A. et al. (1996) “Multifidus recovery is not automatic after resolution of acute, first episode low back pain.” Spine 21(23): 2763-9
5. McGill 2. M, (2004) “Linking latest knowledge of injury mechanisms and spine function in the prevention of spine disorders.” J. Electromyogr Kinesiol 14(1):43-7
Mark Pitcher DC, Msc
chiropractor, exercise physiologist
At the clinic, we've used Graston Technique for muscle and tendon injuries, but the recent research suggests that it may be useful for increasing the recovery time from ligament injuries as well. It is generally accepted that ligaments repair through repetitive scar formation rather than true regeneration. This can lead to mechanical weakness in the ligament and may be one reason that re-injury is so common in patients with previous ligament injury.
A study published this summer in the Journal of Orthopaedic & Sports Physical Therapy (1) examined instrument assisted cross friction massage (Graston) in an experimentally induced ligament injury in rats.
Four weeks after the injury, the treated ligaments were 43.1% stronger and 39.7%
Stiffer, able to absorb 57.1% more energy before they failed than the non-treated ligaments.
Twelve weeks after injury the differences between treated and untreated ligaments were minimal in terms of strength; however the treated ligaments were 15.4% stiffer.
Although an animal study, this study does support the theoretical basis of using early cross friction massage to speed repair after ligament injury. Although the differences in strength even out over time, lasting increases in stiffness could confer additional protection to the joint itself.
1. Lohgmani MT, Warden SJ. (2009)“Instrument-assisted cross-fiber massage accelerates knee ligament healing”. Journal of Orthopaedic & Sports Physical Therapy. 39(7): 506-514.
New Study from Dr. Stuart McGill’s Biomechanics Laboratory at the University o
f Waterloo
As many of our patients know, we favor research based exercise and rehabilitation at our clinics. For many types of low back pain, spinal stabilization exercises are very commonly used. For patients with back trouble, the back’s load bearing capacity is often diminished so that many commonly prescribed exercises can excessively load the back and are usually inappropriate.
One of the exercise protocols we use for improving spinal stability while minimizing excessive loading is based upon research out of Dr. Stuart McGill’s laboratory at the
Dr. McGill’s publishes exceptional papers more often than some people change underwear. But we found the recent article published this year in the Archives of Physical Rehabilitation titled “Exercises for spine stabilization: Motion/motor patterns, stability progressions, and clinical technique” especially relevant for patients and clinicians.
The article investigates three well researched and commonly used spine sparing exercises that are used in our clinics for spinal stabilization. Three exercises and their progressions were studied: (1) curl-up (2) side bridge, and (3) bird-dog (the “Big 3”). With these exercise, they studied muscle activation, 3D spinal mechanics and the effect of theclinician offering corrective input during exercise.
While I rarely see anybody doing the neutral crunch at the gym I do occasionally see the side bridge and bird dog. However when performed, they are usually done too fast and without the control, neutral spine posture, or attention to muscle co-contraction that is talked about in McGill’s methodology.
One of the co-contraction techniques widely used is an‘abdominal brace” where the patient contacts the abdominal muscles like they are bracing for a abdominal muscles like they are bracing for apunch. Not pushing the belly out or sucking the belly in. Dr. Mcgill’s research showed that raising the elbows off the floor during the neutral curl up increased rectus abdominis activity. Co-contraction with an abdominal brace during the neutral curl up increased the internal and external oblique to 30% of maximal voluntary contraction.
The studies involving the side plank exercise showed clear progression in muscle activation from ½ bridge to full bridge (with legs straight) with the most muscular challenge moving from side bridge to plank resulting in muscle challenge of 50% of maximal voluntary contraction in the rectus, abdominis internal and external obliques.
The bird dog progression was from the all fours position to just arm, then just leg and then both arm and leg, using abdominal bracing and then abducting the arm slightly. The study again showed a clear progression of muscle activation through the progression of the exercises.
When evaluating clinical guidance, factors such as addressing patient asymmetries and applying fascial raking (using firm fingers pressure on the abdominal musculature to add feedback and better activation) were assessed. The fascial raking resulted in increased oblique muscle activation and decreased rectus abdominis activation, therefore improving the neutral spine posture. It was also especially useful in decreasing the amount of twisting (or uncoupling) of the torso during the plank to side bridge.
Although we currently use employ feedback on abdominal bracing and clinical corrections for asymmetry during the exercises, strive for neutral posture and promote abdominal bracing, we have not used the abdominal fascial raking to any large extent. Given the findings of this study, I think patients should expect to start seeing our practitioners digging their fingers in some abdominal musculature during stability exercises.
Mark Pitcher DC, Msc
chiropractor, exercise physiologist
For additional information read Dr. McGill’s Books:
Low Back Disorders and Ultimate Back Fitness
Visit www.backfitpro.com for more information.
VIMG is proud to celebrate Martin’s 3rd Paralympics! GO Martin!
There is often great confusion around the concepts of core and spinal stability. A simple but excellent model is the integrated model of stability described by physical therapist Diane Lee and clinical anatomist Andry Vleeming. Although initially developed to describe stability in the pelvis it is relevant for any mobile joint and certainly in the spine. They originally describe three factors that when operating together result in optimal stability in a joint:
1. Form closure
2. Force closure
3. Motor control
Form Closure describes the passive integrity of the joint system. “Form” refers to how the parts (joint surfaces) fit together. Ligament stiffness, disc health, joint alignment all contribute to this integrity.
Force Closure refers to active muscular component. Inherent muscle stiffness and appropriate muscle contraction applies tension to the joints in the spine like the guy wires of a tent. Tension creates joint compression maintaining integrity of the joint. Tension and compression in the spine must obey the “goldilocks effect”. Too little compression results in instability and too much compression results overloading the spinal structures; it needs to be just right.
Motor Control is achieved through coordination of the nervous system and muscle feedback to create appropriate amounts of tension. Tension needs to be applied through activating the right muscles at the right times. Unlike the tent pole, the spine has moving parts and changing demands requires near constant changes in muscle activation. Although mechanically the spine may act like a complex tent pole, muscle control is more like an orchestra. All the instruments have to work harmoniously to achieve the desired music. If one or more instruments are out of tune, or come in at the wrong time we don’t get the desired symphony, but noise. If the muscles don’t act harmoniously, then the forces exerted on the spine may not protect it when needed, or worse apply uncoordinated forces which may cause it to buckle under load.
These three systems must work together to achieve the conditions for optimal stability. They work in a continuum so if one system becomes compromised, the other systems can compensate. However certain methods of compensation are clearly less than desirable than others.
If the muscle activity or control are compromised and muscles are not activating when they should, or with inappropriate forces, then injury may occur causing damage to passive joint structures. Research has shown us that these deficits in muscle activation and control can also be caused by previous injury. Therefore motor control and muscle activation deficits can be both a cause and effect of pain. Over time, these deficits are compensated for by the damage and anatomical change to the passive structures. Degenerative changes in discs and joints typically results in instability, but the damage over time like drying out of discs and formation of bone spurs eventually increased joint stability. This stability typically comes only after years of pain and disability.
In the opposite situation where passive structures are compromised, muscle activity and good motor control able to compensate with far more favorable outcomes. For example, if there is disc degeneration and decreased disc height, then ligaments can no longer exert the same stiffness across the vertebrae and prevent undue movement. (You’d rather not rely on ligaments to do this anyways – but that’s another article.)The resulting instability can be countered by appropriately increasing the muscular tension across the involved joints. The only disadvantage with this strategy is that unlike anatomical decay, it is not automatic and requires exercise and practice. In people with previous injury, proper motor control often needs to be re-learned and repeated to become habit.
This integrative model is a very useful way to visualize how stability is achieved. Having good motor control, training multiple muscles and ensuring proper joint mobility and alignment are all important elements in maintaining and restoring spinal stability.
Mark J. Pitcher DC, Msc
chiropractor, exercise physiologist
If you have additional questions about core or spinal stability, or wish to make an appointment with Dr. Pitcher to address stability issues, please feel free to contact us at the clinic 970-479-6262, or by email at drpitcher@vailhealth.com
