Archive for February, 2012

Some Monday Randomness…

Posted: February 27, 2012 in Uncategorized

1) It’s probably one of the most common questions I get from friends, family, and patients. And after reading Dr. Jeff Cubos’s blog post, it seems I am not alone. If you were ever curious about the benefits/problems of yoga, So what do you think about yoga? is a great piece to read. I think in the end it always comes down to the same thing; the right exercise for that individual person. Or, straight from Dr. Jason Brown’s blog…

Professor Stuart McGill reminds us that, “There is no good or bad exercise” only ones that are inappropriately applied.

2) For any of you who watched some  college basketball this weekend, you may have noticed a few coaches sporting blue bow ties. And while the fashion statement is much appreciated…

looking dapper

it was done in order to create awareness for prostate cancer. I always love when athletes and coaches use their fame to raise awareness for a good cause like this. It’s just one of the many reasons why sports are so near and dear to my heart.

Yes, I do realize that the bow ties worn this weekend were of the clip on variety but no one is perfect :)…

For anyone interested in further reading about the significance of the blue bow ties, click here.

3) Stay tuned for an article later in the week about foam rolling for athletes (hint: it’s really, really important)

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 Spoiler Alert: Today’s post has nothing to do with Jeremy Lin or Linsanity but my last post had an abnormally high amount of views which I have to credit solely to Mr. Lin’s picture. So, give the people what they want right?!

Earlier in the week I talked about my trip to watch some high school basketball games and how I paid particular attention to the warm-up routines by each team. Not only did I watch what they were doing but also how they were doing it. In other words, I was evaluating the quality of movement. 

It has been drilled into my head every time I go to a rehab seminar that every exercise is a test. This means that while we may add an exercise in to a strength or rehab program for a specific purpose of strength or stability gains, we will also observe how the exercise is performed and constantly check and re-check these exercises with hopes of an eventual progression to something more challenging for the individual once the movement pattern is adequate. To take it one step further, every warm-up is also a test. I know that the athletes who are going through the warm-up think these activities are simply helping them get ready to play. However if used correctly, a coach or strength trainer can gain a ton of information by watching the athletes move.

As I talked about in my last post, the lunge pattern was the most common warm-up exercise I saw and also the most common one that was butchered. The lunge is extremely versatile in that it is a fantastic warm-up, strength, and stability/ mobility movement pattern.

 As many of you already know, there are hundreds of variations of the lunge: walking lunge, walking lunge with overhead reach, backward lunge, side lunge, inline lunge and return, weighted lunge, grilled shrimp, boiled shrimp, fried shrimp… and the list goes on and on.

For the purposes of this post however, I want to share the 3 most common lunge pattern flaws that I observed this past weekend during warm-ups:

  1. Anterior Patellar Shear (APS): This is just a fancy way of saying that the knee is traveling too far forward over the toes. This is also probably the most common flaw I see. The problem with APS is that it makes the lunge more of a quad dominant exercise rather than glute/hamstring. Often times, we know right away if this is problem because the athlete will “feel the burn” on the front of the thigh rather than the back. You will also find in the lead leg that the people who demonstrate APS push-off with the front part of the foot rather than the heel. As with most lower extremity movements (particularly the squat, deadlift) we want most of the force being transmitted through the heel as this facilitates the posterior chain to activate. The easiest way to do this is by removing the shoes altogether so the athlete can really feel his/her engaging with the ground. Obviously, this is not always possible (although it would be interesting to coach a team and make them do an entire pre-game without shoes. Talk about intimidation!). APS is also common in people who say they can’t do a lunge because it makes their knees hurt. Usually, they are just not doing it correctly as APS puts a ton of stress on the knee-joint itself. 
  2. Knee Valgosity: Knee valgosity during a lunge/squat/ really any movement pattern at all, especially in the female basketball population is a HUGE red flag. The incidence of non-traumatic ACL injuries among the female population is way too high and often times landing in knee valgosity is the culprit. Most often this is due to a lack a hip strength/stability (gluteus medius) and really makes me cringe whenever I see it. While we can never prevent all ACL injuries, I strongly believe we could cut down on the incidence simply by screening out and correcting this problem.
  3. Inability to reach an (almost) kneeling position: This was something I saw far too much of at the basketball tournament. I think this is partially due to laziness, but I also feel like a good portion of the athletes simply could not get all the way down. In most cases, I like to see the back knee get within an inch or two of the floor at the bottom of the lunge. The reasons for this inefficiency are endless. One is certainly an overall lack of stability and balance within the movement pattern as I observed a few athletes who started the descent into the lunge, began to shake, and just stood up so they would not fall over. A second reason is  a lack of extensibility within the soft tissue of the hips and leg and mobility within the hip capsule. These findings could only be confirmed upon further, specific testing. 

Finally, here is a lunge pattern without anterior patellar shear or knee valgosity, and with the ability to get the back knee (almost) to the ground: 

In conclusion, the lunge pattern and all its variations are a fantastic group of exercises that serve multiple, useful purposes. However, like  most exercises, if done incorrectly they can cause more harm than good.

Have a great day!

Some Monday Randomness…

Posted: February 20, 2012 in Uncategorized

1)This weekend I was back home in New Jersey and had a chance to watch some high school basketball games. My old high school was playing in the Somerset County semifinals and it turned out to be the craziest finish to a game I have ever seen in my life. For the game story click here. For those of you not wanting to read the story let me just tell you the game went into overtime and was won on a pass deflection that bounced off the defender’s hand and through the hoop. Crazy, Amazing,(L) insane? (sorry, I couldn’t resist)

2)On a more relevent -to- this- blog note; since it was a tournament, I had a chance to catch parts of 3 different games (girls and boys). What I found interesting was watching each team warm-up and observing the quality of movement. I’m going to pretend I didn’t see the one team static stretch for 15 minutes on the court before the game and focus on the teams that were at least attempting to do a dynamic warm-up. One common warm-up move was the walking lunge. The walking lunge (IF DONE CORRECTLY), is a phenomenal exercise that challenges both mobility and stability as well as an exercise that can be butchered very easily. Without going into too much detail (don’t worry that is coming up later this week), let’s just say some of the lunge patterns left ALOT to be desired.

Anyway, Happy President’s Day and stay tuned for my breakdown of the lunge pattern later this week!!

Posted: February 17, 2012 in Uncategorized

A great follow up blog to my post yesterday. Yes, ‘old’ people can do that stuff.

Coach Kevin Carr

My favorite part of coaching at MBSC is training my  6 AM adult group on Monday, Wednesday and Friday mornings. Some may think I have lost my mind for finding so much enjoyment in waking up at the crack of dawn to work with this group of aging, often flawed group of adults but I highly respect my athletes who continually wake up early to wage their war against injury, obesity and atrophy. I think it’s pretty damn impressive that I can get a dozen people in their 3x a week to train BEFORE they go to work. If you think that’s impressive how about the 25+ Brendon Rearick has on Tu/Th mornings!

When creating the adult program for my group the biggest problem I found was the widespread movement dysfunction and past injury history. Sure we had plenty of people who needed to lose weight but I’m a firm…

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Earlier this week, I posted an article about the Benefits of Tia Chi for people diagnosed with Parkinson’s disease. The intent was to whet your appetite and follow-up with something (possibly a rant) concerning an exchange I witnessed…

I attended a rehab seminar taught by Dr. Jason Brown last Saturday. As we were workshopping some of the exercises, one attendee asked (asked is a polite term, challenged is a better term :)) a question concerning how this ‘stuff’ could be used with older people. Not to put words in his mouth, (ok maybe I am putting words in his mouth) but this gentleman made it seem that because someone was ‘old’ that the only thing we as manual therapists could do for them were passive treatments (manipulation, soft tissue, E-stim, etc.) and that physical exercise/rehab was out of the question. I think after hearing Dr. Brown’s response, the opposite is closer to the truth.

Note: I am going to combine Dr. Brown’s response at the seminar with an email follow-up I did with him a few days later.

Dr. Brown started out by asking this gentleman what the most common and serious problem that we as practitioners have to deal with concerning the older population. The agreed upon response in the room was independence. I think we have all heard or experienced this in our personal lives especially when a parent or grandparent can no longer live on his/her own because they lack the ability to perform functional activities (sitting, standing, bathroom use, bathing, getting dressed, etc.). Generally, when a person can no longer do these type of things on their own, intervention needs to be taken. ( There are obviously various considerations that are taken into account but for the purpose of this post I will just focus on the functional activities of daily living)

To break it down even further, let’s get specific:

1) Hip Hinge/squat pattern

As you can see, this picture looks pretty similar to something, no? (If not, use your imagination and insert a toilet behind the picture on right.) The point here is simple. This ‘exercise’ looks like something that you can only do if you are ‘young and healthy’ but really, this movement pattern is essential for daily functions like a)getting in and out of a car  b)getting on and off the toilet c)getting in/out of any chair.

2) Balance Training

Here are a couple quick facts from Dr. Craig Liebenson’s article on Fall Prevention:

  • The two-year mortality rate for 75-year-old individuals who fall and break a hip are greater than heart disease/cancer (yes, you read that correctly)
  • Tens of thousands of elderly people each year become disabled from falls that result in broken hips or other bones

I think those stats are pretty telling and perfectly answer the question, “Can old people do that stuff (exercise and rehab)?” Yes they can, and yes they should. In fact, those stats really tell us that old people need to do that stuff in order to continue with any sort of quality of life.

A quick way to test for adequate balance  (for anyone not just older people) is to stand in a doorway (for safety) on one foot. You should be able to do this for at least 10 seconds without needing to grab the wall for balance. (I think you will be surprised how many people, regardless of age, will fail this test)

This balance drill is a great place to start, but is their more we can do?? Glad you asked…

In fact, research published in The Journal of Gerontology  found that Power training (Power=Force x Velocity) improved the balance of older individuals. Specifically, the group that trained at 20% of their one rep max showed the greatest improvement in balance. (For anyone who wants to get geeky and read the whole article, shoot me a message)

I think she stole her grandson's wrestling singlet

To recap:

1) Yes, old people can do that stuff  including weight lifting and balance training.

2) It may actually be more important to do this type of training with older individuals vs the young, healthy athletes.

3) Active treatment can aid in prolonging an older persons independence.

4) Power training can aid in fall prevention.

Thanks for reading!

A quick Monday read…

Posted: February 13, 2012 in Uncategorized

I came across an article in The New York Times the other day titled Tia Chi Benefits Patients with Parkinsons.

The reason for this post is less about promoting Tia Chi and more about the idea and metalilty to get people of all ages, ailments, and abilities up and moving.

Stay tuned for a post later this week where I discuss this topic is greater detail.

Happy Monday!

I came across an interesting editorial in The New Yorker the other day by Dr. Atul Gawande called “Personal Best.” If Dr. Gawande’s name sounds familiar to you, it is probably because Dr. Gawande is not only a surgeon at Brigham and Women’s Hospital in Boston but also a best-selling author. The two books of his that I have read are Better and Complications and a 3rd that I have yet to read (but have ordered) is The Checklist Manifesto.

Anytime I see Dr. Gawande’s name attached to something these days, it is an automatic read for me. His writing is insightful, honest, introspective, and inspiring. When I came across “Personal Best” in The New Yorker, I knew I was in for a treat.

So what is “Personal Best” all about? In short, Dr. Gawande takes an honest look at himself and realizes that after eight years as a surgeon he simply had stopped getting better. This realization led him to do some research and explanation into why exactly this happened and if it happens in other professions as well.

Dr. Gawande first explored the world of sports and wonders how they would be different if there were no coaches at all.

When we think of sports, we always think of coaches. Even the best in the world have coaches. I would argue in fact, that the better you are in sport, the more coaches you have.  That being said, Dr. Gawande remarks that he, as a surgeon does not have a coach, or anyone observing him to make him better. (and as he finds out later, to monitor the ‘little things’)

Is this true in other professions as well? In fact, it is. Dr. Gawande explores education next. Research done by the University of Virginia concluded that most teachers feel no need to be coached. The idea of being observed in the classroom or looking incompetent in front of an observer left most teachers skeptical of the prospect of having a fellow teacher act as their “coach.” But again, at what point do these professionals simply stop getting better?

Dr. Gawande took matters into his own hands and called one of his former teachers, a retired general surgeon named Robert Osteen asking him if he would be interested in observing a surgery and then providing feedback on what he saw. Dr. Osteen agreed and so the experiment began. The question was, after eight years of doing surgery what could Dr. Gawande do better?

The surgery was a thyroidectomy for a patient with a cancerous nodule, one that Dr. Gawande had done “thousands of times.” Upon completion of the surgery, Dr. Gawande deemed it a great success. In fact, he wondered if his ‘coach’ could find anything to critique.

As they sat down in the surgeons’ lounge, Dr. Osteen pulled out his notebook and began. He stated that while the surgery went well overall, their were several small things that needed to be corrected. Things like the fact that Dr. Gawande did not realize that for about a half hour, the operating light drifted out of the wound, leaving him to operate with only light from reflected surfaces. Or that his right elbow rose to above the level of his shoulder leaving him limited in his ability to be precise with his work.

Dr. Gawande goes on to say that this 20-minute interaction gave him more to consider and work on than he’d had in the last five years.  

As a student, I often find myself waiting for the day when I am no longer being ‘coached’ and finally able to call my own shots. But at what point will being on my own cause me to plateau as a doctor, business owner, and person?

This begs the question: How much better could any of us be at our chosen profession if we all had a coach? The idea that only certain professions expect to be coached is for lack of a better term, arbitrary and/or short-sighted. I know in the case of teaching that being observed is always looked upon as a negative because the feeling is that if harsh criticism is received that a job may be lost. I can even remember while I was in school when some teachers would almost coach the students the day before observation so we all knew how we should behave and react. Or the teacher would perform this brilliant lesson plan in front of the observer and then the next day, go back to the same boring stuff we were used to. Not only is this not a realistic learning situation, but the teacher would never get better because the feedback they were receiving was not based on how they regularly taught. Please don’t get the wrong idea, this is not a Cameron Diaz-type situation. I have teaching experience myself and respect teachers probably more than any other profession. The point is more that because teachers do not expect being observed to be a positive experience, they are fearful of it. And I think that is where the problem lies.

The bottom line: No matter what profession we are, we must always strive to continually make ourselves better. Our biggest fear as professionals should be staying the same. There is always something new to learn, a little thing to make better, and a negative to turn to a positive, or maybe expanding on something we already do well. The point is we should all welcome critique and criticism as it allows us to continually advance and be better at what we do. Or as Dr. Gawande puts it,

 “The top athletes and singers have coaches. Should you?”

 For the full text article of “Personal Best” please click here.

As the title indicates, I stole this idea from Peter King of Sports Illustrated. So thank you, Mr. King. And on that note… In what I hope to be a somewhat regular topic title, I’m going to share some things I think (because I know everyone cares soooo much :))

1) I think the further I am removed from competitive athletics, the more I appreciate things like marathon and triathlon training because these events keep competitors with a specific goal in mind. People in general are competitive and goal oriented. Moreover, people always look to work towards something. That something may be a marathon or it may be simply looking good for an upcoming vacation. As (former) athletes like myself get out of college and move on with our lives, we often still have  an ‘itch’ to be competitive (or at least have something to occupy brain power that is not part of work). I really do enjoy training and doing athletic things, but I have to admit, it still becomes a grind for me to stay consistently motivated in the gym. Without a specific event to work towards, I really have to dig deep sometimes to avoid simply going through the motions of a workout.

2) I think positive reinforcement is one of the nicest and helpful things you can do for someone else. Quite frankly, I believe it can be the best motivational tools out there. This blog is a perfect example. I started writing because well, I thought I had something to say that could be useful to others. Add that to the fact that I can formulate a sentence, and it seemed like a winning formula.

Sorry, I couldn't help myself

All Charlie Sheen references aside (although Major League II was a classic), after I started writing and posting blogs I began to get texts and comments that were extremely positive. This made me think that maybe I don’t totally suck and gave me motivation to continue to write and come up with (hopefully) useful content. Human nature naturally makes us doubt ourselves and abilities. Sometimes, positive feedback from an outside source makes us realize that what we are doing is adding something positive to our small portion of the world that we live.

3) I think it is amazing how beauty truly is in the eye of the beholder. I’m not really talking about omg-she-is-so-hot vs omg-she-is-so-ugly type of beauty. I’m more so talking about how two people who seemingly go through the exact same experience have completely different takes on it. A great example is a high pressure experience like giving a presentation to co-workers. For some this is a great learning experience, a situation where they recognize the challenge and make the most of  it. For others, it’s just a total nuisance. All they can think about is how nervous they are and can not wait to get it over. When it is finally over, they are so relieved that they did not recognize what was just accomplished and learned nothing from the experience. In life, we are always going to have situations that make us nervous or uncomfortable. I think the more we can view hard/uncomfortable situations as learning experiences, the better person we will become.

4) I think the day after the Super Bowl should really become some sort of national holiday. Let’s be honest here people, the production level at the workplace right now as I write this is somewhere between atrocious and non-existent. We should just cut our losses and give everyone the day to recover from their food coma!

The original title of this article was,”One thing people with back pain should avoid” or something along those lines. This would have been a critical error in thought process and paradigm. As I have written about here, and here pain is often just the end result of dysfunction and improper movement patterns. Ideally, we want to prevent pain from occurring by teaching patients/clients to move well and avoid things that could (potentially) harm them.

That being said, what I want to focus on today is the concept of avoiding low back or lumbar flexion especially first thing in the morning. I know most of you are probably thinking that you don’t do anything that involves bending early in the morning (yoga,sit-ups, etc.) but I think you may be surprised with how much bending you actually do without even knowing it. But more on that later…

Let’s back up a step and understand why early morning flexion can be so harmful.

As we sleep, our spinal discs attract water. This is known as being hydrophilic (they love water). This is also why we are taller when we wake up in the morning, our discs hydrate and gravity has not had a chance to work its magic and compress us to our normal (shorter) height.

With our discs attracting water this leaves them ‘full’ (think a balloon filled with water) and subsequently much more fragile and sensitive to injury. Add this to a position that the low back really hates (flexion) and you have a recipe for disaster.

                               this looks and sounds awful

According to Professor Stuart McGill, the authority on all things having to do with low back research and injuries (and on having the coolest mustache in North America) the stresses associated with morning bending(flexion) are about 3 times higher than if you were to perform the same exercise a few hours later.

Ok, now back to a few activities that you may do in the morning with a substantial amount of lumbar flexion.

First we have brushing teeth. Pretty easy right? Most people I know will do something like this…

Notice, I am completely bent over and my low back is flexed.

A simple solution: Stand straight up!!! Notice, no low back flexion.

Another common thing we do in the morning is either putting on or tying shoes. Most people are guilty of doing this…

Again, notice the complete lumbar flexion. If you are doing this, your spine hates you. Really, really, really hates you. I swear!!!

A solution is something so simple as using a chair for support as shown below…

Notice my sweet green socks and that my low back is completely neutral with minimal flexion. All of my motion is coming from the hip, not the low back.

So there you have it. Two quick early morning spine sparing strategies that can save you from back pain!

Thanks for reading!