Rehab it as you see it

If this stuff doesn't get you psyched up...

Thanks to Dr. Dave Tiberio for the heads up on this article from the June '08 "European Journal of Physical Rehabilitation Medicine". "Rehabilitation of Adolescent Idiopathic scoliosis: results of exercises and bracing from a series of clinical studies".

The SEAS (scientific exercise approach to scoliosis) was shown to be an effective alternative to bracing. These exercises are isometric in nature, & not the ones I would necessarily choose, but exciting none the less. The concept that soft tissue can ideed influence structure. They actually reduced the Cobb angle. The important concept of SEAS is that there is no one size fits all protocol. It is individualized to the patient.

I think this concept can be generalized to incude athletic injuries. We are on the right track here. Rehabilitation should be athlete driven, not protocol driven. Like Bob Dylan sings, "you better start swimmin', Or you'll sink like a stone, For the times they are a-changin'."

Promenades sous la peau

Or, "Strolling beneath the Skin". I would like my readers to google image "biotensegrity" & "tensegrity" and look at the structures. Then go to Dr. Stephen Levin's (Ezekiel Biomechanics Group) biotensegrity blog. If you you scroll to the bottom of the page, he gives a preview of French hand surgeon J.C. Guimberteau's fascia DVD.

http://web.mac.com/stephenlevin1/_StephenLevins_Biotensegrity/Shear_or_Not.html

You really begin to appreciate the similarities, & how fascia links the body together as system. Manual therapists bring up an interesting point- that the human body's center of gravity doesn't really pass through the spine, but rather through the gut. We begin to see how soft tissue can influence structure. It creates new possibilities for us. For instance, we can understand how we need the entire body working correctly to prevent lower leg stress fx, not just strong legs.



It is the essense of what "core" is all about.

Joe's Training Room, 1 year out

My goal was to get a grass roots movement going at the high school level. Mobilize the foot soldiers into tackling problem areas in the care & prevention of adolescent athletic injuries.

I've failed.

I've gotten over 25,000 hits in the past year. Don't get me wrong, I am grateful to all my blog readers. I'm not just blowing smoke when I say you guys keep me on the ball. It's humbling when I check my hit tracker & see readers coming from almost every continent around the world to read what some high school guy from New Jersey USA has to say.

Unfortunately, barely any are from my home state. And almost none from the high school level. I would really appreciate everyone's opinion as to what I'm doing wrong, and where to go from here. I realize it's not just me. The ATSNJ has had a decline in enrollment in the past 2 years. The new ATC's coming out of college have figured out you can join the NATA BOC without actually joining the NATA. And I hate to sound sarcastic, but we're getting what we deserve. The ATC certification is not carrying much weight any more. I would like to give you specific examples, but I can't without using names.

I'm going to end this post with a quote from Bob Wiersma's "performance builders" blog, referring to the fact that more & more U.S. citizens are going uninsured each year.

"This is about real people in your community in crisis - they have real problems that they can not afford to address in the current health care system. Their solution is not in "the box" of traditional providers and services. What is need is a solution that is out of the box... There is something you can do about it!"

Guys, this is the environment I've worked in for almost 30 years. Most of you have been insulated against it. Get ready because it's coming.

Milestones in Biotensegrity

1948, artist Kenneth Snelson’s “floating compression” principle.
1949, Architect Buckminster Fuller develops 1st working model
1970’s, Orthopedist Stephen Leven applies tensegrity principles to human gross anatomy (biotensegrity)
2004, French orthopedist J.C. Guimberteau publishes “Promenades sous la peau”.
2007, Tom Flemons publishes, “The Geometry of Anatomy – the Bones of Tensegrity”

Biotensegrity as a Core Stability Model

“Tensegrities are self–contained non–redundant whole systems. All components are dynamically linked such that forces are translated instantly everywhere; a change in one part is reflected throughout. These features distinguish tensegrities from all other tension structures, e.g. a sailboat’s mast is fixed at the base and needs that fixed point to keep it upright. The boat does not need the mast for it’s integrity but the reverse is not true.”
- A Biotensegrity Explanation for Structural Dysfunction in the Human Torso, Flemons ‘07

Now we need not be concerned how are bodies are oriented to gravity. Many core training enthusiasts use the term, "you can't fire a cannon from a canoe!" But what if you must? Volleyball players do it all the time. As do divers & swimmers.

Biotensegrity is no new-age thing. It has sound engineering roots going back to the 40's and makes perfect sense. And, it fits in perfectly with the new fascia research that has come out in the past few years. I will elaborate more on this in the coming weeks.

Are there any honest politicians left in NJ?

Black market kidney trafficking, bootleg designer handbags, money laundering; it all goes on here. 3 mayors, a governor's cabinet official & 40 other government officials go down:

http://apnews.excite.com/article/20090724/D99KQQT80.html

Go Roberto!

Former Elizabeth High School N.J. short stop Roberto Ramos tore through the Gulf Coast league last week, posting a .526/.545/.632 line with 2 doubles, scoring 5 runs while batting in four, taking 2 walks and stealing 4 bases in 23 plate appearances over 8 games, for which feats he was recognized by the voters as SoxProspects.com Player of the Week of July 6-12. Ramos, 20, is hitting .448/.485/.517 with five stolen bases on the young GCL season. This is Ramos's second go-around with the GCL Red Sox after having hit .261/.306/.348 in 18 games in 2008. He was signed as an undrafted free agent by Boston in June 2008.

Greg's 5in5 Response:

The following is Greg Thompson's response to my post:

http://joestrainingroom.blogspot.com/2009/07/from-spark-into-bonfire.html

"I will look into posting something. I would love to do it with video for you Joe. Our plan is to have 24 modules with video clips for sale in the fall through Beacon Athletics. As Joe said, the program is designed to be used in concert between the PE teacher and classroom teacher. The exercises are taught in PE class then led by students in the classroom. Our push up numbers were excellent this spring and we hadn't done a regular push up in 5 months or so. Feel free to contact me with questions:
gregory.thompson@farmington.k12.mi.us

Windin' up da butt

I'm suprised no one called me out on a good exercise for training the glutes in gait/running. Here is a good exercise to train the posterior oblique sling system in a manner that is functionally consistent with running.

R SLB, LLE anterior/posterior pivot reach @ankle height c/ toe touch;

BUE anterior @shoulder height R/L rotational reaches out-of-sync c/ pelvis.

The R knee flexion/extension are a chain reaction from the LLE motion, NOT a single leg squat. Yeah, some balance is involved so there is a learning curve here. However, once you get the hang of it try to go as quickly as possible with good form.

The Muscle that Screams the Loudest Please Stand Up

"Gluteal Muscle Activation During Common Therapeutic Exercises"-JOSPT 7-09

Be careful about choosing exercises for conditioning or rehab based on EMG studies. The authors conclude their study by dividing the exercises into "tiers" based on the level of muscle activation. It would not be surprising then that a sagittal plane exercise like a SLB & reach to the toes would be the nominated as best exercise for activating the glute max. The same for frontal plane side lying adduction & the glute medius.

Every muscle has a 3D function, and the most obvious one may not be the most important with regards to joint function. For instance, let's say our athlete has patellofemoral dysfunction with running. While the SLB c/ toe reach may indeed create MVIC >60, the exercise is not consistent with gait, and may not be useful in this case.

Don't Miss Pat Donovan @ NATA '10 in Philly

Dr. Ken Cieslak asks:

"I would like to get a better understanding of the approaches Gary Gray uses in his assessment and rehab. I know you are well versed in this area. I noted on his website that they sell educational materials. Which ones would you suggest (tape titles, etc) I get to obtain a basic grasp of his approaches and methods (kind of like a Cliffs Notes summary of his approach). Any suggestions is greatly appreciated."
*******************************
I've gotten the thumbs up from Gary & Dave T to do a presentation at the nationals on just that subject. Been turned down about 5 years in a row. As a high school ATC I am a non person as far as the NATA is concerned . But, I believe they did approve Pat Donovan (U.Ill@Chicago) for 0-10 in Philly. I believe they are giving him several hours, and he plans to go through the whole spectrum. Be there. I know Pat will do a great job.

Now this is great research

Instrument Assisted Cross Fiber Massage Accelerates Knee Ligament Healing- JOSPT 7-09.

The researchers did Graston Technique on 51 rats who's MCL's were surgically injured. 3X a week for 1 minute; 31 received 9 treatments, 20 received 30.

At the end of the treatments, the rats were sacrificed, and the MCL's were placed under an electron microscope for study. Then, mechanically strain tested also.

At 4 weeks out, the treated ligs were 43% stronger, 40% stiffer, and able to absorb 57% more energy. At 12 weeks out, both treated & untreated ligs were similar, with the exception of the treated ligs being 15% stiffer.

The authors hypothesize that the Graston Technique has an underlying effect on collagen, influencing the fibroblastic cells.

How do my blog readers feel about this? It was fast, and a hell of a lot cheaper than other popular tendon therapies (platelet rich plasma, stem cells etc). Would ASTYM work just as well? Or, how about good 'ole deep transverse friction massage, which doesn't cost a dime to learn (it is well described in Warren Hammer's book).

From a Spark into a Bonfire

Sorry I've been neglecting my P.E. peeps somewhat.

Greg Thompson, an elementary P.E. teacher from Wisconsin, did a presentation at this year's GAIN on his 5-in-5 concept. It is based on Dr. John Ratey's SPARK concept:

http://johnratey.typepad.com/

Dr. Ratey's concept is that daily vigorous exercise improves cognitive function. My only issue is that is very technology dependent, narrow scoped, & difficult to implement in most typical school settings.

Greg amped it up by developing a series of exercises that can be done in limited space- even in a classroom, with no equipment, and is easy to administrate. It is a series of 5 exercises performed in 5 minutes, repeated at regular intervals throughout the day. It involves squatting, pushing, pulling, rotating, balancing, reaching, hopping/jumping. There's no reason to stare into some heart rate monitor, it's very clear you are above 120 beats per minute.

We'll Never Know

"Does Core Strength Training Influence Running Kinetics, LE Stability, and 5000M Performance in Runners?"- JSCR Jan. 2009 p. 133

Jack Blatherwick at GAIN 09 explained to us why you shouldn't just read the abstracts.

In this study, 28 subjects in their late 20's to late 30's were quantified for core stability weakness by way of the Sahrmann Core Stability Test. 12 received core stability training by way of 5 physioball exercises. 8 "were instructed to maintain their training routines". 8 dropped out, not sure why. After 6 weeks, the core training group showed faster times, even though there were no improvements in ground reaction force.

The problem is there was no "plecebo" generalized strength training group. After all, they were not college aged athletes, and may very well not been inolved in any strength & conditioning program. Therefore, any intervention would have seen an improvement.

The other problem is the assessment tool- Sahrmann's core stability test. It is a series of leg lifts done in the supine hook lying position. Does it fit here?

So, we'll never know if the author's protocol was effective or not.

Why

You can lead a horse to water, but don't drown them! This was the workout that caused rhabdomyolysis in a D-1 college American football player. It was prescribed by the school's S&C coach. It could have killed him. Keep in mind this was the day before a game.

1. 10x30 squats c/ resistance bands, 1m rest in between each set.

2. 30 consecutive Romanian dead lifts with 2 40lb. dumbbells.

3. 30 consecutive "shoulder shrug bicep curls" with 2 80lb. dumbbells.

Room temp 84 degrees.

The patient, including several other members of the team, were vomiting during & after the workout.

One workout can't make you, but it can break you.

Pushing off the rubber?

Sports Health July/August '09: Baseball Pitching Biomechanics in Relation to Injury Risk & Performace- Fleisig et al.

Unless I am reading the article wrong, the authors are advocating propelling yourself off the rubber during the stride phase. Those of you who heard me speak in the past know I oppose this for a whole slew of reasons. It sets up a cascade of poor mechanics.

However, these authors are no slouches. And, the pitcher in this pic is literally bounding off the rubber. Remember, the mound's decline would magnify this even further. But, unless I'm reading it incorrectly, not pushing off the rubber is in the "pathomechanics" category.

Propriability

Thanks for all the great comments. Marshall gave us a great insight with his own experience with back pain; that he has what would be traditionally considered a strong core, yet he still experiences pain 4 years out despite numerous bouts of p.t.

Porterfield & DeRosa discuss this phenomenon in their excellent book, "Mechanical Low Back Pain"- "Tissue that is significantly injured or degenerated cannot attenuate stresses with the same efficiency as normal, uninjured tissue", and go on to say, "to assume that 3- 45m sessions 3X per week alone will significantly impact long range outcome is unrealistic." (p.226)

This is part of the problem when discussing core. We typically think of core training as strengthening the muscles.

Never forget that ligaments are part of the core system. They don't just connect bone-to-bone. They are rich in Pacinian Corpuscles & Ruffini endings. They are an important part of the core. If we are doing "stiffness" or "bracing" training in the neutral zone, are we stimulating these proprioceptors??? Do most injuries happen in the neutral zone, or rather in the "transformational zone"-where the body is changing directions?

Remember proprioceptors are the spirit of function. When we speak of neuromuscular training, or re-education, this is where it's at. If there is no proprioceptive stimulation, there is no load, therefore no explode. However, as Juan said so well, we need to work at the edge of their envelope of function if they are to improve, and not be injured. We need to safely take the back patient, or healthy athlete into-and out of the transformational zones. On to you guys- by the way, where have all the ladies been???