This weekend I was on
the Scientific Core Conditioning class at the European CHEK institute.
I have not done anything to do with the CHEK institute for 15 years, so it was nice to return to the sytem that inspired me to become a Physiotherapist.
Our instructor was
Leigh from BodyCHEK, in London.
The course was full of Fitness Professionals revising the core muscles and learning new exercises.
The exercises involve a cable machine, a Swiss ball, A wooden Dowel, some string a pressure biofeedback cuff and of course the Tornado ball!
There has been lots of criticism of Core Stability over the last 20 years.
The Myth of Core stability article by Leaderman is a classic example of this. Where Core stability is described as a "reductionist fantasy."
What was great about about this weekend was the integration into functional movement.
We were not just lying on our backs playing with the pressure bio-feedback cuffs.
There was a very quick integration into four point kneeling, kneeling, standing then standing on a single leg.
We rely on 10 sets of 10 second holds for us to say a patient has successfully grasped the concepts of core stability.
But is this enough?
Of course not, but it is that transition from Pilates style exercise on the floor into Deadlifting and Resisted Rotational Movement with the core engaged.
Core stability provides the support for all dynamic movement, but how much stability training do we actually do?
People today are
growing more and more conscious about their bodies and they are opting to go to
the gym and doing regular exercises. However, if you do not know how to lift
weights and exercise properly, it might be useless for you to go to the gym. It
should be noted that of weights are not lifted properly, they could cause
sprains and other serious injuries. It is, therefore, vital that you know how
to lift weights properly as is discussed below.
As is the case with
most exercise routines, the first thing that you need to do is to warm up. This
s one part of the workout that should not be taken for granted. Under all
circumstances, a full body stretch is extremely important.
After your warm up, you
should then go ahead to observe slow repetitions. It is often advisable that
you do not rush the lift. You should slowly repeat the whole process of lifting
a certain weight, taking pauses between each lift. For example, if you are doing
a bicep curl, the pause should come each time your arm is curled. Once the
weights have been placed down, you should also make another pause. If this is
not observed, too much strain will be put on your joints and the workout will
not be as effective as is required.
Like all exercises, you
need to drink a lot of water while lifting weights. This is because; your body
will be losing a lot of water as you're sweating and this water needs to be
replaced.
It is very important
for you to remember to breathe. Whenever you are pulling or pushing weights,
you should not forget to breathe, since your body needs a lot of oxygen in the
process. As you lift the weight, you should make sure that you exhale and as
you put it down, you should inhale. It should be noted that exhaling relaxes
muscles and the heart, thus, enabling you to have control as you lift the
weights.
You should remember not
to over do it or not to over lift the weights. It is vital that your body is
not over worked; since your muscles need to be given time to recuperate. It is
advisable that you lift weights for only about one and a half hours, three
times a week.
It is very important
for you to remember to use weights that are right. In other words, you should
only deal with weights that you are capable of handling. You should not force
yourself to lift weights that you are not capable of lifting, since this might
cause some injuries. You should stick to weights that you can lift up to ten
times. However, if you feel the weight is too light, you should slowly add some
more.
It is often advisable
that one body part is focused on each day for proper results and reducing the
risk of injury.
You can read more about
lifting weights properly [http://www.tipsonyourhealth.com] on my blog.
'THE CORE' is probably
the most overused term in health and exercise therapies. Flick your television
on to any shopping channel and someone will be selling a new piece of kit that
will improve it. I too thought I knew what Core Control was all about, until
about seven years ago when someone finally tested me properly. I mean I was
pretty strong, I could do countless sit ups and leg raises, I'd not long
finished playing squash competitively and still enjoyed a high club level so I
was fit too. How did I not know how to control my core?
The fitness industry
shows signs that it is catching up on core control, having spent the last
couple of decades fixated on abdominal crunches. Unfortunately, as with many
modern issues, the subtlety needed to do the Core justice often gets
overlooked. A classic example is what I call the Pilates Posture, where the
person does too much 'Core' work in a flexed lumbar spine position, which
results in a flat back posture and a pair of glutes that hang off them like a
pair of wet pajamas.
The Pilates example is
one where the client presents extremely strong in core control but is
dysfunctional none-the-less. However, clients present more commonly with a total
lack of control. So how do we assess core control in the world of Functional
Exercise?
Obviously the signs and
symptoms that present are a big clue and these can be very wide-ranging. Poor
core control presents as Low Back Pain, SIJ dysfunction, bladder weakness, over
pronation of the foot, medial rotation of the femur leading to knee problems,
shoulder injury, forward head carriage leading to TMJ issues and headaches,
poor ability to recuperate post exercise, and the list goes on; sciatica,
lumbar disc herniation, gait instability, movement instability in sports,
recreation and activities of daily living, need I continue?
These days Abdominal
Distension is a common presenting sign of core problems. However in these cases
I usually look deeply into nutritional issues. Nine times out of ten this
distension starts with irritation within the digestive system or a large amount
of visceral fat expanding the abdominal cavity so exercise is a secondary issue
to diet.
With signs and symptoms
so wide spread it is clear that core control is often present in a wide variety
of musculoskeletal pain. So here are a couple of simple assessments that can
tell you at what degree the control is limited.
Transverse Abdominis
Isolation.
Transverse Abdominis
(TVA) is one of the major players in core control and probably the easiest to
assess. When it works correctly it encourages activation from both the Pelvic
Floor and Multifidus muscles. These three sets of muscles are the primary
stabilisers known as the Inner Unit. Capping the Inner Unit off (literally) is
the Diaphragm but this only gets involved fully when lifting heavy weights and
usually needs to be assessed separately. The TVA test is pretty simple: Lay
face down on your tummy on a matted floor and slide a Sphygmomanometer (old
fashioned blood pressure cuff with a gauge or BP as I'll refer to it), under
their abdomen so the middle of the BP is at their navel level. Pump the BP up
to 20 mmHg while the client relaxes. Now lift your tummy button off the BP by
hollowing your abdomen thus dropping the pressure on the gauge. You failed the
test if you either can't move the gauge or can but do so by pushing your
shoulders and knees into the ground to lift your body up. Either way this is
evidence that you don't know how to use your TVA so exercises to address this
should be used.
Pelvic Control.
This is the area that
goes so horribly wrong in Pilates resulting in the flat back. However, when a
lack of control is evident then shear forces in the spine can cause all manner
of problems. Control is key to allowing a neutral pelvis tilt to remain stabilised
with only enough muscular input being used to counteract the forces generated
by movement. Here's how it works:
Lay on your back with
the legs out straight and the BP under your lower back so the middle of the
pillow is at navel level. Pump the BP up to 40 mmHg then tilt your pelvis
backwards until the gauge reads 60 mmHg. Now hold this pressure evenly while
you raise and lower one leg at a time. If the gauge drops by more than 10 mmHg
the test is a positive. In Pilates where there is no feedback gauge used the
person pins their back against the floor through abdominal contraction. If the
gauge was present and you read it, it would shoot up to 90 - 120 mmHg as they
used their legs. This is the over recruitment that leads to a flat back
posture. Getting these people to ease off is a hard pattern to break but
education and practice usually suffice. For those that drop in pressure, well
the future is bright. Learning this control is quick and easy because the
nervous system learns so quickly and is usually crying out for some interesting
stimulus. We just start them on a basic exercise program and build them up from
there.
Conclusion.
With a couple of simple
assessments we can quickly see where core control is failing and a course of
core strengthening can be the answer to reducing the recurrence of injury.
These simple tests give you the tools to understand how subtle the core really
is. If you can't pass the tests then maybe it's time to get working on it. This
is so often the answer to some simple injuries that cost you a fortune at the
Chiropractor's office.
As athletes we often focus on our bodies but forget to work on our minds. When athletes are in pain they have a tendency to think very negative thoughts as our self image is heavily linked to our physical prowess.
This article will help us examine our attitudes, values and beliefs about back pain.
Here's where Cognitive
Behavioural Therapy comes in and chronic pain sufferers should consider
exploring this method as an avenue to back pain relief.
So what is Cognitive
Behavioural Therapy and how can it help?
Over the recent couple
of decades cognitive behavioural therapy (CBT) has become an accepted first
line psychosocial treatment which can help patients to deal with chronic pain,
including low back pain. CBT states that individuals, not the outside
environment, create their own experiences, including pain. The theory behind
CBT is that the process of changing the patient's thoughts about their pain can
bring about changes in how the body responds to that pain.
The sensation or
perception of pain actually occurs in the brain, so the theory behind CBT works
on the premise that the sufferer can change the perception of physical pain by
controlling the thoughts and behaviours that feed it.
The patient cannot
physically stop or alter the level of the pain, but with practice, he or she
may become able to control how their brain deals with that pain. For example a
negative thought such I can no longer do this activity anymore might be changed
into a much more positive outlook along the lines of "I will do it again
just like I used to do."
What the therapist will
seek to do is to encourage the patient to focus his or her thoughts
(Cognitive), and then focus on subsequent actions which to address
(Behavioural). This process may take place over many sessions with the
therapist seeking to help the patient to identify negative thoughts and
feelings encountered during bouts of back pain. These CBT sessions would
attempt to train the patient in how to convert this negativity into positive
thoughts and actions, and to develop healthy thinking. This healthy thinking
involves positive thoughts and calming your mind and body by using techniques
such as yoga, massage, or imagery. Positive or healthy thinking helps to make
you feel better, and feeling better reduces the pain perception.
This transition of
negative to positive thought processes has been demonstrated to help in
enabling the patient to better manage their pain, and change the way in which
the patient's body actually responds to the pain. So although the physical pain
is still present, changing the patient's mindset can alter and improve their
ability to deal with it.
CBT can relieve pain in
several ways. It transforms the way in which the patient perceives the pain. It
changes the thought processes, emotions, and behaviours in relation to pain,
helps to develop coping strategies, and puts the level of discomfort into an
improved context. As a result the pain tends to interfere less with the
patients quality of life enabling the patient to function better. In addition
we can also alter the brain's physical responses that tend to worsen pain. When
we are in pain, this causes stress which can negatively affect the production
of pain control chemicals like Norepinephrine and Serotonin, which are the
body's natural painkillers. CBT can therefore positively impact on the natural
pain relief response.
CBT can also help the
patient to become more active, which is important because regular, low-impact
exercise, for example yoga, pilates, walking and swimming, can help to reduce
back pain in the long term.
So how does CBT work in
practice?
In order to effectively
treat chronic pain, CBT is usually used in conjunction with other pain
management treatment such as pain relief medications, physiotherapy, weight
loss regimes, various massage techniques, or indeed surgery. In a lot of
instances CBT is considered to be one of the more effective forms of treatment,
having less risk or potential side effects than pain relief medications or
invasive surgery.
CBT sessions can be
carried out through a range of formats ie
Individual sessions
Group therapy with
other patients addressing the same pain issues
Self Help modules -
usually in the form of a book from which assignments are carried out
Computer program or App
(CCBT)
Group and individual
CBT sessions generally last between 30 minutes and a hour over anything from
six to twenty sessions
During the CBT sessions
the therapist will work with the patient to break down their problems
surrounding their pain into separate components ie their thoughts, physical
feelings and actions. These would then be analysed jointly to determine which
are unrealistic or negative and then analyse the effect they have on each other
and the patient. The therapist and patient will then draw up an action plan to
alter unhelpful or negative thought patterns and behaviours.
The challenge then for
the patient to practice the application of these changes in their daily life
and provide feedback at the next session, with the objective being to teach the
patient the application of these skills during the CBT sessions to daily life.
By doing this the patient is learning to manage their issues or problems to
prevent or reduce the negative impact on their life, and to carry this on after
the CBT has been completed.
To summarise cognitive
behavioural therapy involves
Developing a positive
or problem solving attitude in the patient to reduce the sense of helplessness
over their pain and giving them a sense of control
The patient carrying
out homework or assignments designed to keep track of thoughts or feelings
associated with pain and recording these for review
Developing life skills
and coping mechanisms for not only in pain control but in other problems
encountered in life such as stress or anxiety
Self help for pain
management.
How to benefit from CBT
for pain control
Have faith in the
concept. There are many research papers demonstrating its effectiveness in
assisting pain relief or pain reduction so its important to engage with the
process
Actively engage with
the concept. You have to put the effort in to get a positive outcome from the
sessions
Ensure that you finish
all the modules. For CBT to be effective its important to attend each session
and complete all the assignments given to you. Indeed one of the major
drawbacks of CBT is that of patient non compliance. Ie skimping or not
bothering with all the elements of the CBT program
Be open minded about
the possibility that CBT could work for you, but it does need your full
commitment.
What now with CBT
If you are interested
in trying CBT for pain management, talk to your GP or healthcare professional
in the first instance. They can point you in the direction of cognitive
behavioural therapists specializing in back pain available in the UK through
the NHS although there are likely to be waiting lists.
If you wish to have CBT
privately then ask your GP to recommend, or alternatively contact the British
Association for Behavioural and Cognitive Psychotherapies (BABCP) who will be
able to provide details of accredited CBT practitioners.
David Pegg, from
Manchester, UK is a director with Lumbacurve International Limited,
manufacturers of an effective lower back pain therapy device, developed in the
UK and Netherlands.
The concept behind the
device was to combine the best of East and West therapies, designed to combat
back pain.
Lumbacurve initially
provides a passive gravity assisted traction (PGAT) - put simply it gently
stretches the lower back, causing the vertebral joints to separate.
This in turn, relaxes
the discs and frees up the spinal nerves, thus giving pain relief, as practised
by Western physiotherapists, Chiropractors, and Osteopaths.
In addition to this the
design features provide the combined benefits of shiatsu stimulation, yogic
stretch, and acupressure massage, all recognised techniques, employed in
Traditional Oriental Medicine.
It's easy to use.
Simply lie on it for a few minutes, do a few simple exercises, and prepare to
be amazed.
This week I have been emailed
by a high level Athlete with Lower Back pain who is having difficulty returning
to her full training.
Lots of Rehabilitation
will talk about activation of Transverse Abdominis.
However, this athlete
is an Ex- Dancer who already knows how to perform pre-activation of the TVA.
The question relates to the fact that this strategy is not helping her.
All we need is “stiffness”
in the abdominal wall rather than “sucking in.”
For athletic
populations I am a big fan of Dr Stuart McGill’s work.
McGill’s Big 3
Exercises are an excellent way to start your back rehabilitation or perform
injury prevention.
The Big 3 consist of:
1.Controlled ¼ curl up with one knee
flexed (hold at the top)
2.Side Plank (10 seconds with maximum
stiffness)
3.Bird Dog (Quadruped)
The Controlled Curl-Up:
This exercise trains the abdominals without moving your lumbar (lower) spine or cervical (upper) spine.
Lie down on your back with your legs out straight. Bend your right leg and plant that foot on the floor next to your left knee.
Put your hands under your lower back. They will prop your lower back up, which allows you to keep a natural curve in your spine.
·Curl your head, neck, and shoulders
off of the ground. Try to keep your neck as still as possible while you lift
your head up. Don't tuck your chin or let your head fall back.
·Try to hold yourself up at the top
for 5 to 10 seconds.
·Lower yourself down. Do half of the
repetitions with your right leg bent and half with your left leg bent.
The Side Plank
•Lie on your side, with your elbow underneath your shoulder. Curl your feet back so that your knees are at a 90-degree angle. To make this exercise harder, straighten out your legs instead of bending them.
•Lift your hips off of the ground, putting your weight on your elbow and knees.
•Hold that position for as long as you can. Try to maintain a straight line from your head down to your feet. Make sure that your hips are in line with the rest of your body.
•When you can no longer hold that position, drop and switch to the other side, once again holding for as long as you can.
The Bird Dog
·Get on the floor on your hands and
knees in a quadruped position. Make sure that your back is relatively flat.
·Raise your left arm forwards and at
the same time extend your right leg straight back.
·Raise your arm and leg until they are
in line with your torso. To increase activation of your back muscles even more
during this exercise, you can clench a fist of the arm you're raising.
·Lower your arm and leg. Once you
complete the desired amount of repetitions on that side, switch to the other
side and repeat.
Also try “stirring the
Pot” (in a Plank position) on a Swiss ball.
With the back muscles,
what is more important is ENDURANCE rather than strength!
(See yesterday’s blog
on the Biering Sorenson Extension Test)
Try integrating McGill's Big 3 into your training and Bulletproof your Back.
