In speaking with an osteopath over the weekend, he really got me thinking about core function. We were discussing the current state of the literature and he pointed out that while the research to date are all fine and dandy, there doesn’t seem to be anyone who’s utilized truly healthy individuals that are free from visceral/organ dysfunction. That’s not to say that the subjects who have participated in McGill’s, Hodges’ and others’ studies are not “healthy”, but it seems as though such particular issues have yet to be addressed.

The rationale behind his insight was the fact that our current society consumes far too much *you know what* to ensure that our abdominal organs are functioning optimally. And as a result, many in today’s society suffer from certain inflammatory conditions that may have negative effects on proper core muscle function.

Take for example the Transversus Abdominis. This is one of the deep muscles of our core and through research, has been shown to have a delay in firing in those with chronic low back pain. Now if our intestines and organs are “inflamed”, the possibility of influencing muscle function surely exists. Think about the length-tension relationship and the ability to generate force. So perhaps the T.A. may be dysfunctional in those with chronic low back pain due to the above.

On a different level, think about the role stress plays on organ function? Aside from the negative cognitive consequences it may have on those with chronic pain, what about those with chronic low back pain?

So where do we go from here? We were in mutual agreement that we should probably start with inclusion and exclusion criteria. Don’t get me wrong, I know that this is not an easy task but perhaps we may be able to get an even better idea of what truly goes on in the core with more optimal subject population.

But in the meantime, if we’re working with people suffering from faulty core function, perhaps it may be prudent to spend even more time considering the role of stress and common allergens.

And that’s why I think I need to strongly consider the assistance of a naturopath and a psychologist.

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Related posts:

1. The Anticipatory vs. Reactive Core A guest post from Julie Wiebe of www.interiorfitness.com...
2. The Secret to Improving Flexibility Everyone's got a secret...

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Authors: W. Meehan

Journal: Clinics in Sports Medicine

Date: 2011

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Summary:

• Here is a little review of potential interventions in one of the most influential and highly discussed injuries in ice hockey today, concussion. While the current state of the literature may still be in its infancy, each incident of this “traumatic brain injury”, particularly in professional hockey, seems to make front page news and cast a shadow of doubt on the safety of our sport. This paper by Meehan discusses various therapeutic options that may be rendered in the presence of such injury.

• First introduced is the role of physical rest in the recovery process. The stepwise return to play protocol is discussed although it is mentioned that studies have begun investigating the role of light physical activity during recovery. Since quantitative cognitive deficits have been demonstrated in the presence of such injury, academic accommodations via cognitive rest were suggested for student athletes.

• Often considered an “invisible injury”, Meehan proposes that education regarding the typical recovery process be one of the mainstays of therapeutic intervention. Studies have demonstrated fewer symptoms at follow up in those that were informed about their symptoms, coping strategies, and the likely course of recovery.

• While most athletes achieve spontaneous recovery of symptoms within days to weeks, some experience prolonged recovery to which pharmaceutical intervention may be warranted. It should be noted that the evidence for such interventions is very minimal and the following information should be taken as a summary rather than a recommendation of care. Meehan suggests that pharmacologic treatment only be considered in the presence of the following:

1. Symptoms exceeding the typical recovery period,
2. Symptoms negatively affecting quality of life to the degree that the treatment benefits outweigh its risks, and
3. The clinician rendering treatment is both knowledgeable and experienced in the management of (sport) concussion.

• Meehan asserts that pharmacologic treatment has yet to be demonstrated to speed the recovery process and that standard approaches are lacking. Instead, he reports that medications are utilized for the treatment of its signs and symptoms. Since previous literature has grouped symptoms related to sport concussion in the categories of sleep disturbance, somatic (i.e. headache), emotional, and cognitive, chosen medications must be specific to the symptom experienced.

• In the presence of sleep disturbance, sleep hygiene that includes the elimination of constant stimuli (i.e. television, computers, caffeine, etc) is strongly considered. Medically, Meehan’s first line of defence for the presence of sleep disturbance is Melatonin. Other considerations are discussed although benzodiazepines seem to be advocated against due to their negative arousal and cognition effects.

• Somatic symptoms such as headaches are common in the presence of sport concussion. Meehan discusses the potential roles of antidepressants (i.e. amitriptyline – his preferred treatment) as well as the potential negative effects (“rebound”) of analgesics such as ibuprofen. Other medications are introduced as well as physical therapy, psychotherapy, and trigger point injections.

• For athletes suffering from emotional disturbance, for example stemming from participation restrictions, Meehan suggests tricyclic antidepressants and serotonin reuptake inhibitors as a complementary intervention to coping strategies, familial support and psychological counseling.

• Finally, since cognitive symptoms are common complaints in those suffering from sport concussion, potential pharmacologic treatment may include methylphenidate for attention and speed processing deficits as well as the domaminergic agent amantadine for executive function and prefrontal cortex glucose metabolism, in addition to cognitive rehabilitation.

• It should be noted that the majority of athletes recovery both spontaneously and quickly from sport concussions. The preceding review merely discusses potential medical interventions that may have complementary roles to physical and cognitive rest and rehabilitation. It must be reiterated that the above MUST NOT be taken as prescription but merely as a review of Meehan’s academic paper, intended for medical professionals. If you or your family member has sustained a concussion, you MUST consult a physician for care.
  

Meehan WP. (2011). Medical therapies for concussion. Clinics in Sports Medicine, 30; 115-124.

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Enjoy.

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Our current definition of the Core is well…ill-defined. I know I have beaten this drum before, but in magazine articles, blogs, internet resources, even research articles, different muscles are included in the “Core” depending on who you read. I even hesitate to use the word because it means something different to each rehab practitioner, and fitness professional (or client) I talk with. Each of us thinks we are doing “Core” work with our patients and clients, but how can we be sure if our starting definitions are so vastly different.

Do we simply agree to disagree? Does this serve the people in our care? Or could we all take a step back and reconsider our understanding of the Core. I will take the first kick at the can on a new perspective of the Core and how to train it.

No matter which muscles we include in our definition, I think we can all agree on the BASIC purpose of the Core, which is to create a strong postural center and maintain central postural control within movements. Our physical center must be a stable, controlled anchor so that muscles that perform movements have something sturdy to pull against. This reduces stresses on spinal and pelvic joints, rather than have them yanked about by exterior forces. A strong center promotes better day to day posture and less achy back and neck muscles. Also, the prepared postural center sets the body up for better performance/efficiency of the shoulders and hips, and of course, the added bonus of a flat belly!

However, HOW the Core achieves this ultimate purpose is where the water gets muddy.

It is easy to understand the inclusion of large postural muscles in a definition of Core. If the ultimate purpose is a stable, controlled postural center, then muscles that assist with posture make sense. So we can throw in Lats, Obliques, Rectus Abdominis, Erector Spinae, Glutes, etc. (often referred to as the outer Core). Looking at the purpose of the Core, these muscles DO promote ongoing postural control during physical action, but they do not activate first to create a central stable anchor prior to movement to insure control and improved performance. They can become those naughty external yanks on an un-prepared, unstable spine and pelvis.

In fact, we have multiple studies that have shown that in a simple arm movement the four muscles often referred to as the inner Core unit – Diaphragm, Transversus Abdominis, Pelvic Floor, and Multifidus – activate before the shoulder muscles that create the movement. These four are the only muscles in the trunk that have the unique capacity to create preparatory or anticipatory contractions in a consistent way to control the center before movement begins. In the same studies, the other postural muscles or outer Core reacted in a different pattern depending on which direction the arm was moved, and they switched on after the inner Core components. Meaning the outer Core also relied on the inner Core to set up a sturdy anchor, so they could do their job of reactive postural adjustments within the arm movement. The action of both sets of Core muscles are intertwined for the achievement of efficient, effective movements.

(note: Julie’s thoughts on the multifidus have been modified slightly but you can learn more about this in her courses – see below)

So, can this lead us to an inclusive definition for the Core that is win-win for all the Core camps? How’s about the classifying things as the Anticipatory Core and Reactive Core*. Both groups of muscles need to be trained in order to create a strong postural center and postural control within ongoing movement patterns. However, because they have different roles in achieving that purpose we must train them differently, but in relationship to one another in order to maximize patient and client outcomes.

Core camps unite! Do your Core training programs ensure the Anticipatory and Reactive Core work together within each exercise? Is a plank a true Core exercise if the patient/client holds their breath to create an anticipatory stabilization, so they can pull it off? Is exercise on the stability ball Core work if clients are seated in a hunch reducing reactive postural muscle function?

*I must give credit for these terms to Carolina Stock, OT. She put a name to the concepts of inner and outer Core interplay in a conversation we had at the Core Restoration in Kids class I taught a few weeks ago. I loved it so much, it inspired a blog!

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Thank you Julie for allowing me to share your insights on this site. For those of you who would like to know more about Julie, please visit her website www.interiorfitness.com. She also teaches several workshops on the core and pelvic floor to which you can find more information here.

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Photo courtesy of lululemon

Study Title: Yoga for Persistent Pain: New Findings and Directions for an Ancient Practice

Authors: A Wren, M Wright, J Carson & F Keefe

Journal: Pain

Date: 2011

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Summary:

• Derived from the Sanskrit verb “yug” which means to bind or join, the term yoga has traditionally referred to the unification of the mind and body for the promotion of health. Commonly advocated for its potential effect on painful conditions and in light of our knowledge of pain as an entity that cannot exist without the presence of the brain, recent research has examined the role yoga may play in painful conditions. Recognizing its comprehensive two-way nature, appreciating this role seems less than difficult.

• This paper reviewed 9 of 13 randomized control trials (RCTs) that examined the efficacy of yoga for persistent pain. Several of these existing studies have looked at its physiological, behavioural, and psychological effects on carpal tunnel syndrome, hand osteoarthritis, low back pain, fibromyalgia, and other chronic (including that associated with cancer) pain conditions. Significant reductions in pain, physical disability, depression, medication, fatigue, and sleep disturbance were found. Although certain outcome measures between experimental and control groups were also found insignificant, the therapeutic role of specific forms of this ancient practice management of persistent-painful conditions was no less than apparent.

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Wren AA et al. (2011). Yoga for persistent pain: New findings and directions for an ancient practice. Pain. doi: 10.1016/j.pain.2010.11.017

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• 1 cup raw oatmeal
• 1 cup chocolate protein powder
• 1 cup almond butter
• 1 cup sliced almonds
• 1 cup cranberries
• 1 cup semi-sweet chocolate chips
• 1 cup ground flax
• 1 cup non-fat dry milk powder
• 4 egg whites, beaten
• 1/3  – 1/2 cup water

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Step 1: Wash your hands!

Step 2: Mix all ingredients with your HANDS (except water) together in a large bowl.

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Like I said, with your hands.

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Step 3: Gradually add water to mixture (mixture is very gooey but should not be wet).

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Gooey, but not wet.

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Step 4: Spray a baking pan or use wax paper. Pour batter in pan and spread as best as possible.

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No need to add chemicals if you don't have to.

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Step 5: Bake in preheated 325 degree oven for about 15-20 minutes. Let cool thoroughly before slicing.

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Ta da!

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Don’t worry about calories, there are more things to worry about in life (and your health) than chocolate chips.

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P.S. It would be wise to freeze these in between consumptions. They only take 5 minutes to thaw.

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Yet:

• I knew Selena Horner, a Physical Therapist from Michigan said they were crap [SnippetPhysTher. 2010. The International Journal of Twitter. Vol 8].

• I had read Science-Based Medicine‘s post on these wristbands.

• And I had read Skepticblog‘s article as well.

However, I have always respected that there are somethings in life that even science cannot explain.

Therefore, rather than immediately discrediting it as utter B.S., I thought I’d give this popular fad an opportunity to shine before I formed my own opinion. I mean, these guys did:

After the first 24 hours, no significant differences in my normal activities of daily life were noted. The following day, however, I experienced something I had not experienced in over 10 months.

I failed on not one set during a bench press workout but two!

I understand that far too many variables may be involved in failing a set but I had been progressively increasing my weight during the past 2 months of training and the week prior was even considered a deloading week. That said, I do know that this is a power balance wristband and I was in no way testing my vertical jump or performing shenanigan exercises on a bosu, but nonetheless, I thought this was an interesting observation.

Several days later, I travelled back home to Toronto and with only 5 hours sleep, wanted to get another workout in early in the day. Interesting observation number 2. I forgot to put the wristband on prior to the workout but notably, was able to press 20 more lbs than that day I failed. Fun stuff!

The last straw.

Yesterday’s workout called for barbell reverse lunges. No different than the last three weeks. The weight for this exercise was the same, as was my warm up, my assistance exercise, and my work:rest ratio. On set 2 of 4, I strained my quadriceps tendon…and you guessed it…the wristband was on.

Now again, I want to stress that I was more than open to experience a positive effect from this wristband but ultimately, I cannot say that it has helped me in any way. Not even psychologically. Lucky underwear maybe, but not the power balance.

So for those of you wanting to improve your performance by wearing something on your wrist, rather than spending your money on a power balance, may I kindly suggest one of these. The folks at the leukemia and lymphoma society will thank you for it.

Purchase at elitefts.com

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YOU!

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You see, the way people think, affect the way people feel. And the way you interact with your patients, may affect the way your patients think.

As you may or may not know, chronic pain is a disease in and of itself and is, by and large, rarely a reflection of diseased or injured tissue. In a musculoskeletal sense, injured tissues generally take weeks, maybe months, to fully recover and the normal healing process typically dictates proper plan of management. But for the most part, a proper plan of management must respect the stages of “healing”.

Let me ask you this…

• In the acute phase, do you chase the pain and perpetuate? Or do you medicate and manipulate and EDUCATE?

• In the subacute phase, do you over-perform passive care and still chase the pain? Or do you provide self-care exercise and EXPLAIN?

• In the chronic phase, do you coddle the patient while you search for the magic cure? Or do you interact with the patient, expose in a graded fashion and REASSURE?

So in the event that you are unsure as to what I mean by the above, may I kindly suggest that you grab a snack and watch this video from one of my lectures in the University of Alberta’s Certificate in Pain Management program through the Faculty of Rehabilitation Medicine.

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Press play to watch the video

*Please note that I am not advocating medication and manipulation for all acute patients, this was simply an example.

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Photo courtesy of Shirley Glua

Working with both athletes and lay individuals who experience pain, I get this question almost on a daily basis.

My response:

It’s Fantastic…95% of the time.

The other 5%? Well, like any other activity, yoga is only helpful when practiced wisely.

Let me explain further with the help of our good old friend Lumbago, also known as Low Back Pain.

You see, in the current society that we live in, far too often (but not always) low back pain is a result of nociceptive input derived from irritated tissues in the lumbar region caused by prolonged or repetitive flexion. Since the prominent biomechanist, Stuart McGill, states that we have a finite number of flexion cycles available in our lumbar spine, I am of the opinion that many of us should not put ourselves at risk of increased stress concentration to this region unnecessarily.

Most of us know by now that traditional sit ups are bad.

But too many swan dives, downward-facing dogs, full boats and happy babies, to name a few, may not be a good thing either…especially with a novice instructor. For the most part, the above poses are relatively harmless however, when practiced by an individual new to yoga, they may be more detrimental to your body than you think!

This is no different than traditional deadlifting or squatting which, when performed incorrectly or inappropriately, can do some serious damage.

One’s form should be of utmost importance. This is where your instructor comes in. Take a look at the poses shown on yogajournal.com. Now compare some of those poses to how you performed them at your last yoga class.

Volume is no different. If your most recent yoga class consisted of 25 downward-facing dogs and 30 swan dives, may I respectfully suggest that you seek a new instructor!

Do you see what I’m getting at?

In fact, Dr. Craig Liebenson, recently directed me to some of the work that Dr. Vijay Vad has been conducting out of New York. Dr. Vad has been looking at the beneficial effect of yoga practice on low back pain for the last decade. But there’s a catch! The “Back Builders” yoga practice that he advocates for completely eliminates poses that may potentially harm the intervertebral discs (sitting poses and forward bends) and other structures of the lumbar region. (*note: many asymptomatic individuals demonstrate disc derangement upon radiographic imaging and by no means am I correlating tissue disruption with pain).

So here are some suggestions I have when it comes to yoga:

• Locate an instructor who truly emphasizes the importance of proper technique and form during his or her classes.
• If you find that you are doing too many forward bends in your class, this would be the perfect time to take a break and grab some water (just don’t grab the person in front of you). This will be easier if you practice hot yoga.
• When performing your poses, really take note of and try to master your breath. This will help foster increased “core stability” and hopefully place your low back at a decreased risk of injury. If you’re willing to practice your breathing strategies at home, have a look at this video from my friends Patrick Ward and Carson Boddicker.
• If you are familiar with the Functional Movement Screen and have specific limitations that you need to work on, then here are some poses that may be beneficial based on your score.
• If you need recommendations for some decent yoga studios, ask the folks at lululemon. They’re fun, fit, and have awesome be-hinds!

To safe yoga…

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“At what age should you start developing movement patterns for the purposes of injury prevention?”

In my opinion, this was a significant question in light of the fact that there as been ongoing discussion on several forums as to what minimum age would be most appropriate for the application of the Functional Movement Screen.

Since many of the athletes I work with fall within the 12 to 21 year old age range, it seems only appropriate that I address this question. Here are some tidbits of information that may assist in clarification:

Childhood ranges from 6 to 9 years of age and is marked by significant physical changes that in general, exhibit a linear growth. Development is typically somewhat predictable.

Adolescence, in contrast, ranges from 10 to 16 years of age and is marked by dramatic and rapid physical changes.

When considering the appropriate minimum age, it is also important to understand the differences between growth and maturation.

• Growth: actual changes in size occurring over a period of time
• Maturation: progress towards biological maturity (timing and rate of maturation generally varies between and within individuals).

Adolescent growth spurts generally occur between 13 and 15 years of age in males and between 11 and 13 years of age in females, while the age of maximal rate of growth (aka peak height velocity) generally occurs approximately 1 to 2 years following the commencement of sexual maturation. These variables may indeed influence motor learning and control.

In general, young children lack the motor skills required to adequately run, jump, and throw. With growth and maturation of the neurological and musculoskeletal systems, so do the development of these skills. The adult forms of these skills are generally acquired between 6 and 10 years of age and while the nervous system reaches 90% of its adult size by the age of 6 and full maturation by puberty, ultimate skill development depends highly on practice and training.

Gender differences do occur with motor performance with boys generally outperforming girls in run, jump, and throw performance. Further, males generally demonstrate continual improvement until early adulthood while improvement in females often slow by age 14…likely a result of proven decreases in levels of physical activity. It should be noted however, that in general, females tend to perform better than males on fine motor tasks.

Through an examination of the Long Term Athletic Development stages from the Canadian Sport for Life resource, it is apparent that the Learn to Train stage (Boys 9 – 12, Girls 8 – 11) is the stage at which adolescents should be developing and refining all movement skills, since the brain is capable of highly refined skill performance.

Interestingly, those who may be classified as “late developers” actually have an advantage since this learn to train stage is actually lengthened in this population.

During my graduate education experience, I had the privilege of working closely with Joe Baker, Phd of York University who’s primary focus and interests lie in optimal human development. When asking his opinion of this topic, his response was:

“…‘lack of consensus’ is a good way to describe most of the recommendations regarding training and rehab issues with youth and adolescent athletes. It’s clear that there are significant and persistent problems with this population but no real consistency in the recommended approach to deal with them. The immature motor system is part of the explanation but it also relates to the motor system’s interaction with the still developing cognitive and physiological systems. Adolescent athletes are at a stage of development that is almost constantly in flux making a ‘one size fits all’ approach very difficult…Unfortunately, I’m not sure of any rehab recommendations for this population.”

So in consideration of the above information, my recommendations would be as follows:

• Movement pattern development for the purpose of injury prevention may be implemented at the ages corresponding to early adolescence

• Functional Movement Screening for the purpose of identification of injury risk may be implemented at a similar age, HOWEVER, it is my opinion that the development and refinement of general movement skills take priority over the screen itself.

• Focus should be on the fundamental of motor development until mid to late adolescents – at least that’s what our research would suggest for most late maturation sports. (a recommendation from Dr. Baker)

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The following information was derived primarily from the text, “Scientific Foundations and Principles of Practice in Musculoskeletal Rehabilitation” by Magee et al as well as the Canadian Sport for Life website.

For more information on youth development please visit the International Youth Fitness Association and Canadian Sport for Life.

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• Improving Thoracic Mobility
• Money Moves

Unfortunately, they may not work for everyone. If this is the case, or if you are simply looking for another tool to add to your arsenal, take a shot at performing the “Wall Slide”. This is one of those exercises that aims to improve both your thoracic posture and scapular positioning. It’s not an easy exercise…but it sure is effective.

Performing the following exercise:

• The individual starts in a seated position on the floor with the buttocks and back flush against a wall.
• The knees and hips are flexed as much as possible, paying attention that the buttocks do not round away from the wall.
• The neck is in a neutral position
• The shoulders and elbows are in a 90 / 90 position with the elbows and hands in constant contact with the wall at all times.
• The individual is asked to press his/ her lower back as close to the wall as possible to “lock out” the lumbar spine and minimize arching throughout the movement. This is especially important when one reaches the top of the exercise.
• The individual is asked to slide his / her arms up the wall, ensuring that they are not shrugging their shoulders.
• Upon reaching the top of the movement (this is where they feel that they cannot go any further), they are asked to take one diaphragmatic breath, both inhaling and exhaling with minimal tension. Note: this breath was not included in the video below but is highly recommended.
• The arms are brought back down following the full breath and the movement is repeated.

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“athletes of various abilities utilize psychological skills in their attempts to enhance performance, although the consistent practice of highly structured skills are generally displayed by higher performing athletes”.

Similarly, I had also posted about the potential psychological intervention of kinesiology-type taping in sport (click here to refresh your memory) and discussed the potential of a more tangible method of improving performance.

Apparently I am not the only one with such curiosity.

Tara Parker-Pope of the New York Times just wrote a nice piece on lucky underwear and performance. Whether you subscribe to this belief or not, make sure you have a read.

Does Lucky Underwear Improve Athletic Performance

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