What is a “good posture”? When  295 physiotherapists across the world were asked this question, they could not agree on what it looks like. If you were to ask more than one person who claims to work on posture this same question, odds are pretty good you will get different answer. Despite a lack of agreement, people still believe that a “good posture” exists. On the other end of a spectrum, a number of scientific research studies have failed to demonstrate that “bad posture” (whatever that means) causes pain; most could not find a connection and those who found a correlation could not separate out cause from effect. For those of you unfamiliar with the literature, please check out Ben Cormack’s Definitive guide to Posture & Pain in 3 minutes flat post for a brief abbreviated overview. Despite these contradictions, the widely held belief that a “perfect posture” and a “bad posture” exists continues to be spread.

As much as I would love to believe we all recognize that the complexity of pain makes something as simple as posture simply a grain of salt in the big picture of the worldwide disabling epidemic of pain, this recognition does not appear to be trending much better, yet…  A slight glimmer of good news occurred as some international news circuits have picked up on a recent study which nicely demonstrates that the fear-mongering “text neck” does not cause pain and the Guardian recently had a great post regarding the myth of sitting posture. If these don’t get you thinking, check out a great video from Greg Lehman titled “Perfect posture doesn’t exist“.

If you think about it, it never really made sense, take a moment to look at life around the world and recognize how what many perceive as “bad postures”, are in fact, a normal variation in the demands of daily living. The body is remarkably resilient and designed to take on the stresses of daily living:

Part of the problem in interpretation of “good” or “bad” posture is the illusion that somehow, we are all keeping certain postures during the day. The truth is, we rarely keep the same posture for long. Dreischarf et al. looked at 208 adults with no current low back pain and monitored their lumbar spinal postures via electronic sensors for 24 hours. They found that the average range of change during the day was 8-33 degrees of lumbar lordosis! What we think of posture is just a tiny snap shot in the motion picture that makes a person’s day:

Another problem is that what we perceive as a “bad posture”, may simply be representative of an unconscious protective behavior. If you introduce a noxious stimuli to someone’s back, IE: inject a high concentration saline in their back, they will change their posture. As shocking as it may sound, our body wants to protect itself, and it will change its behavior with, or without, your input. What the body perceives as threatening is more than simply nociceptive input, your emotions influence your posture as well. Moderate to severe depression is associated with classic “poor postures” and fear of pain reduces lumbar flexion to provide just a few examples. If you combine fear of pain with minor injury such as a workout which produces normal “muscle soreness”, your body may avoid lumbar flexion. Furthermore, if you have an episode of back pain, even if you do not have fear about it, your body will change you trunk musculature to behave in a more protective manner.

So where am I going with this?

I think we are looking at posture too much like a stand alone “thing”. Rather than being a cause, or a victim, it seems posture itself is a biopsychosocial representation of human needs, experience, and expression. It is reflective of a moment in time (or series of moments) and a person’s relationship to posture in that moment. Biologically, our nerves may need blood, movement, and space and posture change may be needed for that to occur. Culture and society may deem certain postures necessary, or conversely, inappropriate, and this may conflict with the needs of the physical body at the time. Emotions could be drivers and/or expressions of posture, ideomotor expression is a fascinating phenomena. Are we at peace with our body, avoidant and ignorant of our needs, or does it appear like it is is constantly on alert for a possible threat? If we are stuck in state of threatened existence, how do we find ease? Is it enough to tell some just to “relax”, do some breathing, move more, or do they need a little more guidance?

Below is the first of a series of “finding ease” guided experiences I wanted to share regarding how I believe we can use physical, cognitive, and emotional strategies to find ease in a posture for a moment. I must give a massive shout out to Joe Witte, a local physical therapist who is also a Feldenkrais practitioner, who cued me into these strategies for laying down, sitting, and standing. However, I will acknowledge I have essentially butchered the original non-verbal guided beauty of how he introduced me to this approach, but this is intentional. My belief is that simple experiences, such as this example of laying down, are ideal opportunities of effective therapeutic neuroscience education that may be helpful to unravel beliefs and open a person to new options for potential change in their life. Combining education, with an experience, body awareness, postural and movement variation, and re-assuring human contact has offered a number of my patients life changing insights into the complexity of their pain and a very real sense of hope that they did not previously have. Many of my patients cannot find comfort in a laying posture, and it is often the easiest place to build awareness and introduce change for other positions and movement, so this is where we start:

 

Ground based rope climbs are great space saving full body pulling exercises. However, the top of the climb ends up being the easiest part of the exercise. Some heavy chain is a great way to maintain resistance throughout the climb. Just be sure to pad the support chain you wear well!

 

This is part 2 of a series of posts reflecting on some highlights in learning about movement that I experienced in this last year. In part 1, I addressed my experience with Applied Functional Science / Chain Reaction™ Biomechanics and presented an application of this approach using hip internal rotation. In this post, I will discuss how my strength and conditioning beliefs have changed in 2012.

I still believe in heavy sagital plane lifting. Power/explosive lifts, deadlifts, squats, various forms of pressing have important places with strength and conditioning in a number of sports. Gary Gray provides good reasoning to support the idea that athletic development does not gain a great deal from these lifts unless they are a competitive weight lifter. However, standardized tests improved by these lifts have been shown to be related to athletic success in research1,2 and professional experience does show these lifts cross over into training. It is possible these improvements may  be related to changes in coaching over the career of an athlete but it doesn’t change the fact that intense overloads over time result is associated with athletes becoming stronger, more powerful, and faster. The carry over effects might not be driven purely by hypertrophy and increased neuromuscular drive, it could be endocrine related (increasing load is associated with increases in GH, testosterone, etc) and it could even be largely related by the mental discipline it takes to safely and properly lift increasingly difficult loads. The argument that he and others make is that there are other ways to accomplish this carry over and provide more specific tissue and neurological adaptation to sport. That may be the case, but it has not had the sheer volume and history of success as heavy sagital plane loading. There are certainly some sports I could see the value in dumping this type of loading today, but I think we might lose something, or cause a new problem, if we drop it all together.

So what about the multiplanar, multi-joint, functional training, corrective exercise realm? This is where I started my journey into movement through attending a seminar at Perform Better in 2003. At that time and many years looking forward, I just wanted to collect exercises and categorize them for individual purposes. I rode the anti-heavy lifting bandwagon for a good 4 years before I realized there was a value in it and put it back in my own system. I juggled the balance between the use of bigger lifts and the use of mobility/stability/sport specific power/strength development. I also began to realize how stability and mobility training was being scarred by the functional training movement. People see individuals squatting on stability balls and doing bicep curls on BOSUs under the claim of being “functional” when in fact, quite the opposite, they’re producing movements which simply do not exist in typical function unless they have some sort of odd circus specialty as a career.

Squat on ball

In fact, for many the idea of stability training automatically seems to perceived as being on an unstable surface, which could not be further from the truth. Worse yet, when they are not on some sort of unstable surface they are frequently isolated and cued to be worked under artificial constraints of stability. Everyone is given at least 5 cues to tighten one muscle, loosen another, fire this muscle, not that one. These cues have a place when someone is painful or are early in a rehabilitation protocol, but they do not belong in an athlete’s prehab or conditioning program in the long term except if they have another exacerbation of symptoms. They do not allow the athlete the freedom of motion to develop control in multiple planes of motion. Stability is a joint by joint function specific task. Stability is not simply the ability to hollow, brace, or maintain perfect hip hinge technique (go ahead and tell any strong man competitor fully flexed over atlas stone that his spine is unstable while lifting).

Atlas_Stone

Nor is stability hip abduction and external rotation strength and endurance which keeps this hip, knee, and ankle in a perfect sagital position. Stability is also nearly impossible to tease away from mobility. When mobility with load and force are only practiced in one plane of motion (IE: sagital plane heavy squatting, dead lifts, etc.), mobility will not improve in other planes of motion unless loaded in those planes of motion. Which brings me to our next topic, mobility needs training, not just stretching (dynamic or static):

I believe we can incorporate loaded and body weight exercises into general strategies for improving mobility which I think is more beneficial than a stretching regimen alone. We now know that long term static stretching flexibility improvements are primarily related to stretch tolerance, not tissue change. We are beginning to see that long-term resistance training with full ROM have similar flexibility improvements. 3,4 My belief is that incorporating more full body multiplanar movements with appropriate loading will therefore make more lasting changes in mobility in ways which are more functionally applicable than stretching because they reinforce active patterns of movement. Furthermore, performing these mobility exercises in weight bearing may theoretically promote joint stability at these newly acquire ranges of motion.

Finally, addressing the concern of timing of implementing all of these exercises into anyone’s program. Overall, I see some effectively implementing multi-planar/multi-joint mobility and stability into supplement work for their heavy sagital plane work. Some incorporate into into their metabolic days. To some extent, I will acknowledge it is possible that the advent of diverse multi-planar dynamic stretching prior to every session is already adequate to address my concerns. However, I still wonder if these are enough to make long standing changes in freeing up movement patterns, in particular in the transverse planes. Simply peppering a couple of mobility exercises from time to time may not be enough.

I began this year developing a program meant to complement existing training programs rather than replacing anything. It started first as a way to implement many of the old school strong man training and unconventional training techniques popular these days: focusing on grip strength and lifting and moving diverse objects into a dedicated session, as a way to expand motor patterns for force generation and just to mix up training. Some of this was just for entertainment and variety. Ultimately, after my exposure to the AFS approach and some of the group training at Shoreline Sport & Spine, this progressed to include a variety of multiplanar activities to promote mobility and stability. I now call these the “Mix” sessions, with the idea being utilize full body movements, lift and move diverse objects which require multiple forms of grip and body positioning, and integrate multiplanar/3D mobility and stability to complement an existing training plan.

The idea behind having these as separate sessions rather than integrated into existing sessions was that although I wanted some mild/brief fatigue from a metabolic style warm-up and a finisher at the end, I wanted to not have neuromuscular fatigue be so great prior to, or during, the session as to prevent the body from learning new movement it might not be familiar with.

I put together a video of some the exercises used in group sessions over the last year as this thought process evolved. This video is not the best representation of everything involved in a mix session or the balance of single plane vs. multi-plane diversity. I still have a large number of sagital plane based exercises, but it still demonstrates how the movement is changed by using objects other than barbells and how freedom of motion is promoted throughout. Of additional note, these sessions were designed for group sessions, the exercises recorded below were primarily for non-competitive athletes, these are different than a competitive athlete and the sessions can be customized be more “general sport specific”, but they are inherently limited in the ability to address an individual’s functional needs.

And if I’m completely honestly, it is just fun to have an entire dedicated session to experiment with movements that are different than what are traditionally used. Sometimes a little change is all that we need to move forward.

1.) Hansen, Keir T., et al. “Do Force–Time and Power–Time Measures in a Loaded Jump Squat Differentiate between Speed Performance and Playing Level in Elite and Elite Junior Rugby Union Players?.” The Journal of Strength & Conditioning Research 25.9 (2011): 2382-2391.

2.) Gonzalez, Adam M., et al. “Performance Changes in National Collegiate Athletic Association Division I Women Basketball Players During a Competitive Season: Starters Vs. Nonstarters.” The Journal of Strength & Conditioning Research 26.12 (2012): 3197-3203.

3.) O’Sullivan, Kieran, Sean McAuliffe, and Neasa DeBurca. “The effects of eccentric training on lower limb flexibility: a systematic review.” British Journal of Sports Medicine 46.12 (2012): 838-845.

4.) Morton, Sam K., et al. “Resistance training vs. static stretching: effects on flexibility and strength.” The Journal of Strength & Conditioning Research 25.12 (2011): 3391.

Most of the time when we deal with an acute inversion ankle sprain, we look at how to manage it for 16-18 hours out of the day and maybe add in some elevation at night if there is significant swelling. But could we do a little more to speed the recovery time or at least decrease the discomfort during the night? If the individual with an ankle sprain sleeps on their back or on their side (if they lay on their stomach, this solution will not work), here is something to try to help mediate some of the acute pain with laying on their back/side with an acute inversion ankle sprain.  This mechanism/solution may seem negligible, but I can assure you that your patient will thank you for at least suggesting this as an option.

Although anatomic variations and pre-existing lack of mobility may prevent this from occurring, but for many, when the leg is rested on a surface, such as in supine with the posterior aspect of the calcaneous in contact with the surface, the effect of gravity naturally places the ankle into a bit of plantarflexion.  With plantarflexion, a concurrent anterior glide of the talus occurs which is slightly accentuated by gravity both on the foot and through the talocalcaneal bridge with the tibula/fibula. This is because the calcaneous acts sort of like a fulcrum in which the talus has a relative anterior glide due to the effect of gravity driving the tibia and fibula gently posteriorly  on the talus towards the resting surface due to size and weight differences. As a result, additional stretching/irritation of the anterior talofibular (ATF) ligament may occur. If the patient rolled on the side which places the injured ankle’s lateral aspect to be faced towards gravity, gravity would then contribute to the foot/ankle invert/adducting and minor stretching/irritation of the calcaneofibular (CF) and ATF ligament. Similarly, having the ankles lateral aspect on the support surface, through bodyweight and lack of conformity of the surface, minor stretching/irritation of the CF/ATF ligament may occur.

One way to counteract this kind of stretching/irritation is with a conforming pillow, which can assist with preventing the amount of plantarflexion in supine, and inversion, in side lying which may occur while laying in bed/couch, etc. But a pillow can be more cumbersome and require a fair amount of adjusting throughout the night to accommodate.  Another way is through a small homemade/athletic training room/clinic made supportive device:

Take a simple piece of foam tubing (IE: pipe insulation tubing or thin floatation device) cut it to a length that can cover the back of the ankle and both malleoli. Thread a piece of string through it to allow it to be fastened around the ankle. Tie the string tight enough to allow it to stay on the ankle above the calcaneous at the talotibiofibular joint, but loose enough to easily remove.

This foam supportive device provides support at the talotibiofibular joint which, in supine, reduces the influence of the posterior glide of the tibia/fibula on the calcaneous (reduced relative anterior glide of talus) and also mildly dorsiflexes the ankle. In side lying, it can be positioned more inferiorly to prevents inversion/adduction with the lateral aspect facing to the sky, and left at the talotibiofibular joint line when the lateral aspect of the ankle is facing the resting surface. Basically, we are trying to prevent additional stretching of the soft tissues associated with anterior glide of talus.

In theory, this may secondarily assist with healing, as it helps keep the ATF,CTF, the capsule, and other tissues in an approximated position. This may be beneficial after aggressive posterior talus mobilization/manipulation as well.

…Ofcourse, everything I just described above could be complete hocum and simply the additional sensory contact around the ankle could act like a counter-irritant. Regardless, speaking from experience, it just feels better.

A few months ago I talked about the Gluteus Maximus Activation Enigma and the conflicting information obtained on the glute max in the clinic versus what has been demonstrated in literature. It has been difficult for me to address this because I too was guilty of really perpetuating the idea of “gluteal inhibition” and that your “glutes are shut off”, when the evidence for these theories does not exist unless you have a true nerve lesion. It may seem like semantics to the some, but the reality is that our patients and clients take these words very seriously. In fact, I would say a good chunk of them catastrophize the fact that their “glutes aren’t working” and likely worsen the associated symptoms involved in the hip extension dysfunction. I think for athletes in particular to be told that something isn’t working in their body is detrimental to performance for individuals with certain psyches, a point which Vern Gambetta really drives home with his opinion on corrective exercise. At the same time, even if the glutes truly are not “Turned off” or “Firing in the wrong order”, clinically, they are clearly not working very efficiently either, especially if they are significantly asymmetrical. Therefore to find middle ground, I like to look for solutions which help the client/patient remain independent while still participating in their sport even if some form of dysfunction exists by using self evaluation and treatment. I previously mentioned my suspicion that muscle fatigue, rather than muscle inhibition or activation order, may play a part in why our glute emphasized treatments result in reduction of symptoms. A recent article from Hong-You Ge, et al.1 demonstrated that latent trigger points have measurable effects on muscle fatigue made me want to revisit fatigue in the evaluation and treatment of general hip extension dysfunction.  However, I’m going to broaden this idea even further (I’m once again breaking my own rules regarding excessive extrapolation of a research study by doing so) by first looking at addressing the antagonists to hip extension, the hip flexors, prior to attempting to address trigger points/restriction in the gluteals.

I want to preface this write-up to make it clear that I have no evidence for the process that I am about to describe and I am certain there are at least 10 other ways to independently evaluate hip extension. I think both Stuart McGill and Bret Contreras have touched on the use of  different types of bridges in determining hip extension dysfunction in the past, but I couldn’t find the articles offhand, so here is my take on it.

I use a 15-20 rep range of single leg bridges for the patient/client to subjectively identify whether they feel a perceived difference between sides relative to fatigue, ease, and whether it feels disproportionately loaded on the hamstrings, possibly even painful if that is their primary complaint. Then, based on which side is perceived as more challenging, we slightly butcher the classic Janda lower cross syndrome2 and just associate hip flexor involvement with gluteal function rather than look at his original cross of abs to glutes.We’ll generalize it even more and call the hip flexors over active antagonists with possible active or latent trigger points in them decreasing performance of the agonist hip extensors just to integrate the Hong-You Ge et al. 1 discussion a little more.

So for the patient to independently treat this, we start with them attempting to inhibit the hip flexors through a 30 second static stretch for and then retest the bridges. They don’t have to go all the way to 20 reps but they should just be able to go 2-3 more reps more and perceive the exercise as easier. If it does improve, have them do a full minute of static stretching of that hip flexor followed by 3-4 sets of 15-20 reps of single leg bridges to reinforce the more efficient hip extension pattern.  If it doesn’t improve, or they feel only a little better, try a self-TFL release next. Use 1-2 minutes of self release on a tennis ball followed by the same 3-4 sets of single leg bridges discussed earlier.  If they still don’t feel an improvement, go for the glutes directly with a self release. If it works, follow the same pattern of reinforcement from earlier. If there is no change, there is a slim possibility they simply need to train that side more aggressively in hip extension. If this is the case, then we want to have them work on quality reps of single leg bridging on a daily basis for the same pattern of reinforcement as described above. If within one week of working this pattern they still find a single set is fatiguing, the problem does not lie specifically in the hip musculature and it is going to require a bigger picture perspective and likely more involved manual therapy (starting with a pelvic/lumbar eval).

A couple of notes: First off, verify that the fatigue is not just related to the position of their foot and whether they are driving from the heel versus the toes because this can significantly impact loading of the hamstrings between sides.  Second, I recognize not every one of our clients and patients can even do a single leg bridge, let alone 20 of them, but this test and these self-treatment options is not for those individuals anyway. Third, by the 3rd set of bridges, if they’re not used to doing these bridges, they’re going to be fatigued anyway, just do a couple reps for them to subjectively evaluate any chance in the performance of hip extension.

Finally, I admit I am probably still going to use the terms gluteal inhibition from time to time, but I swear I’ll do my best to not give patients or clients the anecdote that their glutes are “shut off” again.

***Update 6/24/12: A great example of when self treatment for hip extension dysfunction fails and more involved manual therapy is needed  from Bill Hartman is found here on his blog.

1. Ge H, Arendt-Nielsen L, Madeleine P. Accelerated muscle fatigability of latent myofascial trigger points in humans. Pain Medicine. 2012:no-no. doi: 10.1111/j.1526-4637.2012.01416.x.

2. Janda V. Muscle strength in relation to muscle length, pain, and muscle imbalance. International Perspectives in Physical. 1993:83-97.

Ever had an external rib torsion which just would not calm down? I had one of these for about 6 months and a fellow student had theirs for several months as well. Addressing the t-spine and the rib itself both through manual and exercise helped a little, but didn’t seem to resolve it completely. Instead, we were both able to treat it successfully with this amazing tool:

Towel

Yes, a towel. We folded a medium sized towel to approximately 1/2 to a 3/4 inch in thickness. This towel was then placed under the painful rib, and slept on. It was positioned in way that whether you slept on your back or on your side it would maintain a constant level of compression on that rib. At first, the intent was just to reduce discomfort of the rib pain at night, but unintentionally, it became the complete treatment and resolved the issue. It took about 4 nights for me and about 10 days for other student. Problem solved. Easy and safe intervention to use concurrently with manual and therex, or possibly try it by itself?