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So sit-ups flex your spine? So what? We flex our spine thousands of times a day and sit flexed an awful lot as well. As long as you (1) know how to discern if an activity (such as sit-ups) is harming you and (2) know how to correct it if it is, you are good to go. The best way to know if an activity is harming you outside of symptoms is ascertaining if it decreases your motion. (If we’re talking about the low back, that means flexion, extension, left sideglide, and right sideglide.)
I incorporate sit-ups into my workouts as well as other spinal flexion exercises. I like sit-ups with my legs straight and ones with my legs bent. But, what do I also do? I spend 10 seconds every day checking if I have my normal low back motion and also perform prophylactic movements. (I’m lying on my stomach propped on my elbows right now.) If I were just starting sit-ups, I would check right after to make sure they didn’t cause me to lose motion (they never did). Are there certain things certain people can’t do? Of course. Sit-ups could hurt your back just like brushing your teeth could or a long car ride could; they’re not extra scary. By understanding the concepts of how to keep joints healthy, we don’t have to avoid nor fear specific exercises. I’m here to teach. -- Laura
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If you want an awesome golf swing, a great squat, a long triple jump, or even an efficient gait, the component parts need to be working normally. You want these component instruments - joints muscles, nerves, etc. - to be functioning individually before you start to program or re-program patterns. The independent parts will improve as a unit when the swing or squat is practiced - and we don’t want to engrain abnormal unconscious patterns if we don't have to.
Take running as an example. If you’re lacking normal dorsiflexion that can affect how you run. Worse case scenario, that leads to injury at the ankle or somewhere else. Best case scenario, it doesn’t matter at all. Could your dorsiflexion normalize simply by running? Maybe. I am more exact, however; I investigate how to get a patient more dorsiflexion (there are many causes). There are so many moving parts when it comes to the symphony of running and I realize most people who run aren’t going to check all these things. But if your goal is performance and/or you’re interested in investing time and energy in perfecting your running, it behooves you to see to it that the individual parts work well. -- Laura Most of orthopedics is getting joints moving better, getting nerves conducting electricity and moving better, and getting tendons functioning at full capacity. Rare is the case that true strength needs to be built in a muscle or muscles to resolve a problem. Those scenarios include when atrophy is creating problems (secondary to a number of possible factors) and when there has been injury to a specific muscle. While I often use general “strengthening” exercises as an adjunct to the primary intervention, the intent there is to get the musculoskeletal system moving and working again, not strengthening. Of course, muscular strength, which takes significant time to build, has myriad positive effects on the body, and I wholeheartedly support strength training in general. However, when problems arise, specific distinct solutions are typically called for. -- Laura
As I've written before: most orthopedic answers lie in moving people in directions they don’t usually move into. Top of that list? Yes: extension. How often do you bend your low back all the way back? Your neck? Your shoulder? Your hip?
But that doesn’t mean all problems are fixed with extension exercises. (Taking a step back, not all orthopedic problems are fixed with movement. Over 90% are, but that leaves room for conditions that require different interventions.) A person who responds to exercise, may need repeated rotation, side glide, side bend, flexion, or any combination of movements. I look for the exercise that positively affects a person’s symptoms, movement, and function. It really can be put that simply. While most need some form of extension, there are dozens of potentially therapeutic exercises. Robin McKenzie did not invent the exercise of extension, but, as far as I know, he was the first to regularly explore if repeated extension (in its various forms) could be therapeutic. It’s really a shame that students (and others) have the notion that there are Williams flexion exercises and McKenzie extension exercises. It is not only an oversimplification - it is wrong. I am having one patient now perform lumbar flexion for her home program - and applying the McKenzie method to her problem is what got me there. -- Laura It’s easy to be misguided by immediate results from an intervention, whether the intervention is movement or something else like heat. For example, if we do 20 knee extensions in semi-loaded and you gain significant range in your obstructed knee flexion, that could be due to a few factors. One, I am just “warming up” the knee joint (or whatever structure(s)) so now we get more mobility. Meaning, if we do anything that moves the knee a lot, we’ll get more flexion. Or, two, extension in semi-loaded is truly the specific, necessary exercise for this knee to unlock flexion.
There are ways to answer this inquiry. For one, if we then wait several minutes with the knee resting, we can re-test flexion. After resting, if the gains remain, it’s less likely the factor was simply being “warmed up.” Similarly, if the person does that extension exercise over a few days at home, we should see improved flexion out of the gate (when “cold”) on the next visit. And, if we do a separate knee exercise 20 times and flexion does not improve or worsens, then we know there is something special about semi-loaded knee extension for this particular knee. It’s not uncommon to see great changes in the clinic that don’t hold up over several days of repetition. That’s fine. It was prescribed as a home program to see the effect, not as a cure. That response tells us a lot of information regarding diagnosis and what to do next. But don’t persist if you see any type of positive change that, over time, just doesn’t stick. Sometimes that simply means the positive change that initially occurred was due to a general “warming up” phenomenon. Now look for the intervention that can create lasting positive change. --Laura Once we find the direction a joint needs (its directional preference), we must establish the protocol. A rule of thumb is 10 repetitions every 2 hours, but it needs to be tailored to people’s specific situations. There are many parameters when it comes to the home protocol, mainly total volume, repetitions per set, sets per day, frequency, cadence, and time.
For me, frequency is the most significant - how regularly the exercise is performed throughout the day. Of course the other dimensions matter, but if I had to choose between 100 repetitions at 9:00am, 25 reps in the morning plus 25 reps in the evening, or 5 reps performed frequently (say every 3 hours), I would choose the final option. The reason is simply that in the intervening time people move their bodies, their joints, in all different directions. Doing the exercise regularly in effect “resets” the joint to the desired position. So if 6 hours or 3 days passes, when the exercise is revisited it’s more likely there’s more “resetting” to do. It’s as if the boulder rolled farther down from the top of the mountain and now there’s more to overcome. With high frequency, we want to keep the boulder from rolling down too far and eventually keep it set where it should be at the top of the mountain. This is not my exact mindset when I approach muscle, tendon, nerve, capsule, or other problems; however, for those I diagnose with joint derangements, frequency is almost always the number one priority for improvement. -- Laura I follow a method in that I use an algorithm, an approach, guidelines. The method does not say you absolutely must do this or that. I’ve said this before, if a handstand makes your knee pain go away, then you’re doing handstands. A handstand is obviously not taught as a movement to relieve knee pain within the McKenzie method — but the thought process that gets you there is exactly what the method offers. No one skilled in utilizing the McKenzie method would be dogmatic and tell me not to prescribe something if I had a sound reason to do so. The reasoning matters.
Let’s pretend that when I ask the patient what makes her knee pain better, she replies handstands. I’ve never heard that before, but I ask the question because I actually care about the answer. So I take her knee baselines (ROM, strength, function) and her lumbar baselines (ROM, nerve tension) and then we apply what the patient says is beneficial: handstands. We retest the baselines. If they improve and remain better, handstands become the home protocol. The field of medicine, given it’s both a science and an art, hinges on flexibility. The dogma of “one size fits all” is at odds with treating unique individuals. I utilize the McKenzie method because it gives me the best guiding principles to help people get better faster and stay better longer. -- Laura Sometimes lots of exercise and activity is warranted, but not usually. It’s important to realize that the large majority of a patient’s recovery occurs outside of my office. That being said, we best utilize our time together figuring out what needs to be done when you leave. We investigate which movements or exercises are best for you to do on your own time. We also spend time discussing your prognosis, trouble shooting, reviewing how to self-assess, and so on. If a patient is under the impression that she goes to physical therapy to do her exercises and then does little to no work at home, that ensures very slow progress at best. I love going to the gym (I first joined Gold’s Gym way back when I was 17), but what I offer patients is more critical thinking and problem solving versus a place to work out. -- Laura
I look for direct cause and effect. In most cases, the cause. the intervention, is movement. Movement is usually generated by the patient, but I can use manual techniques if needed. Here’s a simple, common example of how I implement this in the office.
A patient presents with isolated pain on the right shoulder, lateral aspect. History: intermittent pain, pain usually with reaching, no pain at rest, can’t throw, present for 3 months, staying the same, no trauma, notices loss of flexion which can vary. Physical exam: no pain at rest and no cervical or thoracic loss of ROM or pain. Shoulder flexion: moderate loss with pain at end range. Shoulder internal rotation: minimal loss with pain during movement. Concordant pain with resisted abduction and pain-free weakness in external rotation (3+/5). All other shoulder baselines are normal. I don’t regularly do special tests. Now I want to investigate if there is a particular movement (directional preference exercise) that has a positive effect on those baselines. I test 10 reps of cervical retraction and extension with overpressure: no effect on baselines. I test 10 reps of right lateral cervical flexion with overpressure: no effect. I test 10 reps of thoracic extension with ball overpressure: no effect. I test 10 right shoulder internal rotations (hand behind back): shoulder external rotation improves to 4+/5 and flexion is less painful. We do 20 more internal rotations and flexion is now only minimal loss and there’s no more pain with resisted abduction. We have found a significant positive effect with the exercise repeated shoulder internal rotation. That will become the patient’s home program until the next visit. It’s about demonstrable cause and effect, not theories or guessing. It’s about being specific and not giving someone who needs one movement a program of seven things to stretch, strengthen, and retrain when it’s not needed. -- Laura My appointments are investigative - moving this way or that way and assessing the effect minutes or even seconds later - and then prescriptive. To my great curiosity, I’ve had patients respond positively to a movement/exercise (that is, symptoms or movements immediately improve) and state it was probably due to their recent injection or their pills. It doesn’t work quite like that. Cortisone from three days ago was a constant during our entire time together; the variable was the performed movement. The same goes if you've been on a Medrol dose pack for 5 days. While these may have an overall positive influence, they are not the variable we are experimenting with in the clinic.
I am deliberate in my clinical testing specifically so that we can establish cause and effect and not base decisions on probabilities. (Was it the medicine? Was it time? Was it therapy? Was it sleeping in a weird position?) Let's be as precise as possible. Just as I know how to anticipate the result of an intervention, the other clinician giving you the injection or prescription should also be able to tell you what to expect from the shot or pills. -- Laura |
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