Rehabilitation


Iliopsoas Muscle Pain in a Dance Instructor
Rehabilitation
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.   
Sunday, 04 March 2007 10:53

History and Presenting Symptoms

A 25-year-old female presents with a combination of recurring pain in the lower back region and pain and tightness in the front of her right hip. She is very frustrated by her condition, since she has already had six weeks of physical therapy for her hip pain (with only a little relief), and she received four months of chiropractic care (with moderate relief of her back pain). Her prior treatments included adjustments and diathermy heat for her back and stretches and mobilization for her hip. She has had no specific injuries to these regions, and she can’t identify any precipitating activities. On a 100mm Visual Analog Scale, she rates the pain in her lower back as varying from 20mm to 40mm, and her right hip pain as varying wildly from 0mm to 65mm. She is on her feet a lot in her occupation as a dance instructor for young girls.

Exam Findings

Vitals. This active young woman weighs 142 lbs, which at 5’9’’, results in a BMI of 21; she is definitely not overweight or obese. She is a vegan, a non-smoker, and drinks alcohol only rarely. Her blood pressure and pulse rate are at the lower end of the normal ranges.

Posture and gait. Standing postural evaluation finds a lower iliac crest on the right, and a low right greater trochanter. She also demonstrates a mild bilateral knee valgus and static pronation of the right foot (calcaneal eversion with low medial arch). The left foot and ankle show a normal, non-pronated alignment. Gait screening is negative for limp or noticeable asymmetry.  

Chiropractic evaluation. Motion palpation identifies functional limitations at the L2/L3 and L4/L5 levels, with moderate tenderness and loss of endrange mobility. Hip ranges of motion are full and pain-free on both sides. The Thomas test finds a painful tightness of the right iliopsoas muscle. She finds it difficult to lie comfortably on her back while her legs are extended.  

Imaging

Because of her persistent, non-responsive low back and hip pain, AP and lateral lumbopelvic X-rays in the upright standing position are obtained. A discrepancy in femur head heights is seen, with a measured difference of 5mm (right side lower). A moderate right convex lumbar curvature (6°) is noted, and both the sacral base and the iliac crest are lower on the right side. The sacral base angle is a somewhat elevated, but the lumbar lordosis is within normal limits.

Clinical Impression

Moderate functional leg length discrepancy (right short leg), with associated pelvic tilt and lumbar curvature. There is a chronic shortening of the right iliopsoas muscle, and a significant history of recurrent mechanical low back pain and occasional right hip pain.

Treatment Plan

Adjustments. Specific, corrective adjustments for the lumbar spinal region were provided as needed, with good response. Additional manual therapy included contract/relax stretches for the iliopsoas muscle.

Stabilization. Custom-made, flexible stabilizing orthotics were supplied, with a varus pronation wedge under the medial aspect of the right calcaneus. She had no difficulty in adapting to the orthotics.

Rehabilitation. She stretched her right iliopsoas muscle at least four times each day, after a brief brisk walking warm-up. She also strengthened her hip extensor muscles in the upright position using elastic exercise tubing.

Response to Care

This patient responded rapidly to her spinal adjustments and active resistance stretches. She immediately began wearing her orthotics in all of her shoes, and especially at work. After six weeks of adjustments (10 visits) and daily home exercises, she was released to a self-directed maintenance program. 

Discussion

A relatively slight functional short leg can produce chronic symptoms in people who experience a lot of weightbearing biomechanical stress. This situation will often be identified in long-distance runners, dancers, and in occupations such as drill press operators and warehouse stockers. A moderate amount of asymmetrical pronation, when exposed to repetitive or constant loading strain, can develop into chronic muscle tension, with shortening tightness. Spinal adjustments and very specific stretching and strengthening exercises provided relief, but the underlying functional leg length inequality had to be addressed with stabilizing orthotics for long-lasting results.

Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame. He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program and lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation. Dr. Danchik is an associate editor of the Journal of the Neuromusculoskeletal System. He can be reached by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 

 
Establishing a Care Plan for Your Patients
Rehabilitation
Written by Dr. Kirk A. Lee, D.C., C.C.S.P.   
Thursday, 01 February 2007 16:41

The use of rehabilitation procedures is becoming more of a mainstay within chiropractic health care. Core spinal musculature stabilizing exercises, proprioceptive training, as well as activities designed to enhance flexibility are currently being used to help support the chiropractic adjustment. Each of these methods has become a major point of interest to help a patient enhance his/her overall health and wellness. This has subsequently helped patients to be more involved in their health care by physically participating.

There are a few things that we do well, and other things we do not do so well when creating a treatment plan. Are your rehabilitation programs designed to address postural deviations, improve strength, balance, sport specific or prevent injuries?

Depending on the scopes of practice in the state you practice, the amount and types of rehabilitation the Doctor of Chiropractic is allowed to do will vary. For many doctors, the use of rehabilitative exercise, neuromuscular reeducation and therapeutic activities are of most importance. Others choose to use physical modalities to help increase healing time by improving circulation and decreasing edema. The choices you make are more than likely based on your state statute and, possibly, the chiropractic college you graduated from.

The profession’s approach to therapy maybe demonstrated as recently as 1935. When B. J. Palmer established the Rehabilitation Laboratory at the B. J. Palmer Chiropractic Clinic, all the equipment was patient driven. The only electrical piece of equipment used then was a mechanical horse. One of the rules at the clinic included, “At no time, in no way, do we use any therapeutic apparatus on any case.”

A common mistake many Doctors of Chiropractic make when developing a rehabilitation program for their patients is that they overload a joint before it has healed or full ranges of pain-free motion have been reestablished. This usually occurs by using a weight that is too heavy or of too high resistance. The difference between neuromuscular reeducation and strength training should be reviewed by many of us so that we are accurately performing therapy. Neuromuscular reeducation should be established prior to initiating strengthening protocols, especially if the patient is someone who appears to be physically fit and/or has a history of working out.

The mistake of muscle strengthening before neuromuscular reeducation usually results in the patients’ complaining that the exercise or activity you initiated aggravated their present condition or exacerbated an improving condition. Whether pain is present, either constantly or during an activity, it will prevent the body from performing normal moving patterns. To ensure this will not happen, the Doctor of Chiropractic must have a good understanding of the patient’s present-time muscle strength and his physical endurance. This must be established through initial and interim chiropractic evaluations and management.

Gait Cycle:
Another commonly overlooked patient presentation is gait cycle. Evaluation of the patient’s gait cycle can show muscle imbalances. These imbalances can occur from differences between antagonist and protagonist strength, flexibility, and the subluxation complex. One of the most frequent gait alterations that may be seen is the Trendelenburg gait. Clinically, this presents as a dropping of the hip on the unsupported leg during each step of the gait cycle. This usually results from a weakness of the gluteal musculature. Often this problem can be addressed and stabilized by reducing the subluxation complexes and initiating normal motor pattern movements, followed by strengthening exercises.

Base of Support:

Another area to observe would be the patient’s base of support: Is it too narrow or too wide? Are the abnormalities within the gait due to neurological inducement, altered biomechanical dysfunction, or antalgic due to pain? Is the patient’s posture in good alignment from head to toe? Keep in mind, postural defects and movement distortions in one area can affect seemingly unrelated distant areas, causing dysfunction and pain. Does the patient show an anterior translation of the head, rounding of the shoulders with thoracic extension, anterior pelvis translation, functional leg length inequality, and asymmetrical bilateral pronation?

One of the most frequently missed patient presentations is how a patient raises and lowers himself from a seated position. How often has a patient said to you he is having difficulty raising and lowering himself from the toilet, difficulty maneuvering stairs and getting out of bed? Quite often, this is the result of weakened musculature and altered spinal biomechanics. Are the assistive devices (walkers, canes, crutches) being used properly, or are they a contributing factor?

As the Doctor of Chiropractic, you routinely develop a plan for how you will provide the chiropractic adjustment. You do this from a correlation of your examination findings, which may include X-ray and other additional testing. It is important to have and implement a plan that may compliment the chiropractic adjustment with thorough rehabilitative techniques. Please remember, this is much more than merely handing your patients a bunch of exercises and expecting them to do them on their own.

A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan. He is very active with the Michigan Chiropractic Society, serving on the legal and government affairs committees.

 
Are Your Shoes Killing You?
Rehabilitation
Written by George LeBeau, D.C.   
Wednesday, 18 October 2006 15:51

During my early years of practice, while working with youth sports, I met an Athletic Trainer named Bob Ragsland (“Rags”). He had been working with college athletes for many years and emphasized to me the importance of proper equipment fitting. I spent many hours with him learning techniques for fitting shoulder pads, helmets and other sports equipment.

Then, one afternoon at a Pop Warner football game, a mom came up to me and asked if I would look at her son’s feet. She stated he kept spraining his ankles and was always complaining about foot and ankle pain. I noticed that, indeed, both of his ankles were swollen and very tender to touch. Thinking it was odd for both feet to be like this, I asked to see his cleats. She showed me a pair of football cleats that were about as useless as running with plastic bottles on your feet! The “cleats” were ¼” stubs about ½” in diameter that provided no traction whatsoever. Not only that, there was no lateral support and they were about two sizes too big for him. The salesman had assured her, “These are the latest...blah, blah, blah.” 

The shoes were not new—hence, the ankle sprains—but I told her to take them back to the store and complain that they were injuring her son’s feet. I told her what kind of football cleats to look for and the kind of lateral support he needed. Then I asked her why they were too big for him.

She told me her husband wanted to buy them large enough for him to “grow into” over the next year or so. I told her I thought that was a very bad idea and she should fit the shoes to his feet for this season. Another danger with cleats like these is they will give the young athlete a false sense of security in thinking they can “run and cut” at full speed without injury.

This incident started me thinking about footwear for all of my athletes and I started checking shoes regularly. The more I checked, the more problems I found, not only with cleats but also with running and other types of athletic shoes. The photos presented here are of shoes and cleats I checked recently from about a half dozen very well known shoe outlets. In every case, I asked the sales representative to bring me several pair of their most popular brand name shoes. I did not sort through any boxes trying to find “problem” shoes. As a matter of fact, I spent two days searching for one good pair of shoes I could show as “normal” but, after looking at well over forty pair of shoes, I was not successful!

We will start with cleats for kids. Everyone knows how important proper footwear is, especially for kids. So, when you go to the shoe store, the first thing I want you to do is ask the sales person to bring you three pair of the same shoe. They’ll look at you kind of funny, but so what; it’s your money. Find a nice flat counter (move some of the display shoes out of the way if necessary), line the shoes up side-by-side, stand behind the shoes and look at the alignment. Figure # 1 shows a bright blue pair of girl’s Nike soccer cleats.  Look closely and you can see that the right shoe is slightly higher than the left. This may be a little difficult to see here but, when you’re at the store, it jumps out at you when you start to examine shoes. Now, notice that the left shoe tilts outward slightly. The problem here is, over the course of an entire season, as these shoes break down, this young athlete is going to develop any combination of foot, ankle, knee and back pain because the right shoe is too high and the left shoe is tilted outward, precipitating inversion ankle sprain.

Figure # 2 is a pair of boy’s black Adidas football cleats. Again, you can easily see how much taller the right shoe is compared to the left. If you look closely at the logo, you can see the difference. At least these shoes are not crooked. However, over an entire season, these will cause lower extremity and back pain due to pelvic tilt and imbalance.

Let’s move on to athletic shoes. Figure # 3 shows a pair of black running shoes with a white stripe down the center of the heel. The left shoe is much higher than the right, at least ¼”, and this shoe also tilts inward significantly, which places powerful lateral pressure on the ankle, precipitating inversion of the ankle. In addition to this, look how the left lateral heel base raises up higher than the right. This shoe is a disaster waiting to happen! If the person who buys this pair of shoes is a serious runner, he or she will develop serious lower extremity and back pain.

The next pair, Figure #4, is just the opposite. The right shoe is slightly higher than the left, but the left shoe tilts outward. Running in this shoe will place significant medial pressure on the ankle, precipitating eversion (pronation) sprain.

Figure # 5 is two views of the same shoe: A. From behind and B. From the top. These are Nike shoes. The right shoe is high and the left shoe is tilted outward; but look at View B. The left shoe is a full size longer than the right! What happens if this person is wearing the short shoe on his or her long foot? Right! He or she will have foot and toe pain and pain in the ball of the foot. OK, what if the person has his/her short foot in the long shoe? Can anyone say, “plantar fasciitis”? Are you getting this? Can you see how important proper footwear can be, not only with serious athletes, but with your everyday patients who wear tennis shoes to work or the weekend athlete who spends $100 on a pair of running shoes only to develop foot and back pain?

For more than thirty years I have been checking shoes and, I’m sorry to say, at least 50% of the shoes I check have problems in their construction. The only “quality control” I have been able to find is a person who stands at the end of an assembly line and makes sure there is a left and a right shoe in each box. What to do? Remember when I said to ask the sales person for several pair of the same shoe?

Look at Figure # 6, the Speedo shoes. The right shoe is badly tilted, but the left shoe looks pretty good. Now, I’m going to take a right shoe from each of the other boxes and try to make a match for the good left shoe. If I can make a good match where both shoes are equal in height, width, length and alignment, I tell the sales person, “This is the pair I’m buying.” Salespeople don’t care; they just want to make a sale. If I can’t make a good match, I either change brands or go to a different store. When my kids were growing up, I can’t tell you how many times we spent an entire day going from store to store trying to find shoes that would not ruin their feet. 

Here’s more bad news. Orthotics will not help this at all! If anything, trying to make orthotics to correct this problem will only make it worse. Have you been in a situation where you have had to make two or even three pair of orthotics for the same problem, only to have the patient go elsewhere in frustration? Maybe it was the shoes! I am all for orthotics under the right circumstances; but let’s get started on the right foot (bad pun) to begin with! Any athlete coming to me for treatment is automatically told to bring “all of your running or athletic shoes” to the office on the next visit. Yes, this does take a few extra minutes, but the patients love the attention. “No one has ever done this before!”

There are several shoe stores in my area that, when the patient brings the shoes back, the salesperson says, “Oh, you must go to that chiropractor.”
This is great, because it saves a lot of time. They just give the customer a new pair of shoes with no question. Once you get used to checking shoes, you will become the shoe expert in your area.

Couple of other points I want to make: The cost of the shoes has nothing to do with the quality of construction. I was at the Costa Mesa, CA, Bally store and saw a pair of badly made running shoes with a $450 price tag. On the other hand, I have found perfectly made shoes at Payless for less than 10% of the Bally shoes.
For walking and general exercise, the best-made shoes I have ever found, and use myself, are skateboarding shoes. Someone told me once that these shoes are all made in the US. I’m not so sure about that, but I do find these to be very well made.

Invariably, I have patients or doctors ask, “Well, what about leather dress shoes or high heels?”

Very rarely will you ever find a problem with this kind of footwear. (I can hear a great sigh of relief from all of the women doctors out there.)

Dr. Le Beau practices at Chiropractic Industrial and Sports Center; 1365 West Vista Way, Suite 100; Vista, CA 92083. 

Send your questions to Dr. Le Beau, send them to him at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
Build Your Practice with Active Therapeutic Movements
Rehabilitation
Written by Jay Kennedy, D.C.   
Monday, 28 August 2006 21:38

Active Treatment Strategies
Improve Patient Outcome & Clinic Profits

Building a profitable practice takes the right equipment, skills and a commitment to excellence.  Certainly central to that is a clear, results-oriented treatment strategy.  Spinal adjusting and passive modalities are ubiquitous in chiropractic. Decompression/traction is also becoming a staple of passive care.  However, exercise and specific movement therapy is fast becoming a major player in many forward thinking clinics…as the emphasis shifts to an active model of care.

Active treatment methods should, ideally, be integrated with passive care. A substantial result over a wide range of conditions is no longer an option but a necessity.  Competition and managed care necessitates it. We all are faced with the daunting task of getting our patients better faster…and certainly faster than the doctor (or therapist) down the street!  The mind-set of today’s forward thinking clinicians is to develop patient wellness strategies that are active, functional and leading to a patient self care plan. We can no longer wait weeks to get them actively engaged in functional activities—our personal and collective reputations are at stake as well as our bottom lines!

We are all faced with trying to stay ahead of changing healthcare trends.  My practice has evolved to provide treatments that compliment the philosophy you-grow-or-you-die!  I use a new and very effective device called an ATM2 (Active Therapeutic Movement). This type of treatment enlarges the scope of my practice and is an ideal transition treatment method from passive to active care. An Active Rehabilitation Suite with the ATM2 affords dramatic outcome and profit opportunities. The ATM2 creates an ideal dovetail for active relief and transition to real, substantial exercise. It is unique in the world of physical medicine. 

A highly researched concept in physical medicine suggests, IF a painful range-of-motion (a movement impairment) can be made painless (through positional fixation, compression and/or support), the central nervous system (CNS) can, and normally will, improve or optimize muscle activation patterns, i.e., the pattern or sequence of contraction it uses to create vertebral motion. (If the activation is less than optimal, untenable compression or tension on innervated tissues results in pain.) The Active Therapeutic Movement technique and ATM2 system that I use is actually a vertical treatment table with three sets of belts. Using these specialized external stabilization belts, I can safely position patients and comfortably compress and fixate specific body areas. In a matter of minutes, painful movements (impairments) become completely pain-free.  Once the movement is pain-free, a near isometric (safe-range) resistance exercise is incorporated.  This substantial exercise into the once painful direction ultimately provides substantial rehabilitation of the motion impairment. Theoretically, the resistance exercise forces the CNS to memorize a more idealized (and pain-free) muscle activation sequence.  The ATM2 treatments are done in the upright, full weight bearing position, fostering lasting changes both anatomically and neurologically. Within minutes, patients are moving pain-free. It is quite extraordinary and I have yet to find any treatment which replicates its results.

This Active treatment method and the impressive results it provides have changed my practice for the better.  Many of us use active rehab in our practices. However, most simply use a therapy ball and resistance-bands—things that require substantial pain relief before they are tolerated. In my mind, if we are to compete with the “therapist down the street,” we must offer our patients more.  And, realistically, we must offer therapies and treatment methods that are substantial, functional and provide immediate positive feedback to the patient. 

This active treatment rehabilitation involves surprisingly little time (most patients, five to eight minutes) but creates consistent and immediate pain relief in many instances. And, unlike previous PT methods demanding sometimes years of study (and two or more assistants bracing and compressing the patient into position), the ATM2 technique affords a clinician the opportunity to simply, safely (and with virtually no learning curve) attain these results without an assistant.  If you have staff, as I do, this method can be taught quickly and easily. (There is further training on-line and via DVD as well).

At our clinics, the patient is qualified for the therapy, safely positioned and participating in these pain-free therapeutic motions within minutes, gaining substantial relief and substantial therapeutic benefit unavailable anywhere else.  An additional clinician benefit is the strain reduction on your own back.  Less bending over, lifting and rotating—lengthening your own career!  Not to mention the ease of treating those very large or very de-conditioned patients who have not exercised for many years. ATM2 affords many patients the opportunity to start beneficial therapeutic movements on the very first visit, in both chronic and acute conditions.

I have developed a specific patient protocol for combining Active Therapeutic Movement with Decompression therapy (a favorite treatment of mine). Combining modalities and adjusting is also very practical.  And keep in mind that the ATM2 is an excellent and very reliable self-prognosticator.  If a patient CANNOT be set up completely pain-free, they are not, at that time, an ATM2 patient. This is extremely powerful in reducing the potential of negative or less than desirable outcomes and in reducing your liability, as well as channeling a patient to the best intervention at that time. And, since the response to a treatment is immediate, athletes and fitness enthusiasts are continually captivated by the active relief of an ATM2 treatment.  They often will comment that they feel lighter or taller.  This would seem congruent to muscle activation or muscle selection patterns being improved by the CNS, thereby re-organizing the most specific or appropriate muscles, optimally selected to do the majority of the workload.

I hope you will take the time to investigate for yourself the distinct and powerful clinical advantages of using active treatment strategies that are possible with Active Therapeutic Movements and the ATM2.  I believe it will improve your marketability as you provide a more eclectic treatment offering, including an active treatment component, and have a dramatic effect on your patient outcomes, your clinical confidence and your bottom line profits.

Dr. Jay Kennedy is a Palmer Graduate and has been in both a private & MD/DC practice in Berlin PA. for 18 years. He lectures throughout the United States on decompression and rehabilitation procedures and has successfully utilized the ATM2 treatment in his clinics for several years, creating a classification system which utilizes patient-specific conditions and as that relates to treatments with traction/modalities/adjusting & the ATM2.  He is also a clinical consultant and product designer for a major physical medicine manufacturer.

 
The Core Workout
Rehabilitation
Written by Mark Sanna, D.C.   
Saturday, 27 May 2006 04:00

The Core

If you were to ask which muscle group you could focus on to provide your patients with the greatest benefits in the shortest amount of time, it would be the core. What is the core? The core consists of all the muscles in the abdominal and lower back areas. This includes the abdominal muscles: rectus abdominus, internal and external obliques; the transverse abdominus and the intercostals. It also includes the muscles associated with the spine: the erector spinae group and the hip flexors (iliacus and psoas, collectively known as the iliopsoas). The basis of core training is to increase the recruitment efficiency of the smaller, deeper stabilizing muscles around the hip and pelvis. The aim of core training is to recruit the trunk musculature and then learn to control the position of the lumbar spine during dynamic movements.

Why Is the Core So Important?

Weak core muscles contribute to all kinds of problems in the body, the most prevalent of which is lower back pain. Strengthening the muscles that help support the spine and improve posture dramatically decreases the symptoms of lower back pain. Picture the spine as a column of cans stacked one on top of the other. If you wanted to keep that column standing up under stress, what do you think would work better: a “tenser” bandage, as is used for wrapping injured ankles, or Scotch tape? The tape would keep the cans together, but the cans wouldn’t receive a whole lot of support, would they? When you strengthen the muscles of the core, you are, in effect, turning that Scotch tape into a nice, tight “tenser” bandage, increasing the amount of support that the spine receives.

Four Mechanisms of Active Support

The lumbar spine area is inherently unstable and relies upon support from four mechanisms that actively support the area for sufficient stability. These four mechanisms include tension from the thoracolumbar fascia; the intra-abdominal pressure mechanism; the paraspinal muscles; and the deep lumbar extensors. The thoracolumbar fascia provides a tensile support to the lumbar spine via deep-trunk muscle activity. The intra-abdominal pressure mechanism can provide a supportive effect to the whole lumbar area. The paraspinal and deep lumbar muscles act with a static contraction to resist lumbar extension and rotational forces.

The deep-trunk muscles, transversus abdominus, multifidus, internal oblique, paraspinal, and pelvic floor are key to the active support of the lumbar spine. It is not just the recruitment of these deep-trunk muscles, but how they are recruited that is important. The co-contraction of the transversus abdominus and multifidus muscles occurs prior to any movement of the limbs. These muscles anticipate dynamic forces, which may act on the lumbar spine and stabilize the area prior to any movement. The timing of coordination of these muscles is very significant. Back injury patients are unable to recruit their transversus abdominus and multifidus muscles early enough to stabilize the spine prior to movement. The onset of the contraction before any force can act on the lumbar spine is essential for these muscles to act as stabilizers.

Specificity of Training

Having identified the key muscles and how they act, the next step is to establish how best to train these muscles. As with any type of strength and conditioning training, the training protocol for improving the function of the deep-trunk muscles must be specific to the task required. The deep-trunk muscles act as stabilizers and are not involved in producing movement but, instead, involve static, or isometric, contractions. They must act as stabilizers continuously throughout everyday activities as well as fitness training, and require very good endurance of low-level forces. The deep-trunk muscles do not need to be very strong, but they must be correctly coordinated and capable of working continuously. These stabilizer muscles must hold the lumbar spine in the neutral position, which is the correct alignment of the pelvis that allows for the natural S-curve of the spine.

Warm-ups

Begin core training with a three- to four-minute cardio-vascular warm-up, such as walking on a treadmill. “Scouring the Joints” is an excellent warm-up that stimulates nutrition in the joint capsule. This warm-up is performed with the patient in the standing position. Instruct the patient to actively rotate his or her pelvis clockwise three times and then counter-clockwise three times. The patient should feel a “scouring” sensation in the acetabulae.  Follow this lower body warm-up with a warm-up of the shoulder joints. Instruct the patient to lower the shoulder blade on one side and then to move the humeral head through the hours of the clock three times in one direction, then three times in the opposite direction and, finally, to repeat the warm-up with the opposite shoulder.

The Basics: Co-contraction

Core-stability training begins with learning to co-contract the transversus abdominus and multifidus muscles effectively as the key to the lumbar-support mechanism. To perform this co-contraction requires mastering the abdominal hollowing technique with the spine in the neutral position. Begin by instructing the patient to lie on his or her back with knees bent. The lumbar spine should be neither arched up nor flattened against the floor, but aligned normally with a small gap between the floor and the back. This is the neutral lumbar position the patient must learn to achieve. Instruct the patient to breathe in deeply and to relax all the stomach muscles. Ask the patient to breathe out and, as he or she does, to draw the lower abdomen inward, as if the belly button were going back toward the floor. Pilates teachers describe this movement as “zipping up,” as if you were fastening up a tight pair of jeans. Instruct the patient to hold the contraction for ten seconds, while breathing in and out and holding the tension in the lower stomach area. This exercise should be repeated five to ten times.

Important Coaching Points

It is vital for patients to master the performance of the abdominal hollowing exercise correctly, otherwise they will not learn to recruit their transversus abdominus and multifidus effectively. Don’t allow patients to let the whole stomach tense up or upper abdominals bulge outward, as this means they are using the large rectus abdominus muscle instead of transversus abdominus. Coach patients not to brace their transversus abdominus muscles too much. A gentle contraction is enough. Be sure that patients do not tilt the pelvis or flatten the back while performing abdominal hollowing, as this means they have lost the neutral position they are learning to stabilize. Patients should breathe normally while maintaining the co-contraction of transversus abdominus and multifidus. Breath holding means the patient is not relaxed. Once a patient has mastered abdominal hollowing while lying in the supine position, it’s time to practice it while lying prone, in a four-point kneeling position, sitting and standing. Be sure that the patient resumes a neutral lumbar spine position in each posture before performing the hollowing movement.

Functional Stability

Once a patient has learned to recruit the transversus abdominus and multifidus muscles correctly in various positions, it is time to increase the challenge. Core stability is not defined by the ability to recruit deep stabilizing muscles in isolation. Instead, it is defined by the ability of the core muscles to work in an efficient and coordinated fashion to maintain correct alignment of the spine and pelvis while the limbs are moving. It is important that, once patients have achieved proficiency of the simple abdominal hollowing exercises, they progress to achieving stability during more functional movements. You can achieve this by adding limb movements, such as leg raises, while the patient performs abdominal hollowing in the lying, kneeling, sitting and standing positions. Use your imagination to think of ways to improve your patients’ dynamic stability. The approach only works, however, if the patient focuses 100% on posture and alignment. The aim is always to develop the correct and efficient core muscle recruitment patterns.

Dr. Mark Sanna is the CEO of Breakthrough Coaching. For more information on core training or to attend a Core Workout Training Seminar, contact Breakthrough Coaching at 1-800-723-8423 or visit
www.mybreakthrough.com.

 
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