Many individuals with back pain of mechanical nature will often present to their Family Physician’s office, walk-in clinic or an urgent care centre. These individuals are often treated with first line anti-inflammatories/pain medication as well as an X-ray or MRI studies. These are great tools and have provided significant improvement in many diagnostic features of health care. However, these tools are still often over used as a diagnostic tool for neck and back pain.
A common term or diagnosis that is heard following the results of the x-ray/MRI is “degenerative disc disease” (DDD). To keep this post as simple as I can without going into a lecture of the proper use of medical language, people will see the word “disease” and automatically think that there is something inherently wrong with their spine and that it no longer works properly. This is quite common. Now add the fact that likely no one has described to them their findings or what this term means, it’s no wonder people tend to stop moving afterwards. We hear things constantly like “ I can’t do –insert blank statement--because I have degeneration in my spine.”
What people need to understand is that according to recent research by Brinjikji et al. 2015., degenerative changes are commonly found in spine imaging but often occur in pain-free individuals as well as those with back pain (1). The prevalence of disc degeneration in asymptomatic (without any pain) individuals increased from 37% of 20-year-old individuals to 96% of 80-year olds (1). What is important here, is that many imaging-based degenerative features are likely part of normal again and unassociated with pain (1). It is very important that these results be interpreted in the context of the patient’s clinical condition. So instead of worrying about the label that is put on your imaging results, what you shoulder focus on is the function that you possess. Function is key.
To summarize as Dr. Stu McGill says, “Saying to someone that they have degenerative disc disease, is like telling an elderly person with wrinkles on their face they have degenerative face disease.”
Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, Halabi S, Turner JA, Avins AL, James K, Wald JT. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology. 2015 Apr 1;36(4):811-6.
Regional Interdependence and why you should know it
Regional interdependence as defined by Wainner et al. 2007 is the “concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with the patients’ primary complaint.”
What does this really mean?
This concept essentially states that although you may be experiencing symptoms such as pain, stiffness/tightness in one area of the body, that body part may not necessarily be the cause.
Let’s talk about an example, knee pain while squatting. Now there can be many different reasons WHY you may experience knee pain while squatting that do not necessarily mean the knee is the direct cause. It could be very likely that the knee is the messenger for another anatomical region that is not working as efficiently as it should be. When squatting there are certain movement pre-requisites that you should have such as adequate ankle dorsi-flexion (ankle range of motion) and adequate hip flexion/extension just to name two (there are more). Now, if you do not have the required pre-requisite range of motion for this movement, the human body will likely develop some compensatory movement pattern to achieve the goal of performing a squat that could lead to some knee pain. The knee, like many joints in the body is constantly affected by what is going on at the joints above and below it, this is something that is called the kinetic chain.
Why does this matter to YOU?
If you are ignoring the joints above and below the area of primary complaint, you are likely to leave a lot on the table in terms of treatment. Back to our knee pain example, you can treat the knee all you want but unless you address the deficits at the ankle or at the hip you will not get the full benefit at the knee. Treating just the knee in that case is like putting a band aid on the problem and hoping it fixes itself.
Here is a quick guide to the body that maps out the Joint by Joint Approach and general what body parts need more mobility versus stability. (disclaimer; we did not create this image)
Last week we discussed why diaphragmatic breathing was important and the role it plays in helping stabilize our spine. We went through common compensation patterns that are seen as well as a quick exercise to help train the diaphragm, lower abdominals and pelvic floor.
This week we are going to focus on the application of the basics to a common abdominal exercise, the dead bug. Starting at the basics, we will start by lying on our backs in a comfortable position with the bottom of our feet flat on the floor. In this position, we will apply what we went over last week, deep breath in focusing on full 360∞ expansion of the lower abdomen.
To help progress this exercise in this position, what you want to do is cough slightly and hold this contraction in your abdomen. While maintaining this contraction/pressure we are going to now breathe. By practicing this breathing method with a mild contraction, we can make sure that we are breathing adequately during exercises. With a mild bracing in the abdomen as well as diaphragmatic breathing, we are making sure that our spine is stabilized throughout the exercise.
Now to apply this to the dead bug exercise, do all the above and slowly bring your hips and knees to 90∞. Make sure to keep a “neutral” spine throughout this exercise. This does not mean to flatten your back against the ground. That is not what we are looking for. Neutral means whatever the “normal” curve you have in your low back, is what you are to maintain. Common mistakes as we become fatigued, our mid back/low backs will come out of neutral and our ribs will flare upwards. Again, make sure to maintain this contraction in the abdominals as we move through the movement. Start by just moving the arms, then the legs, then to progress further, add opposite arm and opposite leg.
The great thing about the dead bug exercise is this; if we were to pick you up from the dead bug and place you on your feet, you would be in the front deep squat position or the overhead squat position (depending on where your arms are in the movement). This exercise translates well to your lifts and overall performance by teaching you stabilization, sequencing and how to breathe all at the same time. Essentially, control and coordination are at the fore front of the dead bug.
Below is a link to a video on instagram of the dead bug and a recording of the video.
The Achieve Movement Team
Dr. Steve Martinow and Drew Martinow D.C(c)
Image Source: Complete Anatomy App (presentation licence obtained)
Breathing Part 1: Beyond the traditional core exercises.
When people reference a strong core, often the first thing that comes to mind is a 6-pack. One thing that is often rarely mentioned is the diaphragm and an individual’s breathing capacity.
First off, why does this matter? Now we all know that you CAN breathe, you have been doing so for many years. The question is, have you been doing this motor task as efficiently and as optimal as you can. We know that Intra-abdominal pressure (IAP) is one of the main stabilizers of the spine. IAP is simply the balanced coordination between the diaphragm, pelvic floor and abdominal muscles.
For simplicity sake, think of your torso and abdominal region as a can of soup. Ideally, what we look for is full 360∞ expansion of this can of soup with inspiration. This means that we expect the front, sides and back side of our abdomen to expand outwards with each breathe in and to relax with each breathe out. With inspiration, this increases our IAP thus stabilizing and helping to protect our spine with each breathe.
One of the more common compensations is breathing through your chest. This is visualized when you inspire and notice chest movement initiates prior to abdominal movement. This is a classic example of the secondary respiration muscles such as pecs and the front neck muscles acting as the primary respiration muscle, which should be the diaphragm. Breathing with chest movement first does not allow the diaphragm, abdominal muscles and the pelvic floor to stabilize and support your spine by putting them in a non-optimal position that leads to mechanical disadvantage.
A quick test of this is to lay down on your back and place one hand on your chest and your other hand on your abdomen. Close your eyes, breathe normally and try to appreciate the movement of your abdomen and chest. See if you can tell which one moves before the other one.
To help train the diaphragm, lower abdominal muscles and pelvic floor, lie on your back and place your index fingers around your waist at the level of your belly button and rest your thumbs on the lower part of your back. The goal here is to breathe so that you have abdominal expansion through both your index fingers as well as your thumb. What you should feel is your fingers moving slightly away from each other with inspiration and slightly back together with expiration.
Let’s focus on this exercise for this week. Next week we will go through how to progress this position and apply these principles to some common abdominal exercises.
Move Daily, Move Often.
Achieve Movement Squad.
If you're older than ten years old, you have probably heard or remembered your parents at some point telling you to sit up straight or stop slouching. Or perhaps you have been to a manual medicine practitioner (chiropractor, massage therapist, physiotherapist) and they have drilled into you the "shoulders back and down" cue with everything that you do. Although that can be good advice if given at the right time for the right person, it may not be the best.
Going into the details and dynamics of the scapula, neck, shoulder joint and thoracic spine is beyond the scope of this article. But just understand that the scapula (shoulder blade) needs to be able to move freely amongst its articulation with the thoracic spine and shoulder. If it wasn't we would all be moving with our shoulders pinned back and down and anytime that you would need to reach for something, lift something or scratch your head, that glued down scapula would be preventing you from doing it. Thus, causing compensatory movement elsewhere in the body to get the job done. The body is an amazing thing. Just ask any human over time. If you tell them to do something , they will figure out a way to do it, even if it is not optimal.
Going back to the posture thing. If we tell someone to always pin their shoulders back and down, eventually the body learns from that. The cells will start to lay down more tissue in the lines of tension you create, locking down the scapula over time. So if you never actually explore a range of motion outside of that, the body and nervous system will not give you that range. The nervous system will determine which movements are needed for YOUR specific needs and will eliminate the remaining, unless you constantly explore those end ranges.
Enter the banded tempo scapular adduction/abduction control exercise. This exercise is demonstrated in the coronal plane. Ensure that you try to slow the movements down, which requires you to control it. The more you can control, the more you own it. The more you own it, the more degrees of freedom you can possess. This exercise is great for the person who is bound to their desk or sitting constantly. You can also work the movement in various shoulder ranges (not shown in the video). If you can breathe and talk during the movement and don't feel a sense of "juddering" in your shoulder blade, you can safely progress to higher rep ranges. If not, that signifies brute effort and reps and sets are recommended to be in the 3-5 range.
Thank you and happy moving.
The Achieve Movement Team,
Dr. Steve Martinow and Drew Martinow D.C(c)
“The doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease.”
First of all, we would like to welcome you to the grand opening of Achieve Movement. We are beyond excited to begin our journey together with you towards a healthier tomorrow.
Our goal is to educate, inspire and empower you to make the right changes to get you out of pain and moving better. There is often a large gap of what is known in the scientific and healthcare community with what is known in the general public. We would like to narrow this gap.
We will provide weekly to bi-weekly posts about a variety of topics from breathing to best exercises for certain types of conditions. These posts will include a short description of why we believe it is important/relevant and how to perform these movements/exercises.
What we believe in is movement. Movement is the key to making long and lasting changes when it comes to how you feel. We will primarily focus on optimization of quality, performance and efficacy of movement.
Until next time, Move Daily, Move Often.
Achieve Movement Crew, Dr. Steve Martinow and Drew Martinow D.C(c)