The Functional Movement Symposium (Coffee, Wafels & Argentinian Steak).

This is an overview of The Functional Movement Symposium hosted by Human Motion, that was held just outside of Amsterdam on Sunday 13th October.

The speakers on the day were Kyle Kiesel, Lee Burton, Mark Scappaticci, Behnad Honarbakhsh, Craig Liebenson and Gray Cook.

Firstly, I have to say Amsterdam is the friendliest city in the world and really does live up to the stereotype, everyones on a bicycle or tram, every other shop is a coffee shop (normal ones and special ones) or a bar. It also appears to be where Supermodels are harvested from. So after spending the first day wandering around the town with my colleague Nick and my girlfriend Tiss, drinking coffee, eating cake, partaking in several local beers, eating a very tasty Argentinian steak (why are there so many Argentinian steak houses in Amsterdam?), having a wafel with cream on, getting lost and being constantly rained on it was time for an early night to catch the shuttle bus the next morning at 7am to the symposium venue.

As my notes on the day were taken through a haze of sleep deprivation, caffeine and micro brewery beer any mistakes or mis-quotes are my own fault.

Coffee and Cake Amsterdam style (Nick 'our man in Amsterdam' Heasman on the left)

First talk of the day was Kyle Kiesel & Lee Burton - A Systematic Approach For Exercise Design.

Kyle Kiesel kicked off the presentation (he had been standing in the doorway of a hotel in central Amsterdam with us at 7am waiting for the shuttle bus too).

It started with a brief overview of the Functional Movement Screen, which I won't repeat here as I am assuming you are familiar with it. Then Kyle did a live FMS screening on a guy from the audience, he scored a 13, which is below the cut off point of 14 (I think the guy may have scored higher if he wasn't wearing supertight Euro skinny jeans!). Interestingly, even though the guy said he wasn't in pain, because of his borderline score, lack of smooth movement and high threshold strategies (grimacing to do simple movements) Kyle then did some additional SFMA screening. This was interesting stuff, but I think most of us want to know what we then do with the screen information, how do we construct a program with this information?

Lee Burton then took over, and went through a simple checklist. What do they (the client) not need? Correctives? Conditioning? What do they need? What do they not want? What do they want?

Using the example of a young American football player, Burton then went through the other information you need, such as medical history. This was good to see, as all too often people can become obsessed with the minutiae of movement assessment and forget about the case history of the person in front of them. Have they had previous injury or surgery, what goals do they have? In the case of the American football player, previous shoulder surgery, his age (17), positional needs are all addressed in the program even if the screen presents as non painful and symmetrical.

It was good to hear Burton talk about give and take with a client as well, as any of us who design programs all day know, you have to give the client a bit of what they want, a little bit of what they need and challenge them enough without breaking them down and equally not spend an hour doing correctives if its not needed.

In the case of the young football player a circuit of mobility exercise including T-spine rib rolls and Turkish Get Ups were put into his warm up. Mobility or motor control work can also be supersetted with strength work, so Burton still had power cleans, box jumps and kettlebell strength moves in the young athletes program.

Bag to prove I actually went to it

This whole concept is expanded on further in the DVD The Future Of Exercise Program Design - which I only watched yesterday. If you are involved in program design or writing programs in anyway I think this DVD is required viewing, especially the Alwyn Cosgrove section, as he uses several real world examples of clients and their movement screens and how you use this in conjunction with other information to construct a program.

Other points of note from this talk were

• The re-tear rate of ACLs after surgery is 20-30%!
• Back pain can be because of excessive core activation, not a weak core, a motor control issue
• Lack of mobility can = instability

The next presentation was by Mark Scappaticci, entitled Functional Integrated Therapy - Optimising Performance.

 I must confess I had never heard of this guy before, which goes to show some of the best people in the world aren't promoting themselves on the internet and social media all day long, because they are out there working with clients and athletes on a daily basis.

I enjoyed this presentation, even if by Scappaticci's own admission, it's something he only put together a few hours earlier. But hey, when a guy has been to the last 6 Olympic Games with the Canadian team and consulted with the GB Olympic team it's worth listening to what he says.

Scappaticci's background is a chiropractor, and was there treating Donovan Bailey when he broke the 100m world record. He has his own assessment system, and like all good systems whether it be FMS, DNS (Dynamic Neuromuscular Stabilisation) or Scappaticci's FIT - they have more things in common than they don't.

His first point was to asses the body as a global structure and look for areas of increased tension/ forces. It is surprising that assessing as a global structure is still really not part of mainstream physiotherapy in the country (UK), it is still very much look at the injured area in isolation, whereas Osteopaths, DNS, FMS, NKT etc all seem to assess globally first.

He then outlined his systems theory - the sphere of optimal performance needs:

Optimal biomechanics

Optimal nutrition (at this point Mark informed us that if you go into any Olympic village food hall two thirds of the track and field athletes are in the line for McDonalds. Yes, sorry to disappoint but genetics is a factor and even elite athletes are not optimal)

Optimal rest

Optimal program design

Optimal technical skill

Optimal mental focus

Optimal adaption to stress

Optimal restoration

And we don't want to wait for the first injury, we want to be able to predict it and prevent it before it happens.

Optimal biomechanics need the neurosensory system, soft tissue and joint all to be working optimally.

An injury will result in different compensations in different people, for example an ankle injury may result in a different sensorymotor adaption depending on the individual (for example, the glutes switch off to protect the ankle resulting in hip or knee issues - my words here) and world class athletes are masters at compensation. Poor mechanics result in increased stress on tissue.

"Outcomes are only as good as your ability to assess." - Scappaticci

Another interesting point is to separate the clinical diagnosis from the causative diagnosis. For example, in my field, you have been diagnosed with a disc bulge at L4/L5 but what caused it? The weak link breaks but the structures away from it may be the things that are not working. (Joint by Joint theory anyone?)

Scappaticci also went through the injury mechanism - injury leads to reduced oxygen level in the area, an increase in alpha procollagen which causes scar tissue. This may show up as abnormal tension in the fascia long after an injury has 'healed'.

The fact that someone is afraid to move may drive pain signals was another point that resonated with me, I see this all the time with chronic back pain or people afraid to squat because their knees hurt.

Scappaticci stated that you need to have a treatment strategy 'power of intention, what are your goals?'

Other points

• Poor posture is a a barrier to optimal performance
• Do sports specific testing where appropriate. A poor assessment doesn't mean they are poor at their sport.
• Can I do something to enhance performance, if not I might leave it alone
• Taping  (like kinesio, rocktape) affects the nervous system
• Use whatever tools you've got - dry needling, fascial abrasion (a tool invented by Mark, to me it looks like a bit like a gua sha or graston thing, though Mark assured us it was different, but at 690 euros for the tool set I think I might follow Leon Chaitow's advice from when I saw him talk 'use a jam jar lid!')

At the end Mark got the guy on stage who had previously done the FMS with Kyle at the start, his active straight leg raise had been asymmetrical with the left leg no where near 90 degrees. Mark did some dry needling in the guys sacro-illiac area for literally about 10 seconds and then retested the guys leg which went up about another 30-40 degrees. Would it stick? Mark said he didn't know. What makes the best the best is they are also humble, sometimes you don't know why something works, it just does, but you gotta have a system. And you've gotta assess and test, treat then retest..

Next up was a practical session with Behnad Honarbakhsh (who also happened to be standing outside the central Amsterdam hotel at 7am waiting for the bus) called Reset Techniques for the Thoracic Spine.

First point form Behnad was to define a reset technique as 'anything without the active participation of the client'. And any change you do manage to make has to be set. And the technique you use should be based on your diagnosis.

I believe Behnad is a Canadian Osteopath and also teaches the SFMA course. I got the impression quite a few people in the room had taken the SFMA course during the week as Behnad asked certain questions about anatomy of the ribs and spine; the Symposium was the culmination of a week of courses including FMS, SFMA, dry needling and so on. This practical session was very much aimed at the manual therapists in the room, as it involved manipulation and visceral techniques. So if you are a Chiro or Osteo you can do this stuff, if you are a coach you can't. (my girlfriend is in her 4th year at Osteo school and currently one of her electives is visceral manipulation, so this is very much her field).

The session started by doing an assessment on a guy attending the symposium. If you aren't involved in manipulative techniques then this is still interesting for a couple of reasons. Firstly, 'the opportunity for compensation is greatest standing' and 'mobility takes precedence over motor control'. Which means, yes, looking at standing posture but then look at other postures and see if things change. If a problem is coming from the head and neck down, it will still be there in a seated position, an asymmetrical head position will stay asymmetrical, if it is coming from the feet up it will disappear during seated posture. So it gives you an idea where your treatment or corrective exercise strategy should start.

Behnad then went through reset techniques for breathing, ribs and visceral manipulation. To be honest learning practical techniques in these type of sessions is almost impossible, as what you need to do is observe and then go away and practice. Also, I think for a lot of the group it wasn't relevant, as like me they aren't going to do visceral manipulation. And even things like breathing resets which can be quite simple still take time to learn and practice (as I know from DNS).

Take home points were though-

• Don't discount the viscera referring pain, we tend to think in musculoskeletal issues and forget about the major organs and how for example the liver is attached to your diaphragm, so can influence breathing
• The driver of a problem is the thing that changes the other one. For example, if you manipulate a rib and breathing improves, then the rib was driving the breathing disorder.

Next up was Craig Liebenson - Building a Durable Athlete - Introduction of the Prague School and athletic development.

For me (and my colleague Nick) this was the stand out presentation of the day. Although, I have heard audio interviews with Craig Liebenson talking to Stuart McGill, I have never seen an entire lecture from him or seen him in person. It was one the most galvanising and inspirational talks I have seen.

And I almost didn't go to this one, as I have done DNS courses A, B and C and have a fair grasp of what the Prague School does. But this talk wasn't really about the Prague school, it was about bringing everything together, a call to arms if you will.

DNS and all that jazz source: rehabps - facebook page

A few key quotes from Liebenson

"Pain is not an early warning system, its already too late, the damage is done."

"Assess without expectation"

All too often we have a preconceived idea about what we will find or what a client wants or needed. But it's not about us, it's about that persons quality of life.

"Ensure competency before adding capacity"

And don't be "a prisoner to protocols". Liebenson was very much in the camp of movement philosophy and similarities between the likes of Janda, the developmental model and the FMS. Yes, the assessments may be different, but there are some underlying principles of movement that drive everything. You assess and then you analyse and then he gave us the classic Karel Lewit quote

"He who treats the site of pain is lost"

Maybe they should write this above the door of every physio department in the country.

Then Liebenson gave us some stats on MRI and CT false positives. For example 30% of 30 year olds will have a discogenic issue on an MRI but will not have pain. And also a Korean study I don't have the reference for - basically quality of life must match quantity, there is no point living longer if our functional capacity dramatically decreases and your levels of pain go up. Our job is to get people moving better and more often.

Other key points from Craig

• After injury tissues heal but muscles learn. An echo. Guarding.
• Ankle sprain -brain switches off the glute to allow ankle to heal
• A  fine line between building and breaking
• Get Strong first, he referenced Pavel Tsatsouline here
• And adopt a middle way.

Liebenson then quotes another person I had never heard of, Henk Kraaijenhof, but turns out to be a famous Dutch coach and another person too busy being awesome to bother writing a book I guess

"Train as much as necessary, not as much as possible. As much as is necessary in order to improve."

and then another Lewit quote

"The first treatment is to teach the patient to avoid what harms him."

This very much echoes Stu McGills advice and something that is easily forgotten in our rush to use fancy techniques and exercises. And then Janda again

"The brain thinks in terms of movements, not individual muscles."

Old Vlad Janda was ahead of his time. Then there was a quote from Laird Hamilton, the big wave surfer. I forgot to write it down. But it was very much in the vein of movement quality and authentic movement. What I liked about this lecture was Liebenson brought all these disparate sources together, whether it be Laird Hamilton, Greek Philosophers, Dutch coaches, Lewit and Janda from the Prague School or Pavel with the kettlebells and showed the thread that connected them all. Authentic quality movement is writ large in all their philosophies. And I like the fact that someone like Liebenson is constantly learning and remaining humble and in wonder at the human body like us all (he said a couple of years ago he didn't know what a deadlift or kettblebell swing was). A true renaissance man for the new rehab renaissance.

A final quite from Janda

"Time spent in assessment will save time in treatment."

And then echoing the DNS approach - every exercise is a test.

DNS - everything is connected. Source: rehabps, prague school facebook page

And then Craig made us all stand up, and reach for the ceiling, decompress the spine, and breathe to engage the core and bring the ribs down (it is always surprising that on most fitness courses and lectures you spend all your time sitting down in a terrible posture, doing exactly what you tell your clients not to do).

And lastly a call to arms

"The world has stopped moving."

Sedentarism (did Liebenson just make this word up?!) is this generations smoking. People aren't moving and its killing them.

To finish a clip from www.designedtomove.org



And up last, the big man himself Gray Cook - Cooking with Gray.

At this point I think we are all flagging. The symposium has been going since 8.30am, its now pm and we got up at 6am (5am UK time).

Gray Cook

Gray Cook has the ability to bring it back to basics, to reduce it all down to its essentials. To make you think about the very basis of it all.

In the lecture Cook went through the principles of movement as outlined in his book Movement. You need principles, a checklist, a system.

"Movement is a behaviour."

If you are in a gym or fitness facility you are 'the front line of defence, we do fitness a little differently here'. Never forget that if you are doing this stuff you are still in the minority. Maybe there were 50 or so people in the room listenening to this lecture, that's 50 people in the whole of Europe. Yes, if you use these things you are in the minority. To echo what Alwyn Cosgrove says in the Future of Exercise Design - if you are in this room and continually learning, or doing this stuff you are in the top 0.5% in the country.

Anyway back to Gray, some key points

• You need two perspectives - movement & performance or movement and impairment
• Mobility before motor control (as stated in previous lectures)
• What is dysfunction? We talk about it all the time, but whats the definition
• If we compensate the workout may be harder but not efficient. If you can't squat, trying to get someone to do 20 loaded squats is going to be hard for them but is just going to break them down or injure them or produce a load of inflammation and cortisol which may be detrimental to their goals such as weight loss.
• Total body tension doesn't over stress joints - such as in the deadlift
• Core may not be globally weak, it might be how it responds in one pattern
• Don't overkill corrective exercises.
• Delete the insulting movements
• They could be too sedentary or too specialised

And that was that. A video clip from the Erwan Le Corre and Gray Cook video, in which my girlfriend wondered if Erwan was single.

Any questions? Of course, at this point I couldn't think of any, no one else could either. Afterwards I thought of some questions
1) Will the movement screen always be the same 7 movements or will some get added or deleted?
2) Behnad had mentioned a breathing screen/assessment earlier - will it get added in?
3) And a question from my colleague Nathan - why no hinge pattern in the FMS assessment? There is a squat movement but no deadlift movement, why only multi segmental flexion in the SFMA not in FMS?

But of course, none of  that got asked. And before you know it, we're all back on the shuttle, including Gray and the FMS guys (I thought Gray might drive us all in the movement bus, like the equivalent of the Scooby Doo Mystery Wagon but no such luck).

In my mind this was well worth going to, for 149 euros. A chance to meet like minded people, realise 'you are not alone' and inspires you to carry on.

And before we knew it, we were lost in the Amsterdam rain again and then drinking Heineken in a small bar.

Micro brewery beer menu - I guess there is a reason this picture is blurred

Take home messages

• If you're not assessing then you are guessing
• You gotta have a system, principles are more important than methods
• Dutch women (and men) are hot
• I can't read a map

Anterior Pelvic Tilt (A Paradox, A Question, Some Possible Answers)

In this post I will cover anterior pelvic tilt, back pain, why your tight hamstrings may be trying to save you, why trying to counteract pelvic tilt with strength exercises may not work, open scissor posture and how the diaphragm could be the culprit. But first, the question.

Why do some people have excessive anterior pelvic tilt and lordosis when standing but when then go into 4-point kneeling quadruped they are able to get their spine into neutral, and sometimes when they lay on their back the spine is nearly flat? But when you return to standing they can't tilt their pelvis, they can't achieve a neutral position, they are locked in anterior tilt and hyper-lordosis.

If it was a structural issue they wouldn't be able to tilt their pelvis in 4-point kneeling and the back wouldn't go flat in supine. If it is a 'tight' muscle, why is that muscle not tight when they are on the floor?

I have observed this over and over again. As a background, I deal with a lot of people with lower back pain, but not all the people I have observed this in have back pain, but most do. I also see this mainly in women, again, mainly because I probably see more women with back pain and in classes, but also I just don't see this anterior pelvic tilt in many men.

But first things first.

What is anterior pelvic tilt?

Pelvis rotates down and forward, lower back becomes 'excessively' curved

If we consider a level pelvis to be neutral, then if it tilts down and forward it is no longer neutral, anterior pelvic tilt (APT), if it tilts the other way the pelvis has gone posteriorly and the lower back can end up flat. You can also get a paradoxical lumbar curve without the pelvis moving, the curve goes the wrong way, I have observed this in men, according to Pavel Kolar (prague school, www.rehabps.com, Dynamic Neuromuscular Stablization -DNS) this is caused by hip dysplasia. (I will say no more about this).

A couple of things to consider:

1. If the anterior pelvic tilt isn't accompanied by any back pain or movement restriction is it really a problem?
2. Some people have genetics that pre-dispose them to APT, this is most commonly seen in sprinters, therefore it may have an advantage for certain movements. Also be careful when looking at sprinters and some people, it may look like they have excessive APT or lumbar curve due to the size of their glutes. The glutes give the illusion of a large lumbar curve, but when you look at the lumbar spine in isolation it is  'neutral'.

What causes APT & hyper-lordosis?

As stated above it could genetics. Two other obvious scenarios: if someone is 8 months pregnant or is carrying an extra 2 stone on their gut then the reason for the APT are obvious and no amount of 'corrective' movement or breathing will make a difference.

In the women I mainly observe this in it could due to several reasons

1. Cultural: stick out your bum, push out your chest and suck your abs in to exaggerate your attributes!
2. Lifestyle: women wearing high heels, changes the whole kinetic chain, weight is shifted forward at the foot and everything above compensates. To be fair to the women I have observed this in aren't always big high heel wearers.
3. A compensation or protective mechanism: If flexion is painful then the body compensates by going into extension to spare the spine and avoid the pain. But why does it go so far into extension, if neutral is also pain free?

All these can result in the classic Janda lower crossed syndrome - tight erector spinae, weak abdominals, weak glutes and tight hip flexors. However, why aren't the erector spinae tight when laying down, they can easily do a knee hug stretch, and some clients can even do core work in supine with a neutral spine, but in the plank or press up position they typically drop back into hyper-lordosis.

In standing, the pelvis tilting down can also be accompanied by the ribs going up or flaring. This results in something that the DNS folks call open scissor posture, and the point where the scissors are pivoting and where the most pressure is occurring is typically in the lumbar spine.

Open scissors posture: the front of the scissors is the pelvis and ribs moving away from each other. The pivot point is in the lumbar spine - ouch!

Toe Touches and Hip Hinging

Using the SFMA there are four scenarios, they can touch their toes (multi segmental flexion in the SFMA parlance) and it is either painful or not, they cannot touch their toes and it is painful or not painful.

The painful scenario is most obvious, flexion causes pain, they are forward flexion intolerant and are avoiding flexion because it hurts. I don't actually see the painful scenario that much in the APT clients, more typical is they can't touch their toes and it is not painful or you ask them to touch their toes and they put their hands on the floor - they are mobile...too mobile.

To the hip hinge, there are three scenarios I see

1. They do the hip hinge, and the APT corrects itself into a normal lordosis, this doesn't happened that often, however much you coach
2. They go into even more hyper-lordosis, with the lordosis extending up into their thoracic spine. Typically see this with the mobile Yoga types
3. As soon as they hinge, their lumbar spine goes into flexion and rounds. They have the hip mobility of a breeze block. Therefore, they need to increase hip mobility, but not in the hip hinge position standing, because they just don't get it in this position. In this case taking them to the floor and doing a rocking squat could be a starting point, with the hips unloaded, and in this position their body doesn't have to worry about the ankle and all the other joints trying to keep them upright.

Glutes

You can try to get the person with APT to squeeze their glutes. I normally demonstrate this, as when I squeeze my glutes my pelvis tilts in quite a big way. Normally 2 things happen when they try to squeeze their glutes

1. Nothing happens, they squeeze but there is no glute contraction. If they have back pain or hip pain the glute may be inhibited, they have glute amnesia (listen to audio lecture with McGill and Liebenson where McGill states they have now proved this in the lab, www.movementlectures.com )
2. The glutes contract but the pelvis doesn't move, the APT is not being caused by the glutes not working.

All the standing glute work in the world trying to strengthen these muscles doesn't work in these cases. RDLs and Good Mornings and all that don't do anything,the glutes don't fire, or they do fire and the APT remains. And the client still has APT, excessive lordosis and is still moving through their lumbar spine.

Take the person into a supine 2 leg bridge, but be careful, at the top of extension you can see their lumbar spine actually going into more lordosis with no glute involvement. And at the start of the movement, watch, their lumbar spine flattens, they have gone into posterior pelvic tilt, but check, the glutes may still not be working. They can get into PPT in supine with no glute activation.

To really isolate the glute action here, try the one leg glute bridge aka cook hip lift. This is humbling for many people, hug one knee in and then bridge up, see how far they get with no lumbar spine help.

There are quite a few videos on youtube showing the cook hip lift, here is one 

Tight Hamstrings?

Typically if the person can't touch their toes they tend to think they have tight hamstrings.

However, in nearly every client I can think of, as soon as you lay them on their back and get them to do a straight leg raise (ASLR in the FMS) they can easily achieve 70 degrees, and most women are getting 90 degrees. And if they have 70 degrees or less, they nearly always get more range of movement with simple passive help. This shows two things, when their hamstrings are unloaded in a supine position they show normal range of movement, and if it can be passively increased immediately could it be something on the front of the thigh that doesn't have the strength to life the leg up.

I find people want to stretch their hamstrings for 4 reasons

1. Someone told them their hamstrings were tight, like a physio
2. They can't touch their toes - see above why in most cases the hamstrings are not short
3. They actually feel tight all the time
4. They want to stretch because they like it, they are good at it, and everyone has always told them more flexibility is a good thing

In the back pain client the tight hamstrings may actually be protecting them. If someone has lower back pain and finds forward flexion painful then

"If the hamstrings are tight and short they effectively prevent pelvic tilting." (Chaitow et al, 2002)

 and

"In this respect, an increase in hamstring tension might well be part of a defensive arthrokinematic reflex mechanism of the body to diminish spinal load." (Vleeming et al, 1997 quoted in Chaitow, 2002)

 So the tight hamstrings are preventing movement that may cause pain. I would personally say that the hamstrings are actually contracting all the time rather than being 'tight'. And if they have normal ROM supine then they definitely aren't tight, your body is doing what it can to protect your spine when you stand up, if it has no other option it uses the hamstrings. These people also typically get hamstring cramping in a glute bridge.

Extension, Centration and The Mind

Normally when I ask a person with APT to lean back in standing (multi segmental extension) they can do it and there is no pain, and all sorts of McKenzie extension positions don't make any difference to pain in those with back pain (pain could stay the same, go away, get worse, or not be a problem on that particular day). On that note, it is surprising the amount of back pain patients who have had facet joint injections when extension doesn't hurt but flexion does.

If we take the person to half kneeling hip flexor stretch position we have taken out any influence from the ankle and knee joint. In this position, it is quite normal to see the hip not extending properly, the glute not firing and the lower back going into more lordosis and increasing APT, as well as the person feeling a big stretch on the front of the thigh. Is the lower back compensating for lack of hip extension?

Also, it is important to note that the person in APT doesn't feel like they are in APT, they feel normal. In the case of forward flexion back pain, has the body gone into extension to avoid pain and over compensated. Even with or without pain, has the body decided this is the default postural position, it believes it is centred. It could be compensating for head forward posture or ankle restriction or a whole host of things in the chain, but it thinks this is normal. To use Weingroff core pendulum analogy, the pendulum had swung into flexion, so the body overreacted and swung the pendulum too far into extension.

But this is only happening in a loaded position, note that when the spine isn't being loaded by gravity in standing it can go back to neutral. The brain is in control. The person has what Kolar and the DNS guys would call 'body blindness'. In the movement system Feldenkrais they talk about a Homunculus in your mind, a little version of you in space, your body has an image of where you are in space, and it may not match reality, you need to reset the system.

In the standing loaded position.

"internal forces developed by our own muscle are often more detrimental than external forces..external forces are decisive in what way external forces apply on our system." (DNS course notes)

You get told to strengthen your core or back or posterior chain, but strengthen what? In standing we're making the position worse, we need to take the person into unloaded positions or more 'primitive' postures if you will. If we change the function we may be able to change the structure (Lewit, Kolar) with the right exercise.

Its not a strength issue or a muscle issue, its a motor control issue. Having said that, there might be one muscle you need to work on first.

The Diaphragm and a possible answer

  
Breathing is the fitness concept de-jour at the moment, and I will cover it in more detail in another post. However, I think we need to explain exactly why breathing and the diaphragm is so important, especially when it comes to back pain. Firstly the diaphragm actually attaches to the lumbar spine and ribs, as well as many other structures and muscles in the abdomen and thorax (Chaitow, 2002), so it would seem we should train it like the other core muscles. Secondly, "the lower back is stabilised via intra abdominal pressure" (DNS notes). The diaphragm pushing down when you breathe in and helps to stabilise the spine. And in people with lower back pain this may be lost.

Nearly all the people who I have seen with APT and/or lower back pain demonstrate paradoxical breathing, which means their diaphragm and ribs move up when they breath in during normal relaxed breathing. When it should move down when they breathe in.


In a study by Kolar et al (2012, JOSPT) they scanned the diaphragms of people without back pain and compare them with those who had had chronic back pain for 6 months. In the MRI scanner, they did three things, 1) lay down normal breathing 2) then got the person to do isometric flexion of an arm 2) then isometric flexion of a leg.


(I have taken the image below from the paper, before anyone sues me, it is available on the internet for free). On the left is the diaphragm movement during normal breathing of a non painful subject, image B is the movement of the diaphragm in a person with chronic back pain.

Source: Kolar et al, JOSPT, vol 42, no.4, rehabps.com

But the key point is shown in the graph below, when the person is relaxed there isn't much difference between the back pain and non pain people, but as soon as the back pain people have to apply resistance the diaphragm shoots up, it becomes higher in the thorax and the amount it is moving is a lot less than in the non painful subjects.

Source: Kolar et al, 2012, JOSPT, vol 42 no 4. rehabps.com for full article

During strenous activity the breathing pattern in a person with back pain is altered. In a cross sectional view the front and middle of the diaphragm doesn't get recruited but the back part does, this basically pulls the spinal column up and forward causing shear forces which may make back pain worse. Also with the diaphragm higher you can surmise that intra abdominal pressure is lower and the spine is not as stable.

And this may cause the back to be unstable. Of course, there is always the possibility that the back pain caused this dysfunction and not the other way around.

"One possibility is the lack of postural diaphragmatic activation is substituted by excessive activation of the superficial lumbar paraspinal muscles, which may lead to hypertrophy and, eventually, result in lumbar hyperlordosis and/or anterior pelvic tilt. Future research should study this mechanism as possibly contributing to or even underlying the etiology of low back pain symptoms." (Kolar et al 2012:360)

Breathing incorrectly may cause the muscles in the back to become over-developed, until you addres the breathing issue those erector spinae may continue to be rock hard and switched on.

So the first port of call to resolve APT and back pain may well be breathing correctly. See the video below from Evan Osar (though he doesn't mention it all in the video this is essentially the DNS method, he does mention DNS and Kolar a fair amount in his book). This video basically covers what I woudl consider the first thing to do with someone who had APT and back pain. Note the three dimensional nature of the breathing. You will find that many Yoga disciples can easily breathe forward into their abdomen, but they will find it difficult to breathe into their back, which can really help stabilise the spine, relax the lower back and get the area into a more neutral position; all with nothing more than breathing. Simple, but easily missed in our rush to load up with weights.





In Summary

Hopefully this post has raised a few questions and given a few answers.

• Firstly, trying to correct posture in standing with standard strength exercises may never work. You need to unload the system and reset it. And ask yourself why you are correcting it in the first place

• The muscles just do what the brain tells them to do. The movements don't have to be complicated, they should be simple and slow to begin with, and can be quite high repetitions (15-20 reps, re-learn the motor pattern) This could be the DNS approach or a movement system like Feldenkrais or whatever exercises you find work best for you.

• Start with breathing, the diaphragm influences spine position and stability
• Free up muscles that are over- working, for example, 6-10 repetitions of the cat camel are proven to reduce viscosity of the muscles either side of the spine. Then progress to endurance and strength exercises like the bird dog.
• You could then move onto more strength type moves, but stay in these more primitive positions to begin with, could be kneeling rocking squats, then cook hip lifts as well.
• Half kneeling hip flexor stretch with core braced and back in neutral may be appropriate if your movement assessment highlights an issue.
• The hamstrings are probably not tight and don't need stretching, they need to switch off, but they will only do that once other muscles are doing the job for them
• The details matter
• Breathing exercises can even be done in between sets of strength exercises, integrate into the training program
• If somethings worth doing, do it everyday, I think Dan John said that.

The End at last

References

Chaitow L et al (2002) Multidisciplinary Approaches to Breathing Pattern Disorders. Churchill Livingstone
Kolar et at (2012) Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain. Journal of Orthopaedic and Sports Physical Therapy. Vol 42, no 4
McGill & Liebenson From the Lab to the Trenches www.movementlectures.com
www.rehabps.com