In order to help someone towards their health goals, we need to apply the right combination of tools, in the right way, at the right time, for the right diagnosis.

Choosing the right tools involves applying the best evidence, my experience, and patient preference.

More recently, research into the rehabilitation of neuromusculoskeletal pain syndromes has investigated which patient characteristics predict success with a certain treatment.  An article entitled Clinical Prediction for Success of Interventions for Managing Low Back Pain (Clin Sports Med) summarizes some important findings.

The best medical evidence suggests a multimodal treatment approach.

This paper summarizes the aggregate result of other high quality studies, reporting the most significant factors determining success.  It is not intended to be a paint-by-number algorithm, but does give some interesting data. If a patient fulfills the criteria for one subgroup, it does not mean that treatments best for other subgroups should be avoided.  For example, if someone with back pain meets 3 of the top 4 criteria in the “manipulation” subgroup, there is a 95% probability of a successful outcome (Fritz J, Whitman. Arch Phys Med Rehabil, 2005).  Yet if the patient doesn’t meet any of the “manipulation” group criteria, there is still a 45% probability for success! ( Flynn T, Fritz J et al. Spine, 2002). Clearly the best outcomes come from the evidence-based application of a variety of treatments.

A practical progression from pain to performance.

And what about treatment timing? It’s my opinion the diagram to the left represents a logical progression of treatments that would get the most sustainable improvements in both pain and function over the shortest amount of time.  Let’s look at a specific example to see how this progression would work.

Jane (not a real name) came to Cole Pain Therapy Group with 3 weeks of low back pain that occasionally radiated to the right lower leg.  She explained that the pain was worse while stooping over to care for her infant son. She had been stretching her hamstrings, which felt tight, to no lasting benefit. Her goal was to get out of pain and be able to function through the busy day. Eventually she hoped to get back to boot camp style training for weight loss, but feared her back would never be strong enough.

After our discussion, the examination revealed several pertinent features for this example:

• Pain radiated from the back to the leg with repeated forward bending
• Pain improved with low back extension
• She was 28 years old (an easy one to figure out)
• She had an altered movement pattern
• The straight leg raise was >91 degrees

So from consulting the table above, she fulfilled criteria to fit into the “specific exercise- extension” and “stabilization” subgroups.  Treatment isn’t limited to these groups, but the best rehabilitation science available strongly suggest including extension exercise and stabilization into her treatment plan. The pictures below illustrate the progression of treatment. 

A is good. B is bad.

1st session. Instruction about how to move in a way that doesn’t hurt. Jane was squatting/stooping better within 5 minutes, feeling more confident since it didn’t make her back hurt like before.

2 extension specific exercises for the early care of back pain to the leg.

More at 1st session. She was instructed on McKenzie extension exercises to be performed 10x/ day for the next 2 weeks (McKenzie Self Treatment Handout). She also received spinal manipulation to improve spine function and ultrasound with e-stim for pain control.

Start and finish positions for a customized exercise that develops spine stability in the context of hip and shoulder mobility.

Sessions 7- 10. She was instructed and performed a variety of stabilization exercises. The focus of these customized movements was to train stability at the core (her God-given back brace) in the context of motion at the hips and shoulders. It is not a matter of strength, but of control. I also applied spine manipulation to improve mid-back mobility and applied kinesiotape to support a related shoulder blade tracking problem.

A good corrective exercise stretches movements, not just muscles.

More at sessions 7-10.  When normal movement was no longer painful, she went through a series of functional movement screens to uncover dysfunctional movements that were not necessarily painful. The above corrective exercise was prescribed in order to correct a predisposing factor to the original low back pain episode.  So the purpose of global correction is to address movement problems remote from the site of pain.  It’s these silent dysfunctions that derail fitness goals.

After the last session, she returned to the office every 4-6 weeks per her goals to address minor pains or movement issues and to discuss the application of her customized stability principles in the context of her boot camp training.  Since she knew how to check her own movement performance via self-audit, she was able to train more confidently.  Building durability involves the above five steps proposed by author and researcher, Dr. Stewart McGill.

This post is based on a presentation that I was pleased to deliver at the 2013 ChiroAdvance symposium. Thanks to Dr. Kevin Foley, Dr. Autry Parker, Dr. Ron Fudala, Dr. Bruce Fox, Dr. Jeff Luebbe, and Dr. David Schimp for graciously sharing the lectern.

1. strengthening weak muscles can reduce back pain
2. certain muscles are more important for stabilization than others, particularly the transversus abdominus
3. a unique group of muscles (the core) worked independently of other trunk muscles

Let’s set aside these assumptions and look at the facts for direction about back pain prevention and treatment.

Myth 1- Strengthening weak muscles reduces back pain. 

If strength is the goal, then how much muscular contraction is required to stabilize the spine? The research tells us that the core muscles should contract minimally. In fact, upon standing the spinal erectors, quadratus lumborum, and psoas are nearly relaxed.  Walking involves 2% of maximum voluntary contraction (MVC) of the rectus abdominus and 5% MVC of the external obliques. Then lifting a 15kg (33lb) kettle bell causes these muscular contractions to rocket up 1.5%. [source]  This is all possible because of a complex coordination of minimal muscular contraction to orchestrate a balance of stiffness and mobility. Sweating and shaking at near 100% of your effort (think MVC) is a great way to get bigger muscles, but it wont improve the coordination.

Thinking that someone can improve coordination by training strength, is like thinking that someone can train with finger weights in order to become skilled at the piano.

Instead, training/rehab should facilitate coordinated efficient movements like rolling, standing, walking, stooping, and lifting. 

Myth 2- Training the transversus abdominis (TA) is the key to core stability

Early research into the role of the transversus adbdominis (TA) found that when performing rapid arm movements, patients with chronic back pain had a delayed activation of the TA. It contracted a fraction of a second later in those with back pain than those without back pain. Unfortunately, some assumed that the late contraction with causing/complicating back pain and sought to improve the timing by strengthening the TA. This resulting in may back pain patients being coached to perform abdominal hollowing (sucking in the belly button).

Hollowing and vigorously contracting the TA prevents the abdominal pressure system from doing anything else.

In actuality, the TA contributes to spine stability in synergy with all the other deep muscles (diaphragm, obliques, pelvic floor, etc.) It acts with these other muscles as a complete system, controlling abdominal pressure for breathing, talking, singing, laughing, defecating, vomiting…

Assuming that strengthening the TA with hollowing exercises can improve it’s coordination with other stabilizers is almost as bad as assuming that a delayed contraction of the TA is causing back pain in the first place.

Instead, training/rehab should facilitate subconscious efficiency of  abdominal pressure system. One really does need to stabilize and breath at the same time. 

Myth 3- The “core” works independently of other trunk muscles

Attempting to isolate the chest.

Most “core strengthening” exercises attempt to isolate “core” muscles from “global” muscles.  In fact, these muscles only exist independently in a drawing. When dissecting a cadaver, a knife is used to separate the bundles of muscles.  Thinking of a muscle as separate from an adjacent muscle is useful for studying anatomy but not for understanding function.  When your nervous system thinks, “time to scratch the nose,” it is not performed via muscle-by-muscle activation.  Instead the nervous system performs a finger-to-nose movement. The neurological wiring is based on the movement, not muscle-by-muscle.

Attempting to isolate the core.

Instead, every training day is “core” day. Every rehab session should train movements, not muscles. 

Training a pressing movement.

Better prepared for life’s pressing moments.

Had a lot of fun talking with Mike and Doug-  two excellent coaches and athletes in their own areas.  Most readers know that CrossFit has exploded as a sport. The functional movements required of CrossFit leave no room for inefficiencies of motion. As one who evaluates and treats the movement system, I have a strong appreciation for the goals of CrossFit athletes and enjoy being part of an athletes support team.

I hope to sit down with these guys behind the microphone again, so please message me regarding what topics you want discussed.

In this episode of the Barbell Shrugged podcast we are joined by chiropractor Brad Cole to discuss chiropractic therapy, injury prevention, and CrossFit movements.

For more episodes of the podcast visit:   http://www.BarbellShrugged.com
http://www.FITR.tv

Michelle Kinney of Crossfit Chickasaw introduced me to an

If it doesn’t work, don’t blame the screwdriver.

interesting blog post by Kelly Starrett, DPT.  Kelly does a great job of making advanced rehabilitation techniques accessible to the masses.  I am really impressed by how proliferative his blog is.  You should check it out.

Medicine advances by tossing out previously held ideas in favor of newer ideas that have a greater weight of scientific evidence.  Sometimes a “sacred cow” develops, and idea about a certain treatment that has more cultural/authoritative support than scientific support.  I love killing sacred cows, and Dr. Starrett takes on a big one here.  But I think may take his recommendation too far.

Below are excerpts from the Kelly’s post entitled, People. We’ve Got to Stop Icing. We Were Wrong, Sooo Wrong.

We should not ice. For the last year, I’ve advocated for no icing with every athlete with whom I’ve helped either post-surgery or post-injury. The outcomes have been nothing short of stunning.

Observations like this are pragmatic, and should be balanced with the weight of scientific evidence and the goals of the patient/client.  Yet observations alone do not mean much.

My problem with NOT icing, I told myself was that I didn’t have other good tools on hand to minimize the pain of swelling…

Once again, very pragmatic and patient focused.  No sense in throwing out a treatment if you have no option with which to replace it. Unless the treatment makes one worse, in which case doing nothing is a great option.

Don’t get me wrong, if you need to make something numb, ice is great….if the short-term goal is pain control and the prevention of the body’s normal cellular and vascular response to injury.

I agree.  Both research and observation support that brief application of ice is helpful for pain and the body’s inflammatory response.  Next time you slam your thumb in the door would you rather reach for the ice, or dunk it in warm water?  So, there is an appropriate place for ice, especially in the context of pain control and reduction of an acute inflammatory response.

Let me quote Dr. Nick DiNubile, Editor in Chief of The Physician And Sports Medicine Journal “Seriously, do you honestly believe that your body’s natural inflammatory response is a mistake?”

The inflammatory response is a tissue healing response.  At the basic cellular level, it breaks down and rebuilds injured tissue.  A beautiful thing.  An inflammatory response that is exuberant can result in further tissue damage by compressing other tissues (affecting nerve and blood supply), and chemically damaging adjacent nerves. On the other hand, suppressing the inflammatory response via oral or injected anti-inflammatory medications can abort appropriate tissue healing. Obviously, this varies significantly on a case-by-case basis, so no one can make a blanket statement regarding what treatment would be best.

Or how about this comprehensive literature review from the Journal of Emergency Medicine?… (JEM, 2008; Feb. 25; 65–68)

This report basically reviewed the literature and found that not many researchers have studied the effect of ice on humans.  One human study suggested that it “improves return to participation.” 4 of 4 animal studies demonstrated reduced swelling, yet the paper concludes that there is insufficient evidence.  Conclusions like this are very common in the biomedical literature, especially in regards to physical medicine.  Researchers are very conservative in their conclusions.  The paper concludes that there is not a meaningful amount of research studies that would conclusively support use of ice.  No surprise.

Look, I know you have iced your body about a billion times.

Really?  If that is the case, I agree, you should stop using ice.  If your body is having an uncontrolled inflammatory response either your training activity is not mechanically efficient (you are hurting yourself) or your inflammatory state is out of balance (could be your diet).

Our goal needs to be to improve adaptation by improving circulation, clearing congestion, and facilitating healing. Pretty much everyone I know has stopped taking NSAIDS for the same reasoning that we should stop icing.

Right on.  Chronic NSAID use for athletic induced pain is foolish, and so is chronic ice application.  If you feel the need to ice the same area on a repeated basis, you should probably ask why this is an issue.  Do not ignore the check engine light.

The bottom line is that ice application is a wonderful tool.  It is not the only tool.  If you are unclear about why should use a certain tool, how to use it, or what you are using it for, do not be surprised if it is not effective.

Last night I had the pleasure of speaking to a chronic illness support group about how nutrition relates to health.  To summarize the presentation: every bite we take is either pushing us towards healing/disease prevention or physical degeneration/pain.  Most people have heard this before and intuitively understand it.  What’s usually missing is an appreciation for the biochemical rationale. All this is complicated by a hornets nest of contradictory information.  I can’t think of one food that someone hasn’t added to a “scary” food list at some point. (If you can think of a food that someone hasn’t warned you about, then please comment, I’d like to hear about it.)

Food consumed in 1 week for typical family of 4.

From my perspective, I think people want a rational, evidence-based, and pragmatic approach to making nutritional decisions.  So I’ve summarized the Anti-inflammatory Diet in this short Nutrition e-book  and hope the book provides that perspective.

As promised the those at last night’s meeting, here are the graphics from the presentation. Food and Pain web notes 5-12  Thanks for the discussion.

For further reading:

• Dietary Strategies for Improving Post-Prandial Glucose, Lipids, Inflammation, and Cardiovascular Health
• Deflame- Nutrition for inflammation reduction

Healthy Meal Prep

• http://paleodietlifestyle.com/
• http://www.paleoplan.com/recipes/

Sue came to my clinic for evaluation of chronic headache and chronic neck pain.  6 years earlier, she had suffered a laceration and fracture at the right occipital area of the skull.  Over the next 2 years, complete numbness at the distribution of the greater occipital nerve (area of the scalp on one side) evolved into chronic headache.  The old injury site was very sensitive to pressure.  She developed daily headaches that wrapped around the entire head and often a shooting, knife-like pain from the back of the skull to just above the eye.

Over the years, she had several MRIs which were normal.  She noted mild, transient improvement with chiropractic treatment, physical therapy (exercise and stretching), and massage.

Case Description

Palpation of the scar reproduced the knife-like headache and revealed restricted motion of the skin at the scalp (fascial restrictions).  Palpation of the neck and upper back also revealed tenderness and restricted motion between several spine vertebrae.

Neurological examination did not indicate a problem with spinal nerve roots, spinal cord, or cranial nerves.  Cardiovascular examination was also unremarkable.

Treatment Plan
She was suffering from chronic headache secondary to remote injury to the muscles and fascia adjacent to the greater occipital nerve. We discussed her options, began a course of cervical spine manipulation therapy and active release technique to improve the mobility of her scar and decrease suboccipital muscle tension at the base of the skull.

Outcome
Following the 1st treatment, she had only one more episode of knife-like, shooting head pain.  After the 1st week of treatment (3 sessions), the patient had no more sharp head pain.  At one month follow-up, she no longer head headaches.

Discussion

The nerves move through the fascia to get to the skin of the scalp.

The generation of headache pain can come from multiple sources.  A careful diagnosis is the 1st and most important step to treating any headache condition.  This case demonstrated a confluence of two headache types.  The daily headache that wrapped around this patient’s entire head, was most likely attributable to tension-type headache, originating from muscle and joint dysfunction of the cervical spine.

Additionally, the one-sided, shooting pain, reproduced by pressure at the old scar is more symptomatic of long-term, myofascial restrictions at the scar.  (myo= muscle; fascial= the connective tissue the holds the muscles and skin together).  Therefore a scar is simply an adhesion between the muscle, fascia, and skin.  To apply active release technique (a specific form of myofascial release), I use my hands to evaluate the texture, tightness and movement of muscles, fascia, tendons, ligaments, and nerves.  I then treat the abnormal tissues by combining precisely directed tension and specific movements by the patient.

See more case reports  at the Cole Pain Therapy Group blog.

I’m often asked what supplements are most important. Based on the research that I’ve read, these 5 are the most important.  Please also know that 1) you cannot supplement you way out of a bad diet and 2) there is no magic formulation (blueberry, acai, broccoli reductions, whatever) that replace these key nutrients.

1) EPA/DHA:  Also known as Omega 3 Fatty Acid or “Fish Oil,” this essential fatty acid is a strong anti-inflammatory.  Since inflammation is responsible for all types of degenerative disease, this supplement has been implicated as being beneficial for problems ranging from arthritis to eczema.  In fact, scientific trials have demonstrated EPA/DHA to be effective for treating arthritis pain, decreasing cardiac disease risk factors, and lowering cholesterol.  If an ounce of prevention is worth a pound of cure, 3 grams of EPA/DHA is worth a cure for heart disease, knee replacements, cholesterol problems…

2) Multivitamin:  No; it’s not too easy. The single source of a myriad of essentials should not be overlooked.  Even with the healthiest of diets, micronutrient deficiency can occur in the absence of a multi-vitamin.  This is because the soils in which foods grow have become depleted from minerals and micronutrients.  While scurvy and beriberi are diseases found only in history books, current problems of micronutrient deficiency include cardiovascular disease, neurological developmental problems, and DNA damage.   A standard multivitamin has the right dose for most people.  Also, all women of child bearing age should intake 800 micrograms of folic acid per day.  That dose may require her to take an separate folic acid tablet.

3) Calcium: There are several forms of calcium one can take.  If calcium cannot be absorbed from the gut it is useless for our body.  Calcium as a mixture of hydroxyapatite and dicalcium phosphate is the most useful to the body.  Calcium is integral for developing and maintaining strong bones.  Unfortunately, despite many foods being fortified with calcium, 1 in 5 older adults will develop osteoporotic fractures at some point.  Preventing fractures with nutrition should start in one’s youth, and involve all 5 of these nutritional supplements.

4) Magnesium: This nutrient may be the most overlooked according to current public health studies.  All cell function, DNA production, and tissue healing (some 300 different processes) require magnesium.  Thus magnesium deficiency results in all types of degenerative diseases.  Additionally, magnesium is essential for proper calcium utilization.  In fact one should supplement with an approximate 2:1 ratio of calcium to magnesium.  A more specific way to determine the right dose is to take 6mg of magnesium per kilogram of body weight.  You can convert pounds to kilograms by dividing by 2.20.

5) Vitamin D: Like magnesium, vitamin D is essential for proper calcium utilization.  More than a vitamin, D is a steroid hormone produced by the body.  With 45 minutes of full sun exposure while wearing only a bathing suit, your skin produces 20,000 units of the hormone.  Although it looks like a lot, that amount is about 4 days worth of vitamin D.  The problem is that most people wear clothes, use sunscreen, or work inside.  During the winter, most of the United States doesn’t get enough overhead sunlight to activate vitamin D production.  As a result, vitamin D deficiency is epidemic, resulting in diabetes, cancer, osteoporosis, chronic pain, and many other common diseases.  Your supplementation should be managed by a health professional to ensure accurate dosing (from 400-50,000 units).

EPA/DHA may interact with other medications, and the amount of vitamin D in the blood should be checked to ensure appropriate dose (D3 replinishment dose can range form 500IU to 50,000IU per day).   So check with one of our doctors before starting to supplement.

Additionally, supplement quality varies greatly.  It is a largely unregulated industry.  Some supplement companies reach high levels of certification.  To ensure that the product can be appropriately absorbed, contains the right ingredients, and is free of contaminants, always look forGMP certification (good manufacturing process) by the Natural Products Association.  That’s why I offer Metagenics brand supplements at Cole Pain Therapy Group.  I have a lot of confidence in Metagenics quality and value.

Some more really great reading:

• The Polymeal: a more natural, safer, and probably tastier (than the Polypill) strategy to reduce cardiovascular disease by more than 75%.
• Vitamins for chronic disease prevention in adults: clinical applications.
• Benefits and requirements of vitamin D for optimal health: a review.
• Dietary magnesium intake in a national sample of US adults.

httpv://youtu.be/pwKK85jnYTc

Here are the notes and visual media from some of the presenters:
Upper Cross Syndrome- Dr. Jeff Luebbe 2-05-12
Movement Rehabilitation- Dr. Bradford Cole 02-05-12
FMS Pictorial Instructions
Concussion- Dr. Richard Cole 02-05-12

I also had the pleasure of speaking at the CTA (chiropractic therapy assistant) continuing education program.  Here’s the booklet that I had referenced during the presentation:
Nutrition e-book

Lastly, Dr. Cole’s presentation on concussion discussed the fact that much of the difficulty of concussion management results from public misunderstanding of concussion.  This video explains concussion very well. Please spread the word.

httpv://youtu.be/zCCD52Pty4A

That hard hat won’t protect the back and knees.

Your knee is the trash can of your lower extremity.  It collects all the garbage of poor stability and starts causing pain.  It is painful during or after activity because of improper use.  While poor movement drives inflammation and pain, proper movement is like massage for our joints.

Too often, I hear people explain that they can’t squat down properly, because they have bad knees. They cannot run like they want to, because they have bad knees.  The truth is that even in the presence of advanced knee arthritis, fixing the motion can only improve their situation.

In keeping with the theme of the self audit of this series of blog posts, let’s look at a quick screen that reveals poor knee control and review corrective strategies.

Step 1) stand barefoot on a staircase step (which should be about 7″ tall according to Wikipedia)
Step 2) step forward with one foot, tap your heel the the step below, and return.
Step 3) observe the path of the knee upon which you are standing. 

Sidenotes: If you cannot keep the feet pointing forward and the heel of the stance foot flat to the step, then read the Ankle Mobility Audit.
If your stance foot keeps rolling in when stepping forward with the opposite, read the Foot Stability Audit.

http://youtu.be/LV1pR-zbkFg

ITB in red. Gluteus medius in green.

A knee that turns inward when performing the step down test is either poorly controlled by the hip or by the ankle/foot.   At the hip, it may be the product of a weak gluteus medius with or without a tight iliotibial band.  Correction should focus on addressing these problems at the hip and, if indicated, the ankle/foot.

Stability of the knee is crucial during walking, running, and landing from a jump. In fact, a lack of strong control from the gluteus medius is a major contributor to non-contact ACL (ligament) injury of the knee.  As you can see in the high speed camera images below, this lady cannot control the knees diving in. Inefficiencies like this compromise performance and, ultimately result in injuries.

This landing test reveals both knees turning in, uncontrolled by weak gluteus medius. This is preventable risk factor for knee injury.

Here is one example of the many ways one can strengthen the control that the gluteus medius has on the knee.  Each individual is different, so is no substitute for a professional evaluation and customized movement correction.  Here is one great way to strengthen the strengthen the hip and gain better stability of the knee.  Thanks to Mike Reinold for the video.

Enjoy.