TRACEY VINCEL, PT, MPHTY, CBBA
ANDREW BARR, DPT, MSC SPT SCI, BSC (HONS) PHYSIO, CSCS
Editors Note: I asked one of my favorite physical therapists and her colleague to write this chapter. Tracey represents just what I want in therapists with whom we work—(1) a keen understanding of the core principles, (2) judicial creativity within the framework of the concepts, plus (3) a flexibility to work with the injury-specific approaches.
Our rehabilitation principles break many old tenets of physical therapy while getting most patients/players speedily back to full performance. For example, most postoperative core muscle repair patients begin with pretty vigorous muscular activity on Day 0 or 1 postoperatively. The amount and type of activities depend on the specific injury. Activity differs drastically for a de-stabilizing injury vs a non-destabilizing one. Scar is usually our enemy, yet sometimes becomes a friend. Rest is almost always bad. One gigantic factor in the rehabilitation formulae is the relative proportions of hip vs core muscle involvement. Tracey’s emphasis on the thorax blends with the important core principles. Read carefully how Tracey includes the back as part of “the thorax.” Then look back at Chapters 5 and 6, and see that her definition fits so well with the rest of our characterization of the core. Tracey uses her own lingo and defines her terms well, which makes the chapter practical to follow. Okay, it is time to keep on our physical therapy hats and roll up our work sleeves. Let’s try practicing physical therapy the way Tracey and Andy do it.
Variety is the spice of lithe.
—The chapter authors.
No matter how you understand the terms athleticism, agility, or beautiful movement, each requires the body to assume postures and move freely in and out of them without pain or stress on the joints or soft tissues. To perform a specific posture or movement, the mind and body have endless possibilities. An optimally functioning central nervous system chooses the best movement strategy and moment for that specific task. Life—and lithe—can be beautiful. If only life were always perfect…
It’s time to burst that bubble. Whenever pain or dysfunction is present, movement choices shrink. Variability lessens. Loss of variety causes muscle imbalances and strain on joints, perpetuating pain and pathology.
In other words, pain limits our agility—our “litheness” (our dreadful play-on-words again). Bad habits and/or injury exaggerate the defects and reduce the movement options further, forcing us into suboptimal movement choices, a process we call compensation. Then compensation leads to injury and more injury.
In sports and everyday life, we rely on specific movements to accomplish our tasks. Naturally, we would love to accomplish those tasks in as strong and easy a way as possible. The movements that we seek vary from one person to another. The important movements vary, depending on the specific tasks we want to accomplish, the sport or position we play, plus our own physical or mental limitations and advantages.
Let’s start with a simple story to illustrate how dysfunctional movement can easily be restored to optimal movement when you take the time to do a detailed evaluation. We then introduce some of our physical therapy terminology to help you understand how we communicate this.
JEAN-MICHEL THE ICE HOCKEY WARRIOR
Consider Jean-Michel, the archetypal 2-nights-a-week recreational hockey player: “My life’s passion is hockey. Unfortunately, I’ve always had groin injuries. My first was in high school, I had one every season after that, one side then the other. I keep my groin muscles strong and stretch religiously…as soon as I get back to full play, my groin gets me again. We are talking 8 or 9 times just in high school and college. I took a couple of years off after college and just joined a hockey league at Chelsea Piers. Argh, I pulled my right groin again last night!” So JM comes to us, expecting a cure.
As physical therapists, with a specialty in analyzing movement, we did our thing. We looked at his whole body and how it moved, with a keen eye for dysfunction, a driver for his recurring groin issues. We looked at the kinetic chain, compensatory patterns, load analysis, specifically looking at what happened as he transferred his weight to his right leg. Of course, we concentrated on movements that mimic hockey, although we were limited by the non-ice, wood surface of our physical therapy clinic.
He did something consistently as he went through certain routines, postures, and steps. As JM transferred his weight onto his right leg, there was an obvious translation of his rib cage to the left, affecting the position of his center of mass over his feet.
He was on the hard surface inside our studio, and we wondered if this rib cage shift would also occur while on skates. We decided to observe him the next day on the ice.
Sure enough, on skates he not only displayed the same rib cage movement, but also with each stride, that movement became exaggerated. Did this rib cage shift have anything to do with his groin pain? The next week, we had JM go through some more weight transfer drills in our studio. There became no doubt that the transfer of weight to his right triggered his pain and that this shifting movement had something to do with it.
Then came the “eureka” moment. We saw that with each weight transfer, he was, in our lingo, “translating his fourth thoracic ring.” He basically was losing his center—his core balance. He was shifting his center of mass from the midline to the left, trying to recruit additional muscles to power his right side as he shifted direction. This was affecting his entire kinetic chain, causing nonsequential muscle activation and altering loading patterns down the chain. Specifically, Jean-Michel’s left thoracic translation was keeping him from firing his right gluteus medius and maximus muscles. The compensatory pelvic rotation created a false axis for his right hip. The natural protectors of his hip—the pectineus, adductor longus, and adductor brevis—were overfiring in order to brace the hip. The result was a no-brainer—right groin pain! In our minds, his thorax was the culprit. It was driving his groin pain.
The rest of the story: We addressed the thoracic movement disorder and returned Jean-Michel to hockey. He has been pain-free for over 2 years…another cure.
So, what the heck are we talking about? What are these things: the center, core balance, thoracic ring, kinetic chain alteration, etc?
First, let’s first look at the way things have been (and to a large extent still are). And then, let’s look at the way we think they should be.
The greatest obstacle to discovery is not ignorance—it is the illusion of knowledge.
—Daniel Boorstin, former US Congress Librarian.
THE WAY THINGS CONTINUE (TO A LARGE DEGREE)
Frank, a 44-year-old lawyer from Charlottesville, Virginia, comes into the office with 9 months of pain in the left groin, abdomen, chest, and buttock that has now spread to the other side. Frank played lacrosse at the University of Virginia and by his admission “let myself go” for years after college. He occasionally jogged and played golf and paddle tennis. Work and family had higher priorities than staying in shape. “So I tried P90X.”
Now take a step back from Frank. Think of what the 21st century advertising culture has added to our 2 AM television watching: Cross-fit, Insanity, spin, boot camps, Ab Rail, Bowflex, Chair Fitness, Total Gym, iGallop, Zumba, the 20-Minute Work-out, and, of course, Suzanne Somers’s Thighmaster, and Shake Weight. Wee-hour TV watching has added a whole new level of total confusion to the core. Some of these “training” techniques are hilarious. Add all these new training techniques to the yoga, Pilates, and P90X revolutions and what do you get? Well, if it is not total madness, consider the following.
Through subliminal thought, these late-night ads might (hopefully not) bring the following wrong “core training principles” to our minds*:
- Ab training is paramount.
- It’s all about pulling the belly button to the spine.
- Don’t be bothered to get out of the chair to exercise.
In the past few years, the health and fitness industry, armed with our ever-expanding advertising culture, has also attempted to influence our understanding of the “core,” packaging and branding equipment to deliver the aesthetic and perceived performance improvements that the public “need.” There is a lack in clarity in the concepts and the communication between professionals and athletes, and a disconnection between sports medicine and health and performance circles regarding the best methods of delivering core stability programs.
Okay, let’s get back to Frank. All Frank did was what most of us are prone to do. A former athlete, Frank decided he needed to get back into shape. He chose one of the more popular programs, which really does have some excellent aspects to it. Only it turned out that Frank wasn’t ready for the immediate vigor of the program. Within days of joining the program, Frank ripped off his rectus abdominis, pectineus, and a portion of his iliopsoas. He was compensating like mad through, among other structures, his thoracic rings. He ended up requiring surgery to correct the core instability and then several months of core rehabilitation with special attention to the thorax. Believe it or not, he is now using a routine similar to P90X, only after a 2-month ramp-up.
Let’s use a fitness analogy and take a step back. Our main point is not to knock all the fitness programs on late-night television. Our issue is with the misleading information that the programs might convey, which is potentially dangerous. In this chapter we want to emphasize that the development of core stability and strength should form part of any rehabilitative or preventative training program, but this goes beyond simple abdominal crunches and requires consideration of the transfer of load through the entire body in 3 planes of motion and in low- and high-load conditions.
Two Old Medical/Physical Therapy Myths That Just Won’t Go Away*
Myth 1: Core Bracing Is Good for Low Back Pain
It is commonplace for “abdominal bracing” exercises to be prescribed for low back, pelvic, and hip pain. Unfortunately, many of these people do not feel better, and sometimes get worse with these general “core bracing” type exercises. Is it possible that this training is making people stiffer? Has the body adapted to pain by tensing superficial muscle as a protection strategy for low-load activity? Is it possible that we are only feeding into this poor motor control strategy when we prescribe planks and other similar high-load “core stabilization” exercises when the underlying issues have not been addressed?
Truth
When rigid bracing strategies are adapted, movement options are lost, and the remaining options do not allow adaption for the loads or the tasks at hand. Bracing is not the right strategy. With that strategy, injured patients cannot utilize the deeper stabilizing and other muscles. Timing and activation get worse. Overall core function is less efficient. In the next sections, we shall talk more about bracing and rigidity and the superficial and deep muscles.
Myth 2: The Thoracic Spine Is Stable and Stiff
For years, we have regarded the thorax mainly as the stiff component of the overall spine1–4; therefore, not of too much use in rehabilitation and performance training.
Truth
The above could not be further from the truth. The thoracic spine is a part of an enormous, 3-dimensional unit integrated with the ribs and abdomen via huge and hopefully strong attachments. This unit is not “stiff” as generally regarded. Instead, it is dynamic, integrating, and shock-absorbing.4
One should think of this whole unit like a giant Original Slinky, capable of important changes in shape and character that we may use to implement core movement strategies. With this concept, we physical therapists have a lot to work with. The thorax is not a stiff box; it is a lively Slinky with 10 or so rings. It can create (drive) or correct proximal or distal problems.5–7 We should not be addressing the thoracic spine in isolation; instead, we should be considering its influence on the body above (the neck) and the body below (pelvis, lumbar spine, and hip; Figure 34-1).
Figure 34-1. Think of the back and thorax as working together, and also connected to the pelvis.
If you always do what you have always done, you will always get what you always got.
—Henry Ford, the first automaker.
THE WAY THINGS SHOULD BE
We shall now teach you new lingo. As you read this new nomenclature with the associated assessment and treatment modalities, keep Jean-Michel the Ice Hockey Warrior in mind. A detailed assessment permitted us to identify a dysfunctional movement pattern plus a thoracic “driver.” With that, we restored optimal neuromuscular control and took away his groin pain.
We provide some detail here to show therapists how we did this, and, hopefully, to use these concepts on their own clients.
New Nomenclature
- Kinetic chain: Movement that is created through an assembly of body segments connected by joints. This system efficiently distributes forces created during motion through the entire body. For example, movement at the ankle is linked to movement at the knee, which is linked to movement at the hip, through the pelvis and spine, thorax, and so on. Joints should not be viewed in isolation as dysfunction in one joint may be causing pain in another through poor mechanical function of the kinetic chain.
- Failed load transfer: Occurs when the body transfers load (ie, center of mass over the base of support) and there is (1) nonoptimal alignment, (2) nonoptimal biomechanics, or (3) nonoptimal control.5,6
- Compensatory patterns: Movement within the kinetic chain that is nonoptimal. For example, if one joint in the kinetic chain is restricted, then another joint may show a compensatory pattern by moving excessively.
- Driver: The area of failed load transfer in the body that happens first in time and space and, when corrected (with optimal alignment and/or control), corrects all other areas of failed load transfer occurring in the body for that functional movement.8
- Nonsequential muscle activation: A delay in the timing of the deeper stabilizing muscle activation in anticipation to joint motion. This delay increases the shearing forces through the joint and produces suboptimal alignment by an overpull from the more superficial mobilizing muscles.
- False axis: A joint that creates motion in suboptimal alignment, due to the overpull from a superficial mobilizing muscle.
- Core balance: The optimal function of the 3-layer muscular system of the core. This includes sequential activation of the local stabilizer muscles and ideal recruitment patterns of the global stabilizer and global mover muscles.
- An Integrated Approach to the Thorax: An assessment and treatment approach developed by LJ Lee and Diane Lee4,5,8 that incorporates current research on the thorax and considers the thorax as a series of stacked rings and how they interact and function as a complete circle relative to the neck, shoulder girdle, and pelvis. It proposes multiple mechanisms for how the thorax can drive pain and dysfunction in other regions of the body.9,10
- Thoracic ring: Refers to the true functional unit of the thorax, the “ring” (Figures 34-2 amd 34-3).4,5–8 The ring can be defined as 2 ribs of the same number plus the 2 vertebrae to which the ribs attach and all the joints that connect them (eg, ring = vertebra [T4 and T5] + disc + 2 ribs [right and left fifth rib] + other small joints). There are 13 joints per typical ring, totalling 136 joints in the thorax.10
Figure 34-2. The concept of the thoracic ring. The vertebrae plus the ribs act as individual units. (© LJ Lee Physiotherapist Corp. Used with permission from Dr. Linda-Joy Lee.)
Figure 34-3. Model of a thoracic ring that we use in the clinic.
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