The latest Inner Circle webinar recording on Integrating Breathing Drills is now available.
Integrating Breathing Drills
This month’s Inner Circle webinar is on Integrating Breathing Drills. In this presentation, I review a couple of quick techniques I use to determine what type of breathing drills to incorporate into my programming. I’ll overview several different breathing techniques and progressions that you can start implementing.
This webinar will cover:
How to assess for proper breathing patterns
How to choose which breathing techniques to perform
The latest webinar recording for Inner Circle members on Breathing Pattern Disorders is now available below.
Breathing Pattern Disorders
This month’s Inner Circle webinar discussed breathing pattern disorders. There has been a lot of talk lately regarding breathing and the function of the diaphragm. But what is important and what is just “hot air?!” In this webinar, I will discuss:
The difference between voluntary and involuntary breathing
Why simple breathing retraining doesn’t usually work
The effect of breathing pattern disorders on your body
Why focusing on breathing can help you with some of your other goals
What exactly to focus on to put the body in a better position to breath more efficiently
To access the webinar, please be sure you are logged in and are a member of the Inner Circle program.
This week’s Stuff You Should Read comes from Mike Robertson and Conditioning Research.
Inner Circle and RehabWebinars.com Update
We had a great Inner Circle webinar on 5 Tips on Preventing Little League Injuries earlier in the week. This is a big topic for me, so I enjoyed discussing. I will get a recording up of the webinar sometime soon. Use information like this to help educate the youth athletes, parents, and coaches and help reduce the 3.5 million youth sports injuries per year!
Next month’s webinar will be on strategies to enhance balance of the upper and lower trapezius. Upper trap dominance is a pretty common finding that really causes a boatload of shoulder, neck, and upper back issues. I don’t have a date yet but will work on one and announce soon.
I’m also going to be giving away 2 free DVDs this month to Inner Circle members, one of Optimal Shoulder Performance and the other Functional Stability Training for the Core. Check your email next week for details. If you want to be eligible for the free DVDs, please be sure to join my Inner Circle by the end of this week. Also, members please make sure you are signed up to receive Inner Circle updates, it is different from my usual newsletter. You can find a link to make sure you are signed up at the Inner Circle Dashboard.
RehabWebinars.com has an absolutely awesome webinar from Jarod Carter, PT. Jarod is a private practice therapist that has an exclusive cash-based practice. He discusses everything you need to know in detail to understand cash-based services. I already watched this webinar and could not believe how much info was packed in to the hour! Learn more about Jarod’s Guide to Cash-Based Physical Therapy Services at RehabWebinars.com.
Also, webinars from the recent 2013 ASMI Injuries in Baseball Course will start becoming available next week, stay tuned!
Hey guys, I have been officially nominated for the Therapydia blog awards. There is only one more week for voting – what are you waiting for??? Click the link below to vote for me for “Best Overall Blog” and “Best PT Blog.” If I win, I promise to host a free webinar for all my readers to thank you for voting!
This week’s Stuff You Should Read comes from Ben Bruno, Med Page Today, and Leon Chaitow.
Inner Circle and RehabWebinars.com Updates
My next live Inner Circle webinar will be held the last week of November, I’m shooting for Monday morning the 26th but we’ll see. I will be talking about how I stay current with the latest research and information, and how you can set up a similar system based on your interest. I’ll announce the date ASAP. Learn more about my Inner Circle.
RehabWebinars.com posted another must watch webinar from Kevin Wilk on rehabilitation following UCL Reconstruction in the Overhead Athlete. There is no one on the planet that you want to learn how to rehab Tommy John’s from besides Kevin. Kevin discusses the rehab approach and new techniques they are using. Click here for more information on RehabWebinars.com.
We’ll chalk this up to good timing. Ben Bruno recently posted a bunch of videos showing some progressions of skater squats that he performs. This coincides well with my recent presentation at the Boston Sports Symposium on Functional Stability Training for the Lower Extremity. Still working on the next segment of FST, but this post from Ben is a good progression from what I discussed.
Med Page Today has an article discussing the correlation between a lack of sleep and increased rate of injuries. The article cites a paper from the American Academy of Pediatrics and notes that sleeping less than 8 hours showed a statistically significant increase in injuries in adolescent sports. I was more surprised to read that 77% of the students reported sleeping less than 8 hours. I guess kids are staying up later now but I remember being able to easily sleep 10-12 hours! Perhaps all these energy drinks…
I am super excited to announce to my readers that Leon Chaitow will be in Boston next year and has agreed to conduct a one day seminar with my friend Katie Adams. Leon does not get to the states very often so this has easily jumped to the top of the list of seminars to attend next year. The seminar will on Manual Therapy for Breathing Pattern Disorders and will be held Wednesday April 24, 2013 in Boston. This should be a great seminar discussing concepts from his book on Breathing Pattern Disorders, which I would recommend. Click here to learn more and register for the seminar.
The core stabilization concept keeps being a hot topic for discussions. After more than a decade of core-training frenzy there is still very little evidence that core-training actually produces any positive effects. There is no universally accepted definition of what the make-up and function of the core is.
It all started with the Transversus Abdominis and the abdominal hollowing theory, where people were instructed to pull the belly-button in towards the spine when exercising. It has since been shown that abdominal bracing (tensing the abdominal wall as if preparing for being punched in the stomach) is superior to abdominal hollowing in regards to providing stability for the lumbar spine. Abdominal bracing is good, but it is still approaching the core from the outside in. The abdominal wall is the focus of the training. Real core activation has to come from the inside out.
Definition of Core
When looking up “core” in a dictionary we get descriptions like: centre, nucleus, middle, heart and interior.
If someone refers to the core of our planet they mean the absolute centre. When people train their core they concentrate on the outer layers of the wall equal to the crust and the mantle.
People have to stop treating the core as a hollow tube and learn how to pressurize the “centre” of the tube instead of just tensing the walls.
How do we pressurize the “centre”?
The diaphragm contracts and pushes down into the abdominal cavity, which combined with the resistance created by the pelvic floor, and an eccentric contraction of the entire abdominal wall, increases the pressure in front of the spine. The pressure from the front is counteracted by contraction of the lumbar extensor muscles and the spine is fully stabilized. Without proper diaphragm contraction the increased IAP will not reach all the way down to the lower lumbar spine, where the loading is most prominent.
The diaphragm is the key component to core stability. The diaphragm has to contract first and then the abdominal wall and not the other way around. A too early or too strong contraction of the abdominal wall prevents the diaphragm from descending properly and is therefore counterproductive in stabilizing the spine.
At this point I would like to present the results of two interesting MRI studies of the diaphragm by Professor Kolar and colleagues that demonstrated that the diaphragm has dual functions of respiration and stabilization.
The first study (1) demonstrated that the diaphragm has a postural function that can be voluntarily controlled and is independent upon breathing.
The second study (2) showed that the diaphragm can performed its dual functions of stabilization and respiration simultaneously. The diaphragm can perform the breathing task at a lowered position ensuring that the stabilizing pressure is maintained throughout the breathing cycles. There is a close relationship between the diaphragm and Transversus Abdominis which contributes to the respiratory and postural control.
These two studies pointed out that the activity of the diaphragm during stabilization varies greatly amongst individuals, which supports Kolar’s clinical evidence that individuals with limited capability to contract the diaphragm for stabilization have a higher risk of developing back-pain. The simultaneous activation of the diaphragm’s dual functions is the key to proper core stabilization
It is interesting to note that in the study by Hodges and colleagues which started the core craze, it showed that not only the transversus abdominis but also the diaphragm was activated to stabilize the trunk prior to any limb movement. The transversus got all the attention and turned into the core super-star while the diaphragm got ignored.
Respiratory function of the diaphragm
During inspiration the diaphragm contracts and pushes down into the abdominal cavity which decreases the pressure in the thoracic cavity and the lungs fill up with air.
The diaphragm participates in all breathing patterns whether they are ideal or dysfunctional. You cannot avoid using the diaphragm when breathing even if you try, unless there is a medical condition preventing the diaphragm from contracting. The commonly used instruction “breathe with the diaphragm“, has no value. Chest breathing and straight belly-breathing, where only the posterior part of the diaphragm pushes downwards, are two commonly observed dysfunctional breathing patterns, which reduce both the respiratory capacity and core stabilization. In ideal diaphragm contraction the entire diaphragm pushes down into the abdominal cavity and can be observed by an expansion of the lower ribcage and the abdominal wall in all directions.
Assessing diaphragm function
The diaphragm’s respiratory function can be assessed sitting or lying on the back. Holding the fingers at the lower ribcage, an examiner can feel for a lateral expansion of the ribcage and activation of the postero-lateral parts of the abdominal wall. An upward or inward movement of the ribcage is a sign of dysfunctional breathing.
Next, the subject’s ability to pressurize all the way down to the lower part of the abdominal cavity when breathing is assessed, both in laying and sitting (holding the ribcage down assists the activation) .
After that, the postural function of the diaphragm is assessed. Instruct the individual to pressurize all the way down to the bottom of the abdomen while holding their breath. The instructor should be able to feel the pressure against a hand placed at the lower abdomen.
And finally, get the person to breathe all the way down to the lower abdomen and then maintain that pressure while going through normal breathing cycles. The diaphragm is now performing its breathing function at a lower position. This is real core stabilization.
Each of these steps should be properly activated and the testing positions are excellent to use as entry-level exercises. A resistance band can be strapped around the ribcage or the lower abdomen to pressurize against. It is worth spending a fair amount of time ensuring proper activation of the core before progressing to other exercises.
Here is a video, explaining core activation from the inside out:
Once proper activation of the core is achieved, only the individual’s imagination limits the exercise progression. Planks, bird-dogs, dead-bugs would be reasonable next steps. Uni-lateral work is an inventive way of keep challenging the core.
Frequently we see discussions regarding whether to perform core-exercises before or after other exercises. After reading this I hope everybody can see that once the diaphragm is properly activated the core will be trained in all exercises and activities. Proper core-activation is fundamental and should be part of everything we do.
The ability of the core to stabilize the spine and torso is the limiting factor in all exercises. Pay close attention to the signs of proper core activation.
My favourite method of determining if the core is activated is to observe the lower lateral abdominal wall. If there are concavities the core is not properly activated. Concavities indicate a Rectus Abdominis dominant pattern.
The contour of the abdominal wall should take on a balanced, slightly rounded appearance which should be maintained throughout performing the exercise with normal respiration.
Some individuals cannot activate the diaphragm properly by themselves and I would recommend they seek assistance from a DNS or Postural Restoration Institute trained Practitioner. Practicing with faulty patterns will only reinforce the dysfunction.
Core-stabilization has to come from the inside out and is controlled via the diaphragm. I recommend anyone who is interested in improving their performance and preventing low back pain to spend the required time to properly activate the core. It is really worth it. I have had experienced Strength athletes achieve new PB’s straight after we have activated their core.
1- Kolar P, Neuwirth J, Sanda J, Suchanek V, Svata Z, Pivec M. Analysis of diaphragm movement during tidal breathing and during its activation while breath holding using MRI synchronized with spirometry. Physiol Res 58:383-392, 2009
2- Kolar P, Sulc J, Kyncl M, Sanda J, Neuwirth J, Bokarius AV, Kriz J, Kobesova A. Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J Applied Physiol Aug 2010
About the author:
Hans Lindgren is a Doctor of Chiropractic and DNS Practitioner in Brisbane, Australia. He has a special interest in Functional Stabilization, Rehabilitation and Sports-Performance. Hans runs courses about these topics and also writes a blog on hanslindgren.com.
Today’s guest post comes from Dean Somerset discussing 4 things he thinks we are doing wrong with rehab. Great job Dean, I always love reading your stuff! If you want to hear more from Dean (and you definitely should!) I recommend you check out Dean’s new Post-Rehab Essentials program. It is over 12 hours of great content. I am still reviewing but have enjoyed it so far, I’ll try to post a full review once I get a chance to finish it all!
4 Things We Are Doing Wrong With Rehab
I’ve built up a profession working the grey zone between where physiotherapists and traditional rehabilitation professionals leave off with their patients and where strength coaches and persona trainers begin. There’s a definite gap between the two, and hopefully more and more trainers and rehab professionals will be able to bridge this gap to effectively help their clients and patients, respectively, through the entire continuum of wellness. Today’s post will hopefully show a few ways to bridge the gap in a more practical sense for some of the common things that aren’t being adequately addressed by either side.
#1. Not looking at foot mechanics – For Everything
A simple test I use with a lot my classes: I get everyone to put their arms overhead as straight and high as possible with a tall and upright posture. Then I have them make their upper back kyphotic, and try to do the same thing, and watch everyone’s expression as they wind up getting half the range of motion necessary. Then I have them do both a posterior and anterior pelvic tilt and see what happens. Yep, you guessed it, less range of motion. As the grande finale, I have them stand tall, and then simply pronate their feet to see what effect it has on their shoulder range of motion. Most if not all involved, will have some reduction in their ability to abduct their arms. Give it a try and see what happens.
Mike made an excellent post a few months back about the kinetic chain ripple effect versus the kinetic chain, and this is an excellent example of that concept. When the spine was kyphotic, it had the most dramatic effect on shoulder mechanics than when the foot was pronated, but the effect was still there, much like ripples in the lake from a stone hitting the surface on the other shore. This shows that even if the foot isn’t directly involved in a lot of issues with the body that it may in fact be indirectly involved with issues of the knee, hip, spine, and even shoulder and neck.
By checking to see if the foot has a fallen, normal or high arch structure to it, as well as if any arch alterations are structural in nature (the bones are formed that way) versus postural in nature (the muscles holding the ankle are weak) can allow a practitioner to get one more piece to the puzzle. If the arch has fallen due to weak muscle support through both the tibialis posterior and the compound effect of a weak greater hallicus longus, you can train the muscles of the foot to stabilize and resist collapsing, which would prevent the internal rotation of the tibia, and everything that would result up the chain.
Altered foot mechanics can affect every movement, from heavy deadlifting (my drug of choice) to how you throw a fast ball, to how at risk you are of low back pain.
#2. Not watching runners’ stride and technique
I’m fortunate enough to have been able to work with a lot of distance runners, even though I consider distance running one of the most pointless activities you could ever do. Seriously, if you have that far to go, drive there. You get a cup holder and air conditioning. Be that as it may, I’ve been able to do hundreds of run stride analyses clients, from beginners looking to complete their first 5km race, to elite marathon and ultra marathon runners looking to shave time, and even those who had repetitive strain issues with their legs and needed to know why. You can see amazing things happen when you use even a basic digital video camera and slow down the replay to watch things like calcaneal eversion, midfoot pronation, valgus collapse, tibial rotation (both internal and external), pelvic stability on impact, foot strike mechanics, knee position and angle on impact, stride length and frequency, and even whether they are in the right shoe for their stride or not. We could debate barefoot versus shod running forever, but I’ll just leave it to say that barefoot isn’t for everyone, and typical running shoes aren’t for everyone either.
A lot of repetitive strain injuries in runners could be corrected by simply altering their run mechanics, much like a golfer can reduce their incidence of golfers elbow and low back pain by receiving coaching on proper swing mechanics. This could be as simple as using a hand-held video camera to show real-time feedback about performance, or as complex as using a DartFish software package to analyze force vectors and angle and rate of pronation, but in each situation it would result in an improvement in run stride, which would reduce the stress on the involved tissues, and allow runners to keep running with less pain, and probably while going faster.
It’s one thing to watch someone in static posture, and another entirely different beast to watch them move in their desired activity. By simply working on the muscles, joints, and fascia, we’re missing the boat on how their activities are impacting those tissues and what can be done about it. Athletes in most sports that involve running in one way or another (basketball, soccer, field hockey, and to a lesser degree football and baseball) would benefit from having someone analyze their gait and see where there may be some energy leaks and ways to decrease risk of injury.
#3. Not checking breathing mechanics
With the majority of upper body muscles attaching in one way or another to the rib cage, it would be common sense to think that an alteration in breathing mechanics could alter not only core function, but also scapular, glenohumeral, cervical, and potentially even lumbopelvic and lower leg function. If a client isn’t breathing properly through one side of their lungs, they may wind up getting side stitches on the opposite side as it works extra hard to compensate during forced heavy breathing. If they aren’t using their diaphragm properly, they may get neck cramping as their scalene compensate for the short-comings, and so on. On top of that, if the ribs cannot expand and contract properly, it will affect the ability of the thoracic spine to extend and rotate, which will affect the mechanics of the above-mentioned body parts. If they are collapsing into kyphosis, it will alter breathing capacity, which will alter performance and lead to further postural and repetitive strain issues.
Here’s an example of a runner who came in to see me with shoulder pain during her runs.
Notice how the rib cage elevates, but doesn’t actually expand width-wise? Here’s what she looked like after two weeks of doing three breathing exercises each day.
She’s still restricted, but using her lower ribs more instead of just relying on scalenes and upper ribs to do her breathing. This is a woman who can run at 10 miles an hour for ever and hold a conversation with you, and has won marathons, Death Races, ultra marathons, and 50-100 mile trail running races galore, all while only using about one third of her lungs. She shaved 6 minutes off her personal best marathon time by only altering her breathing mechanics and stretching her thoracic spine through extension and rotation.
#4. Not communicating with everyone involved
I’ve been able to work with a lot of good rehab professionals who have been willing to discuss their patients’ status and ways to help them out in our training sessions, and also take my observations and questions in stride. I’ve also worked with a few who weren’t so willing to work with me, and as a result the quality of care wasn’t as good, and the results that the client was able to get were less than optimal.
One of the first questions I ask any rehab professional when it comes to any workouts I’m going to have them do is quite simply “What do you want me to focus on, and what should I avoid?” Essentially, I’m always going to defer to the direction of the doctor or physiotherapist or chiropractors’ directives, and work my program around their guidelines. I may question certain aspects based on the results of my assessments, and occasionally can give them some new information, but most of the time my questioning is to get more information and to learn more from another set of eyes and educational background.
The same could be said in the reverse direction. If your patient is working with a personal trainer or strength coach, reach out to them and ask to discuss their training program. Odds are you can both come to a collaborative conclusion that will only benefit that patient, and result in them getting healthier faster and make you look good to everyone involved. One example stands out in my mind of a client who came in with really severe brachial plexus impingement in both arms, had been to physiotherapists and chiropractors, and seen no relief. I wanted to talk with her neurologist to see if there was anything that I should work on or avoid, and his response was amazing.
“I don’t know, just get her to lose some weight and increase her flexibility. If she says it hurts, move on to something else.”
I then proceeded to refer her on to a really good physiotherapist in my area who checked her out and gave some very good and specific recommendations, and within 6 weeks her pain was nearly half of what it was. The combined approach will always work best.
Strength coaches and personal trainers who don’t have an established network of health care practitioners scare me, and they should scare anyone who is willing to work with a trainer, especially if they already have specific medical or injury concerns. I’ve had countless situations where I needed a second opinion and referred a client out to get an assessment and report back on what they can and can’t do, and as a result we’ve been able to train longer and avoid aggravating issues further. I’m paranoid about making client safety an issue, because if that client isn’t able to train and I can’t find a way to make them better, it affects my bank account at the end of the month, and my reputation as a whole. Having medical referral networks makes trainers money, and increases their respect and reputation. Not having qualified professionals they can ask for help makes them a liability.
For more great information from Dean, be sure to check out his Post Rehab Essentials Program. It’s a 12-hour program that goes over great topics such as above. It is a great resource for the personal trainers that deal with people coming off of injuries.
Mike is the President and Co-Founder of Champion Physical Therapy and Performance, located in Boston, MA. Champion offers an integrated approach to elite level physical therapy, personal training, and sports performance.
Click below to learn more about seeing Mike and his team for 1x consultations or ongoing physical therapy, personal training, or sports performance training: