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Some time ago, a question came up in the member discussion forum at FixYourOwnBack.com as to whether extruded lumbar disc herniations “went away” or whether they remained in the epidural space. This coincided with an older paper (Haro, 2000) that was discussed on Facebook as the potential mechanism for resorption of extruded disc fragments. I thought that would be a good topic to flesh out a bit with a literature search. I’ll attempt to summarize my reading of the past 13 years of investigation into this topic. In direct response to the above question, “Yes, resorption of the extruded herniated disc fragments is part of the natural history of disc injury.” The amount of time that takes to happen varies from person to person but here are a few cullings from several studies:
- Follow up MRI 6-12 months after initial injury demonstrates about 50% of patients see about 70% decrease in size of extruded material. (Fagerlund, 1990, Maigne, 1992, Bush, 1992; Jensen, 1996; Autio, 2006; Monument 2011)
- In a retrospective cohort study, Saal and Saal demonstrated that lumbar disc herniation with radiculopathy can be successfully treated nonoperatively, with nonoperative treatment resulting in “good to excellent” outcomes for approximately 90% of patients. (Saal, 1996)
- MRI findings lag behind improvement of leg symptoms (Ito, 1996)
- Larger extrusions and sequestrations are more likely to resorb. (Maigne 1992, Bush 1992, Jensen 1996)
That last point is interesting as all too often patients report to me that their neurosurgeon suggested surgery because to the large size of the herniated disc fragment. This is somewhat understandable as often a large herniation can cause not only chemical irritation of the nerve root (due to inflammation) but also mechanical compression of the nerve root. Often intense pain in the leg accompanies this scenario and sometimes motor weakness as well. Years ago, more than 3 days of progressive motor weakness in these cases drove the clinical decision to decompress the nerve surgically. These days, this 2011 review article sums it up the current “gray” zone we are in… “In the absence of serious neurologic deficits or for persistent non-radicular low back pain, consensus whether surgery is useful or not has not yet been established. Furthermore, the timing of the intervention with respect to prolonged conservative care has not been evaluated properly.” (Jacobs, 2011) In their review of randomized controlled trials comparing various interventions for herniated lumbar disc injury with sciatica Jacobs, et al found that after 1 year, there was no difference between surgical vs. conservative interventions. The primary benefit in surgery was quicker relief of the leg pain, with average time before resolution of leg pain averaging 4 weeks in quick surgical interventions, vs. 12 weeks for conservative care. For those who opt for conservative care and want to know how they can help the process of resorption of the herniated disc material, we are still learning what those variables are. One clear thing to not do is smoke. Tsarouhas et al in 2011 showed that smoking resulted in more severe pain with disc injury, longer time for resorption of herniated disc material and smokers have a longer duration of symptoms. Many might wonder what the actual mechanism is for resorption of an extruded disc. That discussion gets a bit technical with histochemistry and biochemistry. For those that are interested, let’s “suit up” and get to it!
The Role of Macrophages and Matrix Metalloproteinases (MMPs) in Disc Resorption
Remember those Pac-Man-like things under the microscope in cell biology class that were called macrophages? As it turns out, these differentiated white blood cells (WBC) play a key role in the process. In a very amoeba-like fashion, they sidle up to the extruded annulus and get to work with a toolbox of cytokines and proteolytic enzymes. Some of these macrophages are residents in a normal disc; others arrive if blood vessels in the outer third of the annulus or in the vertebral endplate are disrupted. The more blood vessels that are disrupted, the more macrophages that are on the scene. While we’re still learning a lot about this process, it resembles a lot of other common inflammatory cascades. Among the enzymes that the macrophages bring that have been studied a bit more, are the matrix metalloproteinases (MMPs)
At present, about 24 of these proteolytic enzymes have been discovered and they come not only from macrophages but also from chondrocytes in the disc. I like to think of the different MMPs as different types of cleaners you might use around the house. Maybe you use 409 to clean your kitchen counters, Windex to clean your windows, Clorox to brighten your white clothes and Tide to clean the color garments. Some of those cleaners in certain combinations might not be a good idea for health (ammonia in the Windex + bleach=chlorine gas) and we’ll discuss that analogy a bit more in a minute. Also, you might be able to get a really dirty window cleaner with 409, but Windex will be superior to get the job done. You get the drift? So those 24 MMPs have been divided up into groups depending on their function. 1. Collagenases (MMPs-1, -8, -13 and -18)– the only enzymes that can cleave intact interstitial collagen molecules. 2.Gelatinases (MMPs-2 and -9)–degrade denatured collagen molecules and basement membrane collagens. 3. Stromelysins (MMPs-3, -10 and -11)– cleaves cartilage matrix components, including aggrecan, proteoglycans, and fibronectin. 4. Membrane-type MMPs (MMPs-14, -16, -17 and -18)–responsible for the activation of other MMPs, but only play a secondary role in direct matrix degradation. One interesting finding is that a few of these MMPs are present in low quantities in even normal and young discs. As the disc shows signs of increased degeneration, the amount of MMPs and the variety of MMPs increases. So, if MMPs are needed to clean up a herniated disc, then more must be better…right? Well hold on sparky. These are catabolic proteins, they break stuff down. We have known since the late ‘90s that they are present in greater quantities in degenerated discs, and some suspect that their very presence is the CAUSE of the disc degeneration. As in most bodily reactions, a catabolic agent has an anabolic partner and homeostasis is maintained when we balance those reactions. It seems that when the scale tilts toward the catabolic agents, that’s when we see increased disc degeneration. At least that’s what the correlational studies suggest. Of course you can’t extrapolate causation from a correlation. It could be that the upregulation of MMPs is reflective of a response to injury (essentially a normal inflammatory response) rather than being the cause of the observed degeneration.
Current investigations into MMPs are attempting to manipulate the ratio of catabolic MMPs vs. anabolic agents. Some are also investigating the lifestyle issues that are correlated with low back pain, disc degeneration and with upregulation of certain MMPs. Among those lifestyle items that have been associated with higher levels of degeneration and with higher levels of MMP in the disc is hard physical labor, especially when it involves frequent lifting. The researchers often infer that that lifting equates only compressive load without regard to other vectors of load like torsion and shear. Adams demonstrated to us in 1982 that even in vivo discs are remarkably resistant to pure compressive force but they prolapse with additional flexion + compression. I personally think that an area worthy of investigation is in HOW the disc is compressed. Most of the studies I’m aware of infer compressive load by lifestyle questionnaires looking for employment that involves heavy physical loading of the discs. Some of that sample likely lifts with maintenance of the lumbar lordosis and some likely don’t. I suspect that those that don’t with the inherent flexion + compression moment on the disc, will experience more LBP and more disc degeneration. Indeed, I have noted for years the presence of habitual lumbar hinging (flexion + compression) with naïve and loaded movements toward the floor. Correction of this lumbar hinge by training a hip hinge stereotype has proven to be a remarkably simple intervention to help these painful backs improve.
In regards to disc resorption, what are we left with? The natural history after disc herniation is for resorption to occur at varying speeds and degrees dependent on a variety of other lifestyle factors. If you want to improve the resorption process, don’t smoke, exercise moderately but limit heavy physical labor. We still have more investigation to do on the specifics of dose and type of “physical labor” and “lifting”. As that comes up in the literature, I’ll try to keep you posted. Be well, and if you want my personal advice based on clinical experience…hip hinge when you bend towards the floor. If you need help figuring out how to do that hip hinge thingy, go here…
References:Haro H, Crawford HC, Fingleton B, MacDougall JR, Shinomiya K, Spengler DM, Matrisian LM. Matrix metalloproteinase-3-dependent generation of a macrophage chemoattractant in a model of herniated disc resorption. J Clin Invest. 2000 Jan;105(2):133-41. Jacobs WC, van Tulder M, Arts M, Rubinstein SM, van Middelkoop M, Ostelo R, Verhagen A, Koes B, Peul WC. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. Eur Spine J. 2011 Apr;20(4):513-22. Henmi T, Sairyo K, Nakano S, Kanematsu Y, Kajikawa T, Katoh S, Goel VK. Natural history of extruded lumbar intervertebral disc herniation. J Med Invest. 2002 Feb;49(1-2):40-3. Saal JA, Saal JS, Herzog RJ : The natural history of lumbar intervertebral disc extrusions treated nonoperatively. Spine 15 : 683 – 686, 1991. Bozzao A, Gallucci M, Masciocchi C, Aprile I, Barile A, Passariello R : Lumbar disc herniation. MR imaging assessment of natural history in patients treated without surgery. Radiology 185 : 135 – 141, 1992. Delauche – Cavaillier MC, Budet C, Laredo JD, Debie B, Wybier M, Dorfmann H, Ballner I : Lumbar disc herniation. Computed tomography scan changes after conservative treatment of nerve root compression. Spine 17 : 927-933, 1992. Komori H, Shinomiya K, Nakai O, Yamaura I, Takeda S, Furuya K : The natural history of herniated nucleus pulposus with radiculopathy. Spine 21 : 225 – 229, 1996. Teplic JG, Haskin ME : Spontaneous regression of herniated nucleus pulposus. AJNR 6 : 331- 335, 1985. Yukawa Y, Kato F, Matsubara Y, Kajino G, Nakamura S, Nitta H : Serial magnetic resonance imaging follow-up study of lumbar disc herniation conservatively treated for average 30 months. Relation between reduction of herniation and degeneration of disc. J Spinal Disord 9 : 251- 256, 1996. Orief T, Orz Y, Attia W, Almusrea K. Spontaneous resorption of sequestrated intervertebral disc herniation. World Neurosurg. 2012 Jan;77(1):146-52. Iwabuchi M, Murakami K, Ara F, Otani K, Kikuchi S. The predictive factors for the resorption of a lumbar disc herniation on plain MRI. Fukushima J Med Sci. 2010 Dec;56(2):91-7. Reyentovich A, Abdu WA. Multiple independent, sequential, and spontaneously resolving lumbar intervertebral disc herniations: a case report. Spine (Phila Pa 1976). 2002 Mar 1;27(5):549-53. Cribb GL, Jaffray DC, Cassar-Pullicino VN. Observations on the natural history of massive lumbar disc herniation. J Bone Joint Surg Br. 2007 Jun;89(6):782-4. Zhou G, Dai L, Jiang X, Ma Z, Ping J, Li J, Li X. Effects of human midkine on spontaneous resorption of herniated intervertebral discs. Int Orthop. 2010 Feb;34(1):103-8. doi: 10.1007/s00264-009-0740-2. Epub 2009 Mar 11. Doita M, Kanatani T, Ozaki T, Matsui N, Kurosaka M, Yoshiya S. Influence of macrophage infiltration of herniated disc tissue on the production of matrix metalloproteinases leading to disc resorption. Spine (Phila Pa 1976). 2001 Jul 15;26(14):1522-7. ItoT,YamadaM,IkutaF,etal.Histologic evidence of absorption of sequestration-type herniated disc. Spine 1996;21:230–4. Fagerlund MK, Thelander U, Friberg S. Size of lumbar disc hernias measured using computed tomography and related to sciatic symptoms. Acta Radiol 1990;31(6):555–8. Maigne JY, Rime B, Deligne B. Computed tomographic follow-up study of forty-eight cases of nonoperatively treated lumbar intervertebral disc herniation. Spine (Phila Pa 1976) 1992;17(9):1071–4. Bush K, Cowan N, Katz DE, et al. The natural history of sciatica associated with disc pathology. A prospective study with clinical and independent radiologic follow-up. Spine (Phila Pa 1976) 1992; 17(10):1205–12. Jensen TS, Albert HB, Soerensen JS, et al. Natural course of disc morphology in patients with sciatica: an MRI study using a standardized qualitative classification system. Spine (Phila Pa 1976) 2006;31(14): 1605–12 [discussion: 1613]. Autio RA, Karppinen J, Niinimaki J, et al. Determinants of spontaneous resorption of intervertebral disc herniations. Spine (Phila Pa 1976) 2006; 31(11):1247–52. Monument MJ, Salo PT. Spontaneous regression of a lumbar disk herniation. CMAJ 2011;183(7):823. David G, Ciurea AV, Mitrica M, Mohan A. Impact of changes in extracellular matrix in the lumbar degenerative disc. J Med Life. 2011 Aug 15;4(3):269-74. Tsarouhas A, Soufla G, Katonis P, Pasku D, Vakis A, Spandidos DA. Transcript levels of major MMPs and ADAMTS-4 in relation to the clinicopathological profile of patients with lumbar disc herniation. Eur Spine J. 2011 May;20(5):781-90 Adams MA, Hutton WC. Prolapsed intervertebral disc. A hyperflexion injury 1981 Volvo Award in Basic Science. Spine (Phila Pa 1976). 1982 May-Jun;7(3):184-91. Vo NV, Hartman RA, Yurube T, Jacobs LJ, Sowa GA, Kang JD. Expression and regulation of metalloproteinases and their inhibitors in intervertebral disc aging and degeneration. Spine J. 2013 Mar;13(3):331-41. Zigouris A, Batistatou A, Alexiou GA, Pachatouridis D, Mihos E, Drosos D, Fotakopoulos G, Doukas M, Voulgaris S, Kyritsis AP. Correlation of matrix metalloproteinases-1 and -3 with patient age and grade of lumbar disc herniation. J Neurosurg Spine. 2011 Feb;14(2):268-72. Weiler C, Nerlich AG, Zipperer J, Bachmeier BE, Boos N. 2002 SSE Award Competition in Basic Science: expression of major matrix metalloproteinases is associated with intervertebral disc degradation and resorption. Eur Spine J. 2002 Aug;11(4):308-20. Bachmeier BE, Nerlich A, Mittermaier N, Weiler C, Lumenta C, Wuertz K, Boos N. Matrix metalloproteinase expression levels suggest distinct enzyme roles during lumbar disc herniation and degeneration. Eur Spine J. 2009 Nov;18(11):1573-86. Guterl CC, See EY, Blanquer SB, Pandit A, Ferguson SJ, Benneker LM, Grijpma DW, Sakai D, Eglin D, Alini M, Iatridis JC, Grad S. Challenges and strategies in the repair of ruptured annulus fibrosus. Eur Cell Mater. 2013 Jan 2;25:1-21. Review. Peng BG. Pathophysiology, diagnosis, and treatment of discogenic low back pain. World J Orthop. 2013 Apr 18;4(2):42-52.
Here are 3 new exercises that subscribers have requested at MyRehab. Full versions of the exercises are available for subscribers to send to their patients to help with patient education. As always, this process is easy to perform and allows you to send these videos directly to your patient’s email in-box. If you’re not yet a subscriber, you can trial MyRehab for 30 days for $1 by signing up here. Monthly membership after that is only $19.99 without contract or obligation. More info is on the video to the right of the page here
- YTWL-Standing: Based on Blackburn’s rotator cuff research, this standing version requires fewer props at home using a piece Theraband. The prone version is already in the library at MyRehab.
- Quadruped Rock Back-Gym Ball: This is a nice correction for loss of lumbar lordosis at the bottom of squatting exercises. Sometimes referred to as “butt winking”, this rounding of the lumbar spine under load produces the injury vector for lumbar disc herniation.
- Pallof Presses: Named after John Pallof, PT, these core stabilization exercises are a great intervention for rotary instability. Standing versions on 2 legs are shown as well as single leg versions. I’ve had a lot of success using the single leg version in runners prone to overpronation and patellofemoral syndrome.
If you are a public speaker who presents to groups and are a subscriber or advocate for MyRehabExercise.com, you can help us get the word out by including the slide below in your presentation. Click here to link to larger version PDF with better resolution and drag it right into your Powerpoint or Keynote presentation. Thanks for your help getting the word out!!
Also, the International Society of Clinical Rehabilitation Specialists (ISCRS) is a multidisciplinary group of healthcare pros dedicated to sharing and promoting the emerging rehab and performance methodology with each other and with the general public. Members of ISCRS enjoy a 50% discount to MyRehabExercise.com and similar discount to other incredibly informative sites like SportsRehabExpert.com and StrengthCoach.com. Check it out!
In my clinical practice of chiropractic, I mostly manage pain and the majority of that pain is back pain. In school, we docs are taught that back pain from discs represents perhaps 10-15% of all cases of back pain. However, other research points out that when back pain becomes severe enough to prompt a person to seek care, roughly 50% of that back pain is related to the lumbar disc. If you know what to look for, you can pick up that irritated disc on clinical exam well before the disc injury becomes significant enough to cause neurological symptoms.
My practice has been informed by the works of my mentor, Craig Liebenson, and thus by Vlad Janda, Pavel Kolar, Karel Lewitt and Stu McGill. Gray Cook came along and turned the rehab and personal training world on it’s ear by suggesting that rather than battling over turf, trainers and rehab professionals should work to liase and thus improve patient and client outcomes. I’ve been fortunate in my practice to work hand in hand locally with some cracker jack trainers like Chris Bathke, Tony Gracia and powerlifter and coach Chris Duffin. Here’s what guys like this know that many of us in the rehab world are missing. The magic is in the movement, not in the therapy.
Most back pain significant enough to prompt a person to seek treatment is flexion-intolerant. Much of that pain will ultimately progress to become discogenic if it isn’t already. In the clinical world, we can apply the McKenzie derangement model, some steam and cream, some rubby-dubby and some poppy-cracky to that back all day long and walk on water. “Thank you doctor for helping me get out of pain!!!” Then, when the pain professional cuts the patient loose and says to go back to the job/game/whatever, the patient re-injures themselves, that patient is back in the pain management racket. When the patient says “What can I do to improve my FUNCTION?”, that’s when the pain pros get vague. “Well, maybe you can come in on a regular basis so that we can keep you ‘in-line’ and that might help”. Coincidentally, that’s what the pain pro learned from the MBA in the practice management seminar over the weekend. Luckily most DCs don’t use the type of $$$-first, patient-second tactics identified below. If you’re a patient and you get this kind of treatment, laugh at the “doctor” and walk out of the room…please!
So in the context of the flexion intolerant back, here’s what the personal trainer knows that too few DCs and PTs know…That client’s back hurts because their squat and deadlift pattern sucks! Shout it out trainers! Your squat and deadlift sucks! Fix that crap and your back will get better. The way I explain it to patients, the simplest way of understanding the flexion intolerant, discogenic back is to realize that they have an inappropriate hinge in their lumbar spine and it should instead be in their hip joint. I love it when I see those patients that come back after several years for the odd computer-neck and note that their back pain got WAY better when the found this great trainer who taught them how to squat. I always get those trainers’ cards and keep them on hand so that I have a pool of references when patients want help in the gym.
Now, here’s the dark side…don’t be the trainer checking your email while your client cranks out 3 sets of 10 “bicycling”, performing spine flexing/compressing “core work” because some ACE article said it provided the “highest EMG activity of any ab exercise” (while loading the spine in flexion). Never mind that while you were friending Joe Dowdell on Facebook, your client was gassing in the captain’s chair demonstrating hip and lumbar movement dissociation and flexing that lumbar spine under a compressive load and inching closer to my office. Don’t be the gal wondering if “those are real” on the woman across the gym while your client drops below their functional squat range under load and flexes their lumbar spine. Instead, catch that crappy squat and deepen their functional range with Stu McGill’s cues to “bend the bar” and “spread the floor with your feet”.
Recently Charlie Weingroff had an interesting post on the flexion intolerant back through a McKenzie and an SFMA lens. As I read I remembered Stu McGill’s admonition to us years before when managing a compromised back…Job 1. Correct the poor movement pattern. Fix that crappy squat. Pick up your purse without a lumbar hinge. Move the hip with the spine stabilized. Roll over in bed with the abs braced. Perhaps as Mike Boyle suggests, shift that client to a split squat or Bulgarians rather than a heavy back squat to spare the spine.
A few months ago I put together my clinical approach to the flexion intolerant back in a self-help education and exercise focused website called FixYourOwnBack.com. I encourage those with flexion intolerant backs to:
This stuff works for the flexion intolerant backs! If you’re a trainer, play with this model and find good rehab pros in your neck of the woods to send those pain patients to. If you’re a PT or DC, find good trainers and send them your rehabbed patients. Let’s get out there and help folks, huh? If you’re savvy to this type of functional-focused work, consider MyRehabExercise.com’s library of functional correctives on video to help teach your clients and patients. If you’re someone suffering from flexion intolerant back pain, consider The Plan at FixYourOwnBack.com and look for the locator page there to find a competent rehab pro or trainer in your area.Next up…When Burpees Go Bad, How Do You Know? Peace!
- Correct the lumbar hinge and restore the hip hinge
- Use McKenzie-influenced extension patterns as “First Aid” to help with the back and leg pain.
- Use McGill’s Big 3 and the DNS influenced Sternal Crunch and Diaphragmatic Breathing from Craig Liebenson to stabilize the spine
- Use the FMS-influenced correctives to address common hip and T-spine mobility deficits
- Integrate the stable spine with the mobile hips using more FMS-based correctives
- Build strength, agility, power using kettlebell-focused basic movement patterns with low tech, low cost, low objection exercises like TGUs, swings, front squats, etc.
is a sister site with…
This April, the Royal College of Chiropractic Sports Sciences is hosting the Sports Chiropractic for Ultimate Performance symposium in Vancouver, BC. On April 27-29, 2012 join Dr. Tom Hyde (founder of FAKTR) Dr. Jeff Spencer (DC for Lance Armstrong and the Discovery and US Postal cycling teams) and several others as spring arrives in Vancouver! For more info check out the links below.
Knee pain is the most common pain reported in runners and no one has contributed more to our understanding of this pathology than Irene Davis. I’m a huge fan of researchers that really sink their teeth into a topic and doggedly work to methodically shed more and more light on the subject. Dr. Davis is one of those rare individuals. Working out of the Gait Lab at the University of Delaware, Davis started exploring the biomechanics of the knee in the mid-90s, and has a formidable list of publications that numbers well over 40. Recently, she moved on to the Spaulding National Running Center at Harvard University.
One of the common observations of several studies on patellofemoral pain (PFP) has been that weakness of the hip abductors and external rotators is correlated with, and also predicts PFP. The solution to the problem then seems to be very straightforward…strengthen the muscles that are weak in controlling the valgus knee during gait and all will be splendid. Indeed, were the findings in some studies, but others were less promising. What could be the missing variables?
Last year, an elegant study co-authored by Davis indicated that perhaps the solution is as much related to software as it is to hardware. Brian Noehren, et al, demonstrated one of the most impressive effects on chronic anterior knee pain in runners ever published. And they did it using gait re-training without strength training. They took a small cohort (n=10) of runners (at least 6 mi/week, avg of 16 mi) who had at least 4/10 pain in the anterior knee with running. The average chronicity was 75 months!! They did a gait analysis as well as single leg squat, and measured kinematics including contralateral pelvic drop, peak hip adduction and internal rotation. They also measured vertical impact forces.
Intervention was verbal coaching while running in 8, 30 minute sessions on a force plate treadmill and with live gait analysis. As the runners implemented the coaching cues, they got real-time feedback via the gait analysis software which showed a representation of their peak hip adduction. After 2 weeks, pain was reduced by 86%. On follow up one month later, ALL WERE RUNNING PAINFREE! For more details, here’s a link to that study.
Here are the 3 verbal cues the coaches used to help the runners change their gait:
- Contract the gluteal muscles (or as I tell my patients, pretend you are pinching a coin between you butt cheeks. Don’t crush it, but don’t drop itj!)
- Run with the knee pointing straight ahead.
- Keep the pelvis level (or as I tell my patients, don’t run like a supermodel!)
Granted, your patients won’t have the benefit of the biofeedback equipment these guys used, but I have seen a lot of benefit in my patients over the past year when implementing these verbal cues in runners with PFP. As to the strengthening protocols and proprioceptive training that clinicians and trainers can also implement to do a thorough job of rehabbing runners, check the video tutorials at MyRehabExercise.com. Below you can see a video sample of exercises that I commonly use to correct the valgus collapse of the leg in the gait cycle.Dr. Irene Davis doesn’t get out on the speaking circuit much, but if you want to catch her live, Dr. Glen Harris and MSK+ Seminars are hosting her in Toronto on November 5-6, 2011. I highly recommend running doctors take advantage of this opportunity to learn from one of the icons of running research. Click on the link to get information about registering, Dr. Davis’ bio and the course overview are below.
Dr. Irene Davis’ Bio:Dr. Davis received her Bachelors degree in Exercise Science from the University of Massachusetts, and in Physical Therapy from the University of Florida. She earned her Masters degree in Biomechanics from the University of Virginia, and her PhD in Biomechanics from Pennsylvania State University. Over the past 20 years, she was a Professor in Physical Therapy and Director of the Running Injury Lab at the University of Delaware. In addition, she was the Director of Research for Drayer Physical Therapy Institute. During this time, Dr. Davis has been studying the relationship between lower extremity structure, mechanics and injury in runners. Dr. Davis has recently accepted a position in the Department of Physical Medicine and Rehabilitation at Harvard Medical School to develop and direct the Spaulding National Running Center. Her current areas of study include mechanical factors in tibial stress fractures and patellofemoral disorders along with the effect of physical therapy interventions such as gait retraining. She is interested in the mechanics of barefoot running and its effect on injury rates, and is a barefoot runner herself. She has received funding from the Department of Defense, Army Research Office and National Institutes of Health to support her research related to stress fractures. She serves as a consultant for patients with lower extremity problems related to overuse. Dr. Davis has given nearly 300 lectures both nationally and internationally and authored nearly 100 publications on the topic of lower extremity mechanics during running. She has been active professionally in the American Physical Therapy Association, the American Society of Biomechanics, and International Society of Biomechanics. She is also a Fellow of the American College of Sports Medicine and a Catherine Worthingham Fellow of the American Physical Therapy Association. She is currently the Past-President of the American Society of Biomechanics. She has organized and coordinated national research retreats on topics of the foot and ankle, anterior cruciate ligament injuries and patellofemoral pain syndrome. She has been featured on ABC World News Tonight, Good Morning America, Discovery, the New York Times, the Wall Street Journal, Parade and Time Magazine.Course OverviewThis is a 2-day course on the evaluation and treatment of the injured runner. Day one will focus on assessment. We will cover normal abnormal alignment and structure. In addition, normal and abnormal running mechanics will be presented. There will hands on laboratories on lower quarter assessment, as well as gait analysis in order to reinforce these principles. We will also cover common running related injuries and review research studies providing evidence for the relationship between structure, mechanics and injury. We will end the day with a discussion of the development of a clinical hypothesis upon which to base a treatment approach.On day 2, we will focus on treatment of the injured runner. This will include barefoot/minimal footwear running. We will discuss prescription of stock orthotic devices (we will not be addressing custom orthoses in this course). We will also cover strengthening and flexibility exercises, with lab time provided to practice these therapeutic approaches. We will then discuss gait retraining, followed by a lab to practice these techniques. The course will end with a series of case studies.
Some recent Facebook posts I made need a little bit more fleshing out. I was upset because I had a patient show up 9 months after I rehabbed her lumbar disc injury. She had re-injured her back while performing seated machine crunches on a machine like the one below, while UNDER THE SUPERVISION OF A TRAINER IN A ‘BIG BOX’ GYM! Several folks responded to that thread so I thought we’d explore the topic more.
Recently, some prominent trainers in the blogosphere have begun to question the “no crunch” literature of Stuart McGill and others. While I too think there is more room for us to explore limited unloaded flexion of the lumbar spine (like in Charlie Weingroff’s ‘Core Pendulum Theory’), I think the polarized environment in which this discussion often takes place really makes for a worse world for patients and clients. Young trainers can get caught up in the polarization, become adherents of an influential fitness guru, and lose site of the importance of screening clients well for personal goals and injury history. The resultant adherence to dogma on the training room floor leads to injured clients. When trainers injure patients, both patients and clinicians lose respect for trainers. Then clinicians are less likely to respect trainers and send their patients into those trainers’ gyms. This re-creates the old turf war environment where trainers think clinicians are too cautious and want to steal their clients, and clinicians are afraid to let their patients work with trainers. This represents several steps backwards. In the post-FMS world, we have Gray Cook to thank for providing an effective communication model, a sort of rehab Esperanto (look it up) that allows clinicians and trainers to liase. That handshake from rehab to training is WAY important and we need that model filled with understanding and respect.
So, let me make it clear…WE CLINICIANS NEED TRAINERS ON OUR TEAM TO HELP SEGUE PATIENTS TO SELF CARE! In the competitive environment of personal training, an excellent way for you trainers to bring clients to your door is to bone up on the literature surrounding rehab, then market to chiropractors, physical therapists and medical doctors in their community, showcasing your chops to manage their patients. In fact, just get good at avoiding injury to the most common painful tissue in back pain, the lumbar disc, and you can plan on lots of work. Any clinician worth their salt will give you audience if you send a letter explaining your understanding of the pathobiomechanics of disc injury in the lumbar spine. Those that don’t see the value in your services don’t matter. Move on until you find the heads up clinicians that want your help as much as I do. Many reading this are already savvy to much of this material. For those who aren’t, I will suggest a must-do list of education to get you prepped for your pitch. Those that already know this stuff, forward this post on to the newbies so we can up everyone’s game. There are way too many people in pain out there and we need to work together folks.
THE NEW TRAINER’S GUIDE TO NEW CLIENTS
1. Read Stu McGill’s book, Ultimate Back Fitness and Performance-The go-to manual for managing the spine on the training room floor.
2. Go get certified in FMS, here’s the calendar–Gray Cook has changed the landscape of training and rehab by providing an accessible model of assessment and corrective exercise that trainers and clinicians can both use.
3. Subscribe to StrengthCoach.com–Mike Boyle took his vast coaching experience, added that of the brightest minds in training and coaching, and created an incredible resource that is right on the cutting edge.
4. Subscribe to SportsRehabExpert.com–Joe Heiler, PT tweaked the StrengthCoach format and focused on the rehab end of things. This site is a crazy value and helps you learn the ins and outs of functional rehab so you can liase with the clinicians. Clinician that aren’t frequenting this site are falling behind the curve. Members to MyRehabExercise.com should ALL be using Joe’s site to stay current on the literature in functional correctives.
5. Get Charlie Weingroff’s Training=Rehab, Rehab=Training DVDs.-Charlie Weingroff, DPT scares me. Not only because he can squat 800 lbs, but because he’s one of the brightest folks in rehab and has the chops to crossover between elite coaching, physical therapy, and chiropractic. He also knows WAY too much about professional wrestling and fantasy football.
6. Get Craig Liebenson’s new Functional Performance Training DVDs (more on that in an upcoming post)-Craig Liebenson, DC is my ‘Sensei’…there, I’ve said it. Craig’s work in functional rehab has influenced my work going all the way back to my first year in chiro college. While his Rehabilitation of the Spine textbook is enough to keep you occupied for a year, his release of 3 new DVDs on Core Stability, Functional Training, and Flexibility will be what all of us are talking about in the next year.
7. RSS Jeff Cubos’ blog-Jeff Cubos, DC knows more than you do. He knows more than most of us do. I have never seen a more voracious appetite for learning, in a more humble individual. Jeff truly loves to share his knowledge and does so on his blog, JeffCubos.com. His participation on the recent Muscle Imbalances Revealed-Upper Body, hints at great things to come in the future.
8. And I humbly suggest you subscribe to MyRehabExercise.com just over on the right of this page. I’ve put together a roster of corrective exercise video tutorials for you to share with your clients and patients so that they can “balance their chassis” before you start loading it up with a bunch of weight and intensity. Those videos are from multiple sources (FMS, kettlebell community, McGill, Liebenson, Cressey, McKenzie and many more) but are conveniently located in one place so you don’t have to send patients and clients all over the web looking for rehab examples. The price is right too, at less than $10 per month. Heck, if that’s too much, send 10 of your colleagues to MyRehabExercise.com and you can get the service for free for a year!
Consider this approach as well. In my clinic, I encourage my patients to invite their trainers in to my office during their treatments if they are comfortable with this. I’ll then allow the trainer to stay for an afternoon and observe treatment for other patients that are okay with it. Trainers, see if the clinicians you refer to would be copacetic with this arrangement. Clinicians, offer this opportunity to local trainers.
Now, back to the topic of post-graduate education for trainers…one of the best places
you can go to start your information gathering is Stuart McGill’s work. And if you ever get a chance to see Stu in person, jump at it! It just so happens that Clare Frank, et al at Cynergy Education Group are hosting Dr. McGill in LA on Oct. 15-16. Here’s the link to that gathering, but get to it because there aren’t many seats left.
My personal journey with Dr. McGill began about 10 years ago. A nasty twisting injury to my thoracolumbar junction that occurred in my 20’s when I was a kayak guide, re-emerged after a crappy lifting episode. I found that more and more frequently, my back would seize with less and less provocation. I figured the world had little use for a chiropractor with a gimpy back so it was time for this chiropractic physician to heal himself. Sure, I had had my fill of old-school chiropractic treatment for this issue including manipulation, soft tissue therapies and lots of passive modalities. However, like so many other people’s experience with that limited toolbox, my benefit was only transient. At about that time I was introduced to Stuart McGill’s books and started to read his work suspecting intuitively that that approach of spinal stabilization was going to be my best solution. It did help me tremendously and it also transformed my practice as I shared this approach with my patient base.
I put together my first tutorial videos for McGill’s correctives about 5 years ago to help my own patients learn these exercises. Much to my surprise, clinicians, trainers, bodyworkers, yoga and Pilates instructors and the lay public started using my site and Dr. McGill’s exercises with excellent results. That experience formed the base for the current MyRehabExercise.com. Now, in addition to Stu’s exercises, we also have FMS correctives, material from Craig Liebenson, MacKenzie, the kettlebell community. We’ve even got functional rehab from Eric Cressey, Dan John and folks many of us have crossed in the blogosphere. All of these exercises are patient-friendly tutorials, and are aimed at helping patients and clients not only learn how to do the exercise, but also to learn a bit more about their conditions. Those interested in trialing the videos for use with their own patients and clients can follow the links over on the right side of the page here.
Did you know that MyRehabExercise.com works great on an iPad? Several heads-up users are already finding the service works great right out of the box on iPad and iPhone, no need for an App. This allows clinicians and bodyworkers to send the exercise prescription before they even leave the treatment room and means that trainers can send the Rx to the client while they’re performing the exercise on the training floor! So if you’d love to try that usability out, but don’t have an iPad of your very own, here’s your chance.
We’re going to give one away!
That’s right, when you sign up with MyRehabExercise.com, you may have noticed that you were asked if anyone referred you, and to input the “promo” code of the referring subscriber. You may have then noted on the My Account page, that subscribers are given their very own promo code. Well, we’re making a list and checking it twice, because the subscriber who refers the most new sign ups who stay beyond the trial period, will get a shiny new iPad for Christmas this year!
The Rehab Renaissance has all health care providers upping their game and adding functional rehab to their practice and gym. This approach is not for everyone, but the cracker-jack clinicians, bodyworkers and trainers know that this is the wave of the future. We’re dedicated to making MyRehabExercise.com the best source on the web for functional corrective exercise video instruction and need you to help get the word out. So share the site, and your promo code, with your colleagues, your Facebook friends, listees, bloggers and forum attendees!
Be the top referring subscriber and we’ll send you an iPad for Christmas!
Here are the rules:
1. This contest is open to all subscribers to MyRehabExercise.com except the host of the site.
2. Grand prize will be a 64 GB, top of the line iPad, valued at $699.
3. Winner will be the subscriber who refers the most people who maintain membership with MyRehabExercise.com beyond the 30 day trial period.
4. Tallies of referrals will be based on new signees reference of the referring subscriber’s “Promo Code”, located on the My Account page for members of MyRehabExercise.com. This method of tallying referrals is the only method that will be used and those results are final.
5. December 9, 2011 at 12:00 midnight, the subscriber who has referred the most active members who are not in the 30 day trial period will be considered the winner and will receive the Grand Prize.
6. Winner will receive the Grand Prize via mail delivery and every effort will be made to assure delivery by Christmas, December 25, 2011.
Readers here at MyRehabExercise.com are likely savvy to the work of Vladimir Janda and know the importance of developing excellent co-contraction between agonist and antagonist muscle groups to centrate joints. We’re also learning these days that the faulty joint centration can not only result in long term wear and tear in the joint, but can also result in less than optimal performance. The body reduces force production through the poorly centrated joint and this seems to occur well before arthralgia and pain inhibition processes take hold.
Since the functional rehab paradigm shift is somewhat new, I often get questions about how newbie subscribers to MyRehabExercise.com can learn more about these methods to better help their patients and to make better use of our rehab videos. Of course there are excellent subscription sites such as SportsRehabExpert.com, and StrengthCoach.com and there are also some fabulous blogs out there like CraigLiebenson.com and CharlieWeingroff.com. Folks can often get a jump start on learning the functional rehab methods when these giants synthesize their knowledge into a DVD package or book and you should definitely be all over the DVDs that Charlie and Craig have put together and have at their sites. But this post is about a different guy and what he brings to the table.
Dr. Jeff Cubos is wicked smart…scary smart! If you go to his site to check out his travels to pick up new material from the rehab literati your jaw would drop. I think I could make a decent living just being Jeff’s travel agent! Jeff has an excellent teaching style and ability to bring complicated matter down to assimilable bits. He’s now put together that knowledge and teaching ability into an excellent DVD set called Muscle Imbalances Revealed-Upper Body. In this set, Dr. Cubos has teamed with Tony Gentilcore, Rick Kaselj and Dean Somerset to produce a treatise on how to drill down to the key imbalances for each patient and client, and then how to back up and put together a detailed treatment plan to serve that person best. Dr. Cubos has taken on the somewhat esoteric topic of diaphragm integration into the core by adding tricks to teach patients and clients how to improve pain and stress with breathing techniques from the DNS world. Word on the street is that their is a discount to early orders so get over there and check it out.