I’m still rolling with the excellent presentations I was witness to in Seattle at the Perform Better 1 Day Event on April 21, 2012!! Sadly, when I searched my calendar for the upcoming 3-Day evenets I found that I was already booked on the dates of the Providence, Chicago and Long Beach summits. What are the odds!? The rest of you should be at one of those though. Here is my take on the event that weekend that featured some real heavy hitters…
As fate would have it, Mike Boyle who was on the agenda, was tied up with spring training in his new job with the Red Sox. While I was disappointed to not meet Mike, the guy who pinch hit for him wasn’t half bad either! Gray Cook stepped in to join Charlie Weingroff, Rachel and Alwyn Cosgrove for one of the most enjoyable, well organized and knowledge filled continuing ed events I’ve attended in many years. The format was an hour of didactic from each presenter, lunch, and then the afternoon was 30-40 minutes rotating between 4 hands-on stations hosted by each presenter. In contrast to the typical neck and back numbing sit-fest that usually is present in a weekend CEU event, this one even managed to allow participants to get a bit of a workout in.
Rachel led off with an excellent presentation that chronicled her work with training over the years and her eventual focus on training women and fat loss clients. Participants got a good dose of the psychology that is inherent in managing these clients and keeping them motivated for results. In the afternoon, she led attendees through thoughtful exercise progressions from corrective to high performance and did a masterful job matching the training strategies to FMS scores on the FMS screen. I appreciated the low tech/low space approach of using kettlebells, furniture sliders, resistance bands and TRX suspension trainers to go through some very creative approaches to managing some challenging functional limitations. Keep your eye out for these correctives in the member’s area for MyRehabExercise.com in the future!
Charlie is perhaps the only guy on the speaking circuit who can address 200 people in an 8000 square foot hall without really needing a mic! He brought his obvious passion to breaking down some of the DNS material into the training environment with Understanding Joint Centration. He continually brought the listeners around to the feedforward process of centering of joints to allow for green light from the cortex for optimal and painfree performance. In the afternoon, he navigated that territory using TGU positions, allowing us to feel the difference in loading capacity in centrated vs. un-centrated positions. The sled pulls were especially entertaining in seeing the impact of pulling both with and without shoulder and neck packed positions with several volunteers really getting an excellent take home lesson! 🙂 I particularly liked the simple, elegant demo of toe touching with and without the neck packing. It went like this…
Position yourself with your back to the wall and a foot or so away from the wall. Pack the neck by performing a chin retraction and keeping the neck in neutral, i.e. don’t tip your head down. Bend forward and touch the toes, and wiggle your feet to position yourself where you are simultaneously touching the toes while barely touching your butt to the wall. Return to upright postion and repeat but this time arch your neck up and look at the ceiling. Put your butt against the wall and then try to touch the toes again. Can you feel how much more restricted your toe touch is? Imagine the implications as you try to deadlift and reduce your ability to toe touch. In our challenged patients and clients, this could result in a rounding of the lumbar spine as they try to get to the bar!
Gray was his usual entertaining self as he doled out detail after detail from his voracious reading habit. He made a case for the need for a checklist in our approach to assessment and a standardized system such as the FMS so that we can track changes in our patients and clients.I appreciated the sharing of Ed Thomas’s slides showing the evidence of dysfunctional movement in Americans in the 1950’s whereas 50 years prior movement pattern trends in physical education were much better. The example of the military rifleman shooting from a deep squat position in the 40’s and the need to change that training as the recruits showing up for training in later years steadily lost the ability to deeply squat.
Gray is also a thoroughly quotable figure. Below are a few of the gems that issued forth over the weekend:
Later in the break out session, the bear crawl races were good sport and we all got a chance to put the FMS to a quick application to split up into the motor integration challenged group and the mobility challenged group. Correctives for these were eye-opening with some coming from the Kettlebells From the Ground Up DVD. I rushed over to buy my copy but alas the last one sold just as I arrived 🙁 . One of those demoed was the Brettzel 2.0 which you can see below.
- ”You will not hear me tell a pt to engage the glutes. I’ll put them in a position where they can’t engage their quads and back and ask them to move.”
- ”We teach squatting in reverse in the gym…by putting the weight up high and move under it. Babies start on the ground and move their own weight up.”
- “People are not a bag of parts, they’re a bag of patterns”
- “That functional movement pattern your client/patient is looking for is not missing, it’s on their hard drive, but they’re having difficulty locating it.”
- “We’re all in the wrong business because the mark up on duck calls is like 7000%.” (Author’s note: OK, OK, this was later over dinner after enjoying the local ‘cider’)
Alwyn was very entertaining too but as a clinician, I must admit I was not excited for his talk on Cutting Edge Fitness Business Principles. However, I wound up taking a single pearl home that I think may ultimately be an excellent adjunct to the FixYourOwnBack site that I’m currently re-tooling. More on that later… Honestly, Alwyn’s gym, Results Fitness offers a fabulous training model for group training environment which captures a lot of the fun energy people seem to like in the Crossfit model, but offering sustainable movement exercise that challenges multiple energy systems while focusing on complex functional movements.
Later, he put us through a challenging 27 minute workout that hit all the basic high points: static mobility, dynamic mobility, strength, speed, power, reaction time and agility along with a nice metabolic challenge as a cherry on the top! Nice way to end the day! You can see an example of the gym flow at Results Fitness at this video below.
As it turned out, the day wasn’t over for me, and I had the opportunity to join Charlie, Gray, and Tim Vagen for dinner. As Charlie was co-presenting the following day nearby at Joel Jamieson’s gym along with Patrick Ward, those 2 joined us along with Sounders strength coach David Tenney. Rumours on the grapevine suggest that that event was recorded and will show up as a DVD in the near future so keep your eyes out! Great meal, great company and a fabulous event. I can’t thank the Perform Better folks too much for putting together a great event, and heartily encourage readers to get out to one of these gatherings in the near future. For a schedule of upcoming Perform Better events, click here!
This is the third installment of our series on the ‘care and feeding’ of the injured lumbar disc. In Part 1 we discussed the structural pathology (the broken stuff) and in Part 2 we started a discussion of the functional pathology (why stuff broke). Today, we’ll continue the functional discussion assuming you’ve done some pre-reading or have an understanding of the Joint By Joint Approach. If you don’t, follow the link and brush up. Also, these approaches and the exercises associated with each stage of the rehab process are represented in the library of detailed functional rehab exercise here at MyRehabExercise.com. You can’t use them to help teach your patients and clients unless you’re a member. Membership is inexpensive ($19.99/mo), 30 day trial for $1 and you can discontinue service anytime. Follow the links to the right to sign up.
If you don’t have an office set up to instruct your clients or patients in rehab exercise, or if you just don’t feel comfortable customizing the exercise Rx yet for disc injury, check out FixYourOwnBack.com. There, you can just refer your patients or clients with disc injury, disc bulge, herniation, sciatica and for $9.99/mo they can receive the self-help education and rehab Rx that is being discussed in this blog series re: management of the lumbar disc injury.
The Plan–“Plan the work, then work The Plan”
Once we have an injured lumbar disc, The Plan (as it’s referred to on FixYourOwnBack.com) is as follows:
This flow pattern has been put together based on my clinical experience working with disc injuries daily and by studying with the rehab schools of thought mentioned above. Credit for much of the overall flow is from Stu McGill’s flow mentioned in his excellent books and DVDs. I have added to that flow pattern as I’ve added tools from the sources above. Most readers of this blog are already familiar with McGill’s Big 3, but perhaps not to DNS. I am waist deep in my training in that school of thought but owe my introduction to the Prague methods to my mentor, Dr. Craig Liebenson.Craig will be hosting a DNS instructional course in Phoenix in November as well as several other introductory courses in the US in 2012, if you’d like to get started with adding these innovative and effective approaches (For Dr. Liebenson’s current speaking schedule go here). Let’s segue now to the next area of focus that I often see benefit for with disc patients…mobility limitations in the thoracic spine and hips.
- Stop faulty movements and postures that “pull the scab off” of the healing disc
- Learn disc “First Aid” using McKenzie methods to assist in healing and control pain
- Use McGill’s Big 3 and DNS methods to stabilize the lumbar spine
- Improve mobility in the T-spine and hips to spare the spine
- Use FMS-based corrections to integrate stability and mobility achieved in #3 and 4 above into long term sustainable movement patterns
- Improve strength in the muscles necessary to perform #5 above
- Improve agility in those sustainable movement patterns to help with resilience when life throws a curve
- Incorporate sport specific skills to help manage disc injury and recurrence
The Stiff Upper BackChairs are often the culprits that steal valuable mobility from the t-spine and hips. Prolonged sitting posture often results in slumping, exaggerating the kyphotic curve of the thoracic region. Adaptational shortening of the surrounding muscles and tissues results in loss of thoracic extension and rotation. Passive methods can be used to help restore that movement like foam roll and lacrosse ball mobilizations in the gym, or bodywork in the clinic or studio. Active methods, in my experience, take less time to restore this mobility and tend to last longer. Search YouTube and you’ll find dozens of exercises that help with this area, but I like the Modified Sphinx, Thoracic Rotation and Sidelying Thoracic Extension + Rotation exercises and they’re on the website at MyRehabExercise.com and FixYourOwnBack.com.
The Creaky HipsRemember, the Joint by Joint Approach views problems in the stable joint complex areas to be due to limitations in the mobility of surrounding more mobility-oriented joint complexes. Below the lumbar area are the femoro-acetabular joints…the hips…which are high pay off areas for long term improvement of disc injury. These big ball and socket joints beg for movement that our chairs slowly suck out of us daily. The 2 planes of movement that are typically lost are extension and abduction, as those muscle groups shorten from lack of frequent length changes. Shortening of the resting length of the hip flexors results in mechanical and neurological side effects.Mechanical Effect of Shortened Hip Flexors:
As the shortened flexors’ insertion onto the lesser trochanter persists, the femur shifts anteriorly in the acetabulum. When that individual squats deeply, the acetabular labrum gets munched and sometimes the repetitive loading of this imbalanced hip into deep flexion can result in bony changes now referred to as femoral acetabular impingement (FAI). For more info on FAI, check out this link to Craig Liebenson’s blog. Learning how to test for this is helpful, as an Xray can point to whether that patient should be in an orthopedist’s office. However, all anterior hip pain is NOT FAI, and the condition starts as a soft tissue issue. Catching it early in the progression means you can head off not only a hip replacement years later but also the well-meaning FAI surgery!Neurological Effects of Shortened Hip Flexors:
Charles Scott Sherrington’s Law of Reciprocal Innervation won him a Nobel Prize in 1932 for describing the neurological relationships between agonist and antagonist muscle groups. Stated simply, when a muscle contracts, its antagonist on the other side of the joint is reflexively relaxed to allow joint movement to occur. Several decades later, Czech neurologist Vladimir Janda coined a corollary to Sherrington’s Law which states that when a muscle’s resting length has been shortened, it’s antagonist will be reflexively inhibited. Around the hip joint, the tight hip flexors inhibit the large muscles of the buttock…the glute max and the glute med. This condition in the hips has been referred to in Janda circles as part of the Lower Cross Syndrome, and years later by Stu McGill as ‘gluteal amnesia’.What we then see in the clinic is pain in the smaller muscles of the buttock, namely the gluteus minimus, piriformis and TFL>ITB. Pain in these muscles then represents an overuse syndromeas the smaller muscles are re-tasked to share the load the glute max/med should be bearing. While manual therapies (massage, myofascial release, Graston, Stecco, foam rolling ) are helpful in reducing the pain in these areas, the relief is temporary unless you address the functional causes.Now that you know this, if you’re in the business in your clinic of mining this repeat business for fun and profit, then you’re part of the problem. Either learn how to correct the functional imbalances or refer to someone who does after you perform the worthy service of helping to manage your patient/client’s pain! To improve mobility in the hips, flexor stretches (lunges) are helpful and Goblet Squats are the bomb for opening up the medial joint capsule. Many disc patients though, can’t manage the deep squat position of the Goblet without loss of the lumbar lordosis and resultant stress of the injured disc. For those folks we have the Tactical Frog to help open the hips a bit before progressing to the Goblet.Our next step in rehabbing the disc injury then moves to re-training the hip and spine to function well together. In some circles I’ve heard this referred to as ‘de-coupling’ the hips from the spine. I see it more as integrating the stable spine to the moving hip. We use the sternal crunch + abdominal breathing pattern to get the internal spine stabilization system working, then add a high complexity/low load exercise (Dead Bugs) on top to groove the pattern. After that I really like the Leg Lowering progressions from the FMS corrections to add load. We then borrow a page from Gary Gray and stand the patient up and have them to practice standing hip flexor endurance. The hip flexor endurance test attributed to Shirley Sahrmann was described by Mike Boyle in this paper and the procedure is below.
As the psoas group and the iliacus are the only 2 hip flexors that can flex the hip beyond 90 degrees, the observations above indicate weakness of those muscles if those signs are present. I’ve found that the test can be effectively used as an exercise by cueing the patient to avoid the above faults and work to increase endurance in the single leg stance from 15-30 seconds. We bring all of the cues together from all of the previous work to get all of the parts working together well…ribs down, be long through the spine, pinch a quarter in the butt cheeks, belly breathe. I also cue them to place a hand lightly on the lumbar spine to get biofeedback for spine movement and one hand over the lower ribs looking for flare of the ribs. Your target is to keep the knee over 90 degrees and have NO movement in the lumbar spine.Once the hips are dialed in, our disc patient can start having more fun! Transverse plane movement progressions like rolling>hard rolling>chops/lifts>Pallof presses can begin the journey to strength training and we incorporate those into the program at FixYourOwnBack.com.Since many folks pursue that strength training in a standard “big box” type gym, we take time to instruct them about specific equipment and exercises to avoid. Those that are have aspirations toward some of the bodyweight “boot camp” type programs need caution on some of the excellent exercises like burpees, man-makers and mountain climbers. We’ll save that info for a future post here at MyRehabExercise.com.As a reminder, this progression plan outlined in these posts is already laid out as a self-help membership site at FixYourOwnBack.com. Membership is only $9.99/month, less than the co-pay in most insurance plans, and no contract means your patients or clients can quit when they’ve reached their goals.For those readers already saavy to these types of functional exercises and who want more control over the exercise Rx, consider membership to MyRehabExercise.com. There you’ll find a library of detailed functional rehab exercise tutorial videos you can send to you patients and clients via email to better tailor their progress to your professional assessments. Be well!
- In single leg stance, pull one knee to the chest and release.
- Observe for failure in ability to maintain >90 degrees of hip flexion for 15 sec.
- Is there cramping in the TFL?
- Observe for posterior lean, rounding in the spine or lateral tilt of the pelvis
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Part 1 of this multi-part posting on lumbar disc injury diagnosis and management discussed identification of the structural issues associated with the injury. Next post we’ll look at some of the finesse points that trainers and clinicians can address to improve long term function in the lumbar spine. Today we’ll look at the functional aspects. How do we see a disc injury before it manifests as a fully blown sciatica/radiculopathy event or,…
What are the functional clues to impending disc injury?
Lab studies show that endrange loading of the lumbar discs into flexion in the presence of compression is the quickest way to cause a disc to herniate in the low back. More often than not in my experience, this represents the end result of long term habitual lumbar hinging, until the fateful day when the patient bent forward to pick up ___________(fill in the blank) and felt the searing pain in the butt and leg. Single injury events do occur, usually as a slip and fall onto the butt or as a poorly executed heavy lift. I can’t tell you how many initial onset histories in guys start with, “My first back injury occurred in high school in the weight room after football practice when me and 2 friends (always 2 friends, and poor grammar) decided to see who could back squat the most weight.” Often, they remember a ‘pop’, and back pain, with some sciatica later. Some researchers have said they can hear that ‘pop’ in the lab as the endplate fractures when they load the motion segments to failure in flexion/compression in pig spines. The research of spine biomechanist, Michael Adams, PhD suggests that that endplate failure is frequently the cause of the altered motion in the vertebral segment over time that results in disc degeneration.
If this patient walks into your clinic, studio or gym, that lumbar hinge is what you’re looking for. If they are acute with radicular symptoms and you try a multisegmental flexion assessment per SFMA, you’re a cruel bastard. The seated slump test from the previous post, and the quadruped sit back assessment as in the photos below from Stu McGill’s Low Back Disorders will yield your lumbar hinge under less provocative loading.
Fix that hinge by quickly training them to hip hinge and box squat so that they don’t hurt getting up and down from the chair to the exam table. Video tutorials for these are available to subscribers of MyRehabExercise.com to send to their patients or clients. If you don’t feel comfortable in your clinic setting or your bodywork studio confidently instructing your patients or clients how to do this, I’ve uploaded these as free material on the FixYourOwnBack.com site. Use that as a resource for your patients or clients to learn more about their disc injury.
If you’re a trainer and your client has this history, put down your cell phone and stop texting while your client is squatting, rowing, deadlifting, etc and make sure that they aren’t hinging in the lumbar spine while performing those movements. If you’re doing Boot Camp types of movements like Burpees, Mountain Climbers and Squat Tosses with medicine balls, make sure they don’t hinge with these movements. (I think Boot Camp exercise vigilance might require a separate post now that I think of it). Trainers can help buttress the lumbar spine during squatting by cueing the client to use the lats by ‘bending the bar’ and cueing the glutes by pushing their knees in and having the client resist strongly by pushing the knees out (As of November 2014, we’ve updated these cues after seeing them more effective in one of the best powerlifting gyms in the world. Find that info on Chapter 9 of The Plan, available to subscribers of FixYourOwnBack.com). If this info is new to you, then you need Stu McGill’s other book, Ultimate Back Fitness and Performance. Seriously…go now and get it…we’ll wait until you get back!
The typical disc presentation is flexion-intolerant, but many of these folks also complain that extension hurts too when you stand them up and ask them to bend backwards. This is important to know because you need to repeat that extension in the prone position. You also need to repeat it several times and ask if the repetitions are less painful.
If they are, you’re on the right track and need to continue the extensions with McKenzie protocols. Does that mean you’re done with the rehab? NO!
The following quotes are from member feedback at FixYourOwnBack.com in the Discussion Forum:
“I now understand why 3 months of McKenzie exercises (post position) 8×10 reps a day prescribed by my last PT caused new pain and symptoms.”
“I have been taught to do the Dead Bug by four physical therapists over the past three and a half years. Doing it the way you explained in your video is a completely different experience and makes it a completely different exercise. Thank you for the in-depth explanation.”
I’ll also share a recent patient presentation too: 29 y.o. female 2nd year med student and former Division 1 soccer player presented with low back and leg pain 3 weeks after discharge from PT where she received McKenzie (MDT) therapy. Once her pain improved, she was discharged to normal ADLs. Her first rec league soccer match ended early with raging leg pain and weakness after a long cross field kick.
I’m a huge fan of MDT and use it daily in my own practice, and that approach did not fail with any of these cases. It did fall short of rehabilitating the injuries of these patients. To paraphrase the common question in all of these individuals:
Is There Life After McKenzie?
Full disclosure, I am not MDT certified but learned this approach in my DC training, through reading the literature concerning it and I employ it daily with my cervical and lumbar disc patients. The way I use MDT and frame it to my patients is as a first aid kit. I know of nothing else that allows a lumbar disc patient quicker self help pain relief for disc pain and sciatica. To my mind though, it only gets the patient to Square 1 of the rehab process.
Once the person is out of pain, that’s when the fun starts! I break out McGill’s rehab protocols, Janda’s Movement Pattern Assessments, DNS assessment, SFMA algorithms, Liebenson’s Mag 7, etc and customize an exercise program for them that borrows from all of these schools of thought. Once your toolbox is deep and you’re familiar with these methods they blend wonderfully for the lumbar disc patient. Despite all of these customizations though, probably 90% of these lumbar disc patients have a very similar take home plan.
Most of my patient base might get up to some of level 5-7, but mostly need help from a trainer or PT in a gym environment to really get into the deeper levels well because my office is more set up to manage pain than performance. The similarity between most of these lumbar disc patients means that much of their treatment could be standardized, in my opinion, to help more people. Which brings us to another question:
- Use McKenzie prone press up to control pain
- Correct transitional movement flaws and posture faults to stop ‘picking the scab’
- Stabilize the lumbar spine by building endurance in sagittal and frontal planes/incorporating proper breathing stereotype
- Correct mobility deficits that likely exist in the T-spine and hips, possibly ankle
- Build strength
- Build agility
- Build power
- Address sport specific issues pertaining to the lumbar disc
Does Everyone Need An Individual Assessment?
Wouldn’t that be nice? While I would love to see everyone receive an excellent functional assessment, but so many folks are suffering from lumbar disc injury and it is responsible for such a drain on public health that I think we need to address this from a public health perspective. We need low cost ways to get most of the people suffering from disc injury educated about what not to do, what they should do more of, and how to incorporate exercise into their self treatment without hurting themselves. Once folks get feeling better, they will need guidance and excellent exercise instruction. Are you qualified? If not, why not? And that leads us to another important question:
What Will You Do In Your Next Career When Your Patients Find Out That They Feel Better After Working Out Than After Leaving Your Office?
Those of you who are savvy to Functional Rehab and who are members of MyRehabExercise.com, know that all of those approaches above are already available to you on that website to prescribe those tutorials by sending your patients an email link to their customized prescription. However, what if you’re a bodyworker, or massage therapist and you don’t feel comfortable taking your relaxed, naked patients through rehab exercise instruction after a massage? I just released another site to help those folks distinguish your services by including exercise. Refer your clients and patients to FixYourOwnBack.com where they can get free education and for much less than they would pay for an office call, they can get the exercise plan above laid out for them as video tutorials. Next post, I’ll cover deeper functional approaches to managing the lumbar disc patient by decoupling the hip movement from spine movement, and improving mobility in key areas. Cheers!
Got Disc?: A Structural and Functional Perspective on Lumbar Disc Injury Diagnosis and Management-Part 1 of 3
Can you recognize a disc patient when they walk into your office? The reason I ask is because a sizable number of the chiro students that come through my office find it difficult. The MDs that I see in the office don’t seem to know it when they see it…or even when they have it! It was also enlightening a year ago while working with Dr. Craig Liebenson to see the DC/PT crowd in the 80+ audience struggle with a disc presentation.
I’ve wondered about why this seems to be obtuse to many clinicians and I think that it is ironically due at least inpart, to the way we ingest the literature regarding back pain. An artifact of the RCTs on back pain is that clinicians are trained to diagnose disc injury only in the presence of frank neurological signs. After all MRIs frequently demonstrate disc pathology in the asymptomatic population and that’s the only way we can be sure the disc is injured, right? Recently, one of the world’s best known, and most published spine researchers was rumored to have said (paraphrasing) “Randomized Controlled Trials (RCTs) on back pain should be banned because they’re so f@#$ed up“‘. What on earth did this researcher mean? RCTs are the gold standard of evidence-based practice! In the post-modern, evidence-based world, shouldn’t we be on bended knee to the “evidence”? As a clinician who has taken part in some of those major clinical trials I would say yes…but…
Let’s review the definition of evidence based practice as defined by Joel Sackett. It is defined as practice based on the following 3 components:
- The best available current scientific evidence.
- The clinical expertise of the provider.
- Patient choice in their care.
Here is a quote from Sackett that I think is germane to this blogpost and speaks directly to the 3rd point above and to the insecurities of many who are afraid of EBP:
“Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.”
RCTs are limited by the questions they ask and by the populations they ask them of. For instance, some cynically note that specific exercise has not been shown to be beneficial for back pain. The problem is that historically, the cohort in LBP studies has mostly been heterogeneous and doesn’t account for either what type of exercise is prescribed, or what type of subgroup of back pain is receiving the prescription. Jeff Hebert et al, described these subgroups nicely along with effective treatment modalities for the subgroups in this paper.
I feel another misinterpretation of the literature is regarding the diagnosis of disc injury and radicular presentation (sciatica). Many clinicians are trained to only make the diagnosis of disc injury if neurological symptoms are present (numbness, tingling, pain, motor weakness in a dermatomal distribution). It used to be that we’d rely on MRI to make the diagnosis but now know that many asymptomatic people have disc pathology on MRI. However, a functional approach takes account for a continuum of an injury. I feel that only calling a disc injury a disc injury when one has neurological signs and symptoms is like ignoring the smell of smoke before the fire over takes you. I also feel that failure to identify disc injury prior to neurological deficit has a major effect on the public health and on cost of health care. Reflecting back to point 2 above, the clinical expertise of the provider, I’d like to take an opportunity to describe how I address disc patients now after treating them daily in clinical practice for 10 years.
So how do we detect a disc injury before it causes neurological signs? By assimilating multiple clues from the patient’s history, physical exam and neuro exam as well as any imaging findings.
Family history is very important here as Videman and Battie’s research suggests that a genetic component is at play here, and seems to involve some polymorphisms that result in weaker collagen formation and subsequent disc degeneration (may account for 30-70%!). Also important are the activities of daily living that worsen pain. The hallmarks that I’ve seen are:
- Pain in transition for sitting to standing
- Pain when rolling over in bed
- Pain getting in and out of cars
- Pain putting on shoes/socks
This video shows a quick correction of these movement patterns so that a disc patient can quickly be taught how to stop hurting themselves. It is part of the free educational video area of FixYourOwnBack.com.
In the functional rehab world, it is currently fashionable to poo-poo structural issues in diagnosis and management of patients. My opinion is that this represents an adolescent trend in healthcare. We have errantly over-relied on structural cause for pain and dysfunction for far too long. While the research of folks like Ron Melzack, Lorrimer Moseley and David Butler has rightly brought our attention to the ‘Neuromatrix of Pain’, I fear that we may be throwing the baby out with the bath as we rush to disregard structural pathology. In an interview I did with Michael Adams, he had the following quote re: research on disc injury:
“Most people producing the research concerning back pain don’t talk about disk injury. It’s almost a shock to find someone take a breath and actually talk about disc injury.”
To bring the discussion back to the exam of the back pain patient, the current evidence suggests a cluster of orthopedic tests is best to help identify lumbar disc injury and whether or not that disc injury compromises a nerve root. Below is a video I did putting these 2 tests together in the way that I perform them in clinic for expediency and accuracy. Additionally, I add a functional test for lumbar extension borrowed from the McKenzie folks to help identify quickly how to treat the patient both in the clinic and with home exercise.
Quick overview of the 3 tests :
In the upcoming blog post, I’ll lay out a functional approach to disc injury management that highlights inclusion of functional tests and exercises below:
- Slump tells you it’s a mechanically compromised disc
- SLR tells you if the compromised disc is affecting a nerve root
- McKenzie prone press up (Sphinx in yoga) shows the way for treatment
- Multisegmental movement offers clues but poorly tolerated in disc pt
- McGill’s quad sit back shows the hinge
- Squat/rise shows contributing global movement pattern
- Hip flexor endurance test
- Leg raise per FMS
For those interested in seeing the combination of structural and functional approaches as it applies to disc injury, please visit FixYourOwnBack.com. There you will find an organized, self-help exercise program based on the outline modelled here. Arranged in an innovative, interactive chapter book format, users can work at their own pace to address the mobility, stability, integration, strength, agility and power components of complete rehab of the lumbar disc injury.___________________________________________Sackett D, Rosenberg W, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996;312:71.Moseley GL. A pain neuromatrix approach to patients with chronic pain. Man Ther. 2003 Aug;8(3):130-40.Videman T, Battié MC, Ripatti S, Gill K, Manninen H, Kaprio J. Determinants of the progression in lumbar degeneration: a 5-year follow-up study of adult male monozygotic twins. Spine (Phila Pa 1976). 2006;31:671-8. [PubMed]Battié MC, Haynor DR, Fisher LD, Gill K, Gibbons LE, Videman T. Similarities in degenerative findings on magnetic resonance images of the lumbar spines of identical twins. J Bone Joint Surg Am.1995;77:1662-70. [PubMed]Battié MC, Videman T. Lumbar disc degeneration: epidemiology and genetics. J Bone Joint Surg Am. 2006;88 Suppl 2:3-9. [PubMed]A Patel, WR Spiker, M Daubs, D Brodke, L Cannon-Albright. Evidence for an Inherited Predisposition to Lumbar Disc Disease. J Bone Joint Surg Am. 2011 February 2; 93(3): 225–229.[Full Text]
Majlesi J, Togay H, Unalan H, Toprak S. The sensitivity and specificity of the Slump and the Straight Leg Raising tests in patients with lumbar disc herniation. J Clin Rheumatol. 2008 Apr;14(2):87-91.
van der Windt DA, Simons E, Riphagen II, Ammendolia C, Verhagen AP, Laslett M, Devillé W, Deyo RA, Bouter LM, de Vet HC, Aertgeerts B. Physical examination for lumbar radiculopathy due to disc herniation in patients with low-back pain. Cochrane Database Syst Rev. 2010 Feb 17;(2)
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.
In the world of spine research, few have contributed as much as Dr. Michael Adams. In his work as a clinical professor of biomechanics at the University of Bristol in the U.K., he and his research colleagues have helped to further our understanding of the cause of one of the most common maladies affecting humans…back pain. His watershed research 20 years ago helped us understand the diurnal phenomenon in lumbar discs which results in markedly increased risk of disc injury in the first hour after arising due to increased hydrostatic pressure. Over the past 30 years, his area of focus in his dozens of research projects have moved from pain of vertebral endplate origin, to pain of nucleus pulposus origin, to his most recent interest in pain of annulus fibrosus origin.
Mr. Adams’ recent opinion paper on future strategies for treatment of back pain of annular origin raises some interesting questions that touch on some hot topics in the world of rehab. He notes the similarity of the annular tissue to tendon tissue and wonders whether clinicians should consider loading the annulus strategically during specific phases of rehab to improve outcomes. Given that some of that loading might be arguably be into flexion, I wanted to talk with Mr. Adams about how we might explore these loading vectors safely to avoid risk of re-injury to patients. I also wanted to get his opinion on what the research says about the wisdom of loading the flexed spine with exercise in the un-injured spine.
Quick bullet points in this interview include
- Disc injuries take a long time to heal and may never heal to ‘original factory specifications’
- Endrange loading of the lumbar spine injures discs
- Loading of discs into flexion, but not to endrange, AND WITH CAREFUL ASSESSMENT AND MONITORING may help improve health of a disc during late phase of remodelling
- Tendons may represent the closest other body tissue that we have some understanding of the effect of loading on during healing
- We still haven’t figured out many things about tendonopathy
- We still need to define what constitutes ‘loading’ during flexion of the spine and what safe frequency of loading might be
- Sit ups and crunches at the right time, at the right frequency, and in the right volume, MAY theoretically help to improve the health of discs
As a personal aside, Dr. Adams’ opinion is counter to my clinical experience and challenges my understanding of the science of disc injury and mechanics. He freely admits that his experience is not clinical, or in the field of exercise science. However, we should listen to folks with 30 years of focused attention on the biomechanics of the spine. Some of the points in this interview may rub with some of the tenants of Dr. Stuart McGill’s approach to the spine based on his research. Dr. Stuart McGill and Dr. Adams are colleagues and know each other well and their opinions and research are more similar than different. I would love to see a collegial roundtable discussion that involved these guys and a few others with the focus being on the lumbar disc!Ultimately, my clinical goals and my goals with MyRehabExercise.com, are to improve public health and patient outcomes. As folks listen to this interview, I would encourage us all to keep such goals in mind, rather than adhering to our own viewpoints and refusing to be thoughtful in the consideration of the opinions of others. Ultimately, as healthcare professionals, our duty is to our patients and clients, and they depend on us for distillation of science as best we can. When the path is less certain in practice, we owe it to our patients to let them know when that path moves from the paved roads of science, onto the rocky roads of personal experience and anecdote.I would also be remiss if I didn’t remind you about the membership portion of this blog which is a library of functional rehab exercise tutorial videos to help with patient/client exercise instruction. Cost is only $9.99 per month and you can trial it for 30 days wit no obligation for only $1. To learn more, click on the video and links to the right of the page here, or just click here to go get started.Sorry for the sound quality issue towards the end as a mic battery was apparently failing. I attempted to recap the points that Dr. Adams was making during that time. Enjoy the interview!
Click on the arrow below to hear the interview with Michael Adams, PhD.
Adams MA, Stefanakis M, Dolan P. Healing of a painful intervertebral disc should not be confused with reversing disc degeneration: implications for physical therapies for discogenic back pain. Clin Biomech (Bristol, Avon). 2010 Dec;25(10):961-71. Epub 2010 Aug 23.
As I write this from 30,000 feet on my way home from a recent course in Dynamic Neuromuscular Stabilization (DNS), I hope to provide some personal perspective and something of an overview of Pavel Kolar’s program with this post. My understanding is based on my experience of only 2 courses over the past 2 years, but I hope that it might offer a bit of help to those clinicians, trainers and bodyworkers who are considering ponying up the time, money and commitment to immersing themselves in this physical medicine approach. Below, you can also check out some other perspectives from folks that have been doing this a bit longer. At the end of the post you can find videos from Ken Crenshaw, ATC of the Arizona Diamondbacks; Sue Falsone, PT of the LA Dodgers and Drs. Mike Rintala and Brett Lemire who have been using the DNS approach at the highest levels of pro and amateur sports.
“As to methods there may be a million and then some, but principles are few. The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble.” -Ralph Waldo Emerson
The DNS approach is principle-focused, and thus allows for jazz-like riffs in the assessment and treatment of patients and clients. However, a solid understanding of the basics of human movement and assessment is a prerequisite to the course, and many will find that this material is like a post-grad diplomate for the FMS/SFMA protocols. For the official specs on DNS, check out the excellent Powerpoint presentations at the DNS website, www.RehabPS.com. The following are my own gleanings and represent the ‘bullet points’ that really stuck out for me after the 4 day course.
Principle 1- Proper orientation and function of the diaphragm is key to elegant movement.
Principle 2- In a healthy, developing central nervous system (CNS), proper diaphragm orientation and function are innate.
Principle 3- In a healthy, developing CNS, acquisition of motor programs occurs in a predictable, observable manner in the infant.
Principle 4- In adults, poor musculoskeletal function often starts when diaphragmatic breathing and stabilization is lost.
Principle 5- Improved musculoskeletal function can be re-acquired by returning to developmental stages of movement and re-grooving balanced movement in the presence of proper diaphragmatic breathing and stabilization.
DNS uses the clinical audit process (CAP) in application. In these methods, the patient is first assessed, a treatment is applied and the effect is then reassessed to determine short term effect of treatment. Studies have shown that long term prognosis in musculoskeletal conditions improves by 3 fold when within treatment benefit is noted. Much of the DNS assessment is on breathing patterns and postural stabilization using the diaphragm. Those breathing patterns are corrected by the clinician, often in positions that mimic developmental infant postures and movements. This process was built on the work of former Prague School of Rehabilitation head, Vaclav Vojta.
Vojta’s work with children suffering from cerebral palsy (CP) showed improvement in function of CP kids when this type of developmental approach was used. This is where one of the more controversial aspects of DNS starts to enter the picture. Vojta theorized that during development of motor programs, the infant’s observed progression from supine to sidelying to prone to sitting to kneeling to more advanced vertical postures resulted in areas of high sensory input corresponding to the weightbearing structures during that period of development. Vojta felt that these high sensory areas persist into adulthood and he coined the term ‘reflex points’ to describe them. In the adult, these areas of the body, like the anterior lower ribs, ASIS, medial knee and elbow, palm and medial calcaneus, theorietically can be used to access more primitive movement stereotypes that are innate to the human. Manual pressure to these points, again, theoretically, can ‘re-boot’ the more balanced respiratory and stabilization functions of the diaphragm and motor system, allowing for a better cache memory of movement that is balanced. Building on that temporary improvement with personalized exercise is the next step to restoring function to the musculoskeletal system.
In my own opinion, the evidence for these reflex points and reflex locomotion is tenuous at best. I’m happy to see that the DNS approach, while informed by the possibility of these special points, does not rely on them for application. In the training of the reflex points in the course, students are taught what anticipated movements might occur with stimulation of reflex points, and then they practice on each other. As a result, these “reflex movements” are highly suggestible, and I suspect that much of what is observed in the seminar environs is not truly reflex, but the wishes of the participants to experience the phenomenon. I have only the reports of trusted colleagues that this reflex movement occurs in a predictable manner in the naive patient. I very much try to educate patients about the origins of their dysfunction so that they are empowered to help themselves without need for treatment. Quietly waiting over a patient, while pressing specific reflex points, without telling the patient what you’re doing and why seems awkward to me. Telling them, however, removes the naivete. The real ‘magic’ IMHO, is in the anticipated movement patterns.
To my mind, the beauty of the DNS approach is in refining our understanding of ideal, anticipated movement patterns that occur with basic human movement stereotypes like rolling over, squatting, kneeling, stepping, etc. When adequate deep stabilization of the spine occurs, these pure movement patterns occur spontaneously in the infant. If spine stabilization is hampered in development or later in life in the adult, then aberrant motor programs become ingrained. These aberrant patterns of movement result in joint de-centration, with resultant negative effects on the joints, attached soft tissues and performance. Overuse syndromes, pain and suboptimal performance of movement in athletics are the results. The good news…Kolar has shown us how to intervene clinically by teaching the patient/client how to better stabilize the spine and then re-groove the ideal movement stereotype.
The clinician or trainer leads the patient into the ideal movement and weightbearing, and then can reinforce proper movement using reactive neuromuscular training (RNT) strategies. The challenge is in finding exactly when in the movement pattern that the individual loses stabilization, de-centrates and thus needs help. Practitioners require a refined ability to assess the nuances of movement quality. Prescribed DNS exercises are highly individualized to the patient/client, and rely heavily on internal cuing. That is, the patient/client is taught to feel the loss of integrity in the movement, correct it by stabilizing better and then continuing the movement with different weightbearing and force vectors that mimic the developmental movement stereotypes.
To those who are fond of algorithms and ‘low cortical output’ (read mindless) practice, DNS will disappoint you. This is a systems approach to the human body and requires you to be ‘on’ to apply it effectively. Like much of the modern functional approach in physical medicine, initial focus is on an individual assessment of the patient/client. This assessment frequently starts with territory that has for many of us been considered to be ancillary at best. DNS places great emphasis on the diaphragm and its role in not only respiration but also on stabilization of the core to create a fixed point (punctum fixum) for the hips and shoulders to plug into to generate movement.
I have already seen benefit using these methods on those patients (including myself) that I have not quite been able to rehab completely using the other paradigms like FMS/SFMA, McKenzie, McGill, etc. My next personal challenge will be in how to represent this material well in the exercise roster at MyRehabExercise.com to help clinicians and trainers more easily teach these strategies to their patients and clients. So far, the DNS approach has been tangentially represented at MyRehabExercise in some of the Dead Bug exercise progressions, Baby Get Up from Craig Liebenson, DC and perhaps even in the Turkish get up break downs in the rehab setting. Look for more refinement of the exercises on MyRehabExercise in the future to include more detailed DNS based methods.
Membership to MyRehabExercise.com is only $9.99 per month and allows access to an extensive library of functional rehab exercise video tutorials to help with patient and client rehab exercise training. Trial the site for only $1 for 30 days with no obligation.
Below, Ken Crenshaw, ATC, lead trainer for the Arizona Diamondbacks discusses the role of DNS in the management of pro baseball players.
Sue Falsone, PT is the first female head of athletic training in any of the 4 major league sports in the US. She was recently hired by the LA Dodgers to help oversee the care of those players. Here, she discusses the role of DNS in the athletes she helps to treat in her work as head PT for Athlete’s Performance International.
Dr. Mike Rintala and Dr. Brett Lemire were ‘early adopters’ of the DNS program and incorporated it into clinical practice starting 10 years ago. Dr. Rintala discusses the effect of DNS in working with pro and amateur athletes including PGA Tour pros. Dr. Lemire discusses the effect of DNS in a standard DC practice.
Happy Thanksgiving all! Here in the US, today is a holiday set aside to gather with family and reflect on the things that we have to be thankful for. I feel truly thankful this year for not only my own family, but also for the professional family that I’ve been fortunate enough to be adopted into this past year. I want to thank you folks for playing together on Facebook and in the blogosphere and especially for spending time together at continuing education weekends. This past few weeks have been quite active in that regard with back-to-back long weekends on a cranial download of Fasical Manipulation and Dynamic Neuromuscular Stabilization (DNS) coursework.
For those who haven’t yet been exposed to the DNS material, it is the latest in the evolution of the Prague School of Physical Medicine and is the brainchild of Professor Pavel Kolar. Dr. Kolar is the current head of the school which is housed at the Motol University Hospital in Prague, Czech Republic. Past heads of the school have included Vaclav Vojta, Karel Lewitt, and Vlad Janda. Kolar’s work has been greatly influenced by Vojta’s work with children with cerebral palsy (CP) which started back in the 1950’s. Vojta’s observed that the innate developmental movement patterns of infants are not only predictable in their ontogeny, but that those predictable patterns are disturbed at a very early age in CP kids. To an astute observer, those flawed patterns offer an opportunity to diagnose CP at an earlier age, and then to intervene for those kids’ benefit. Vojta found that grooving more normal motor programs in those children helped them achieve higher levels of function.
Pavel Kolar’s work was also informed by his athletic experience as an Olympic gymnast for the Czech Republic. Kolar wondered whether children with CP might not be the only benefactors of Vojta’s ideas. He began to note that the commonly presenting pain syndromes in adults were coupled to poor movement patterns that mirrored the faulty movement patterns observed in CP kids. When he began to apply the same exercise strategies in these adults, their pain syndromes improved. Given his athletic background, Kolar started applying the DNS principles with athletes for performance improvement and once again found success. Today, high performance athletes are beating a path to Prague and to those practitioners worldwide who are well versed in these techniques.
This past weekend, one of the larger courses in the US was held at Athlete’s Performance International in Phoenix, AZ and included classes in the A, B, C and Advanced levels of training. The roughly 80 total participants were treated to grand rounds with professional athletes and world record holders. The attendees included physical therapists, chiropractors, MDs, athletic trainers, personal trainers and bodyworkers. One of the most satisfying aspects of this DNS community is the ‘cross-pollination’ between the healthcare disciplines that occurs at these events. I was privileged to be able to interview a few of the instructors and attendees before I left Phoenix and those interviews will be posted in this and the next entry here. To learn more about the DNS program, go to www.RehabPS.com and register for their limited seating courses to be on the cutting edge of the new Rehab Renaissance.
Alena Kobesova, MD is a familiar face to US DNS attendees as she works as a lead instructor for the Prague School, but also functions eloquently as Pavel Kolar’s translator. Here, Dr. Kobesova speaks about the DNS perspective on the diaphragm’s role in respiration and stabilization.
Dr. Craig Liebenson has played a pivotal role in the last 20 years in gaining a US audience for the work of the Prague School. He has hosted Vladimir Janda and Dr. Kolar many times, and was the main organizer for this event in Phoenix at API. Here he discusses open chain vs. closed chain exercises in the DNS program.
Clare Frank, DPT is one of the primary DNS instructors in the US programs and was co-author of Assessment and Treatment of Muscle Imbalances: the Janda Approach. Here she discusses the misconceptions of many about the importance of reflex points and reflex locomotion in the DNS system and also explains the influence of Janda’s work on the DNS point of view.
Charlie Weingroff, DPT is a Renaissance Man! After 12 years in the NBA as the head strength and conditioning coach for the Philadelphia 76ers, he added the doctorate to his PT degree and went to work as lead PT and trainer for the US Marine Corps Special Operations. Charlie’s work is highly influenced by his involvement with FMS, DNS and recently RKC. He has been pivotal in arguing for the inclusion of qualified personal trainers in the rehab continuum and his DVDs, Training = Rehab, Rehab = Training help show trainers how to integrate with rehab clinicians like physical therapists, chiropractors and medical physicians. Plainly put, if you’re a personal trainer, and you don’t have these DVDs, you’re behind the curve. Get them and take your seat at the table with those of us who are part of the Rehab Renaissance and let’s make a difference in public health! To help foster that movement, Charlie has also been very helpful in providing direction and guidance on MyRehabExercise.com. This library of functional corrective exercise videos is only $9.99 per month and will help clinicians and trainers teach excellent rehab exercises to patients and clients. Trial it for only $1 for 30 days, no contract or obligation. Check out the information video to the right of the page here.
Exciting new things are now on Dr. Weingroff’s horizon and he took a moment from his busy schedule to chat about some of the buzz topics in the literature and the blogosphere recently.
Things we covered in the interview include:
- Is there a place in the rehab or training program for crunches and other loaded spine flexion exercise?
- Is ISCRS the definitive, multi-disciplinary community of rehab and fitness professionals?
- How does Dynamic Neuromuscular Stabilization influence the TGU, powerlifting, etc.?
- Why should you be keeping your chin tucked if you’re lifting heavy?
- How does Joint by Joint Expanded view elbow pain?
- Recent conversation between Charlie and Pavel Tsatsouline of RKC.
To listen to the interview or to download the podcast, click on the Arrow below
If you’d like to catch more from Dr. Weingroff, check out this link to a webinar at StrengthCoach.com. StrengthCoach.com is a great resource of training info like this and you can once again get CE credits for listening to this broadcasts.
For those of you interested in joining a community of rehab/performance oriented professionals such as chiropractors, physical therapists, personal trainers, athletic trainers and body workers, join the International Society of Clinical Rehabilitation Specialists (ISCRS).
And as a parting shot, here’s Charlie under the bar…love the massive vertical leap at the end. Thanks again Charlie!!
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.