Heartburn (aka acid reflux) is caused when stomach acid leaves the stomach and enters the esophagus.

It would seem quite natural that patients with gastric reflux should be on antacids or proton pump inhibitors like Prilosec.  Antacids and proton pump inhibitors decrease the acid content in the stomach and therefore the esophagus.  The hope is that the symptoms will be managed successfully and the long term chance for catastrophic problems diminish.  Antacids and proton pump inhibitors like Prilosec, have been widely popularized.  You can find anatacids in local supermarkets, drug stores, pharmacies, in local pantries and in medicine cabinets across the United States.  Proton pump inhibitors are just a phone call or office visit away.  Doctors routinely recommend these drugs.  Patients reach for these drugs before, during and after meals.   This is the stereotype with antacids and proton pump inhibitors.  This is the myth!

Do these look familiar? Not a good short or long term solution!

Many doctors have never stopped and asked the question, “Why?”  Let’s reiterate that the what (“What do I have?”) is not in question.  The why question (“Why do I have reflux?”) is.  You see, if the emphasis is on the what (“What do I have?”) you will have a tendency to ignore the why (“Why do I have reflux?”).  Doctors and patients will then focus attention on the what (stomach acid) instead of the reason why stomach acid travels to the wrong area of the body.

Your going to be shocked when you hear this so please sit down.   The patient has gastric reflux because they have too little stomach acid!  Sounds counter intuitive doesn’t it?   Let me state it again, the cause for most reflux is too little acid.  Now you are thinking:  1). Why is there a whole industry built on decreasing stomach acid? 2). Why do thse drugs help me? 3). Why did my doctor recommend them?   4). What solution is there to my problem?

A majority of the gastric reflux is caused by lack of stomach acid.  Officially, this is termed hypochlorhydria (hypo = decreased & chlorhyrdria = acid).  Stomach acid is necessary to begin the digestive process, help in B12 regulation, as well as protect the stomach against infection (1, 4, 5, 6, 7).  The acid content helps in protein breakdown.   Protein breakdown is critical to obtaining the necessary nutrients from food.  Food does not successfully get broken down without sufficient acid.  If food does not get broken down, it will remain in the stomach and intestines and rot.  This rotten mess eventually causes a backlog in the stomach and squeezes food and acid out of the stomach and into the esophagus.  This problem would not occur if acid was contained in the stomach and would not occur if the acidic content in the stomach was sufficient to breakdown food in the first place.

A whole industry developed on a false pretense.  This false pretense is that stomach acid is bad for you.  Stomach acid is not bad for you when it is contained in the stomach.  Your stomach is uniquely suited to contain stomach acid.  When stomach acid leaves the stomach, problems can occur.  This thought process led to the development of antacids and proton pump inhibitors.  Antacids and proton pump inhibitors change the acidic content in the stomach so when there is reflux into the esophagus it is not as caustic.  Antacids and proton pump inhibitors do help, but they are treating the effect not the cause.

Admit it, you want the easy answer. Admit it, you want convenience. The easy, convenient answer that you want to believe is that too much stomach acid causes reflux (heartburn). Unfortunately, this is not the truth!

This is the case with many medications and the medical/pharmaceutical industry in general.  The pharmaceutical industry has sold doctors and patients on symptoms, not processes.  Think about it.  We have all these drugs to treat symptom X, symptom Y, or symptom Z.  Do you have depression?  Take medication X.  Do you have anxiety?  Take medication Y.  Do you have fatigue?  Take this medication or take this energy drink to fix the problem.  What these medications fail to treat is the reason why the problem is there to begin with.

Pharmaceutical companies have exerted a huge influence on how medicine is practiced in the United States.   They influence doctors very early in their careers and even in medical school on symptoms, disease, and medications to treat symptoms.   Pharmaceutical companies also influence patients.  Routinely their commercials try to link symptoms to drugs and even encourage patients to ask their doctors specifically for drugs.  This linear thinking that you have a symptom, you should be treated with this specific prescription medication impairs the diagnostic process.  Doctors and patients are less inclined to want to know why a problem is there, because they have the what (symptom) and a method to treat the what (medication).  Unfortunately, linear thinking comes with consequences.

Getting back to antacids and proton pump inhibitors, these drugs treat symptoms not causes.  A patient on antacids and proton pump inhibitors will forever need to be on antacids because the cause (decreased  acid) is never dealt with.  Pharmaceutical companies have now created life long customers and created an industry based on symptoms and false pretenses. So, the solution of increasing the acidic content of the stomach, although counterintuitive is sound, as it is a method to fix the problem for good.

Further throwing a curveball into the diagnostic process is the presence of infection (1, 2, 3, 4, 5, 6, 7, 8).  The stomach can be infected with a nasty, resistant bug called Helicobacter pylori (H. Pylori). This bug is so resistant that it thrives in the presence of stomach acid and can even change the normal acidic environment of the stomach from a strong acid to a weak acid or even close to the pH of  a base (remember 8th grade chemistry class here).  Acidic pH is less than 7.  Neutral is 7.  Basic pH is greater than 7. The linkage between H. Pylori and reflux is controversial at this point, but we do know that H. Pylori affects the stomach and acidic content of the stomach (2, 3). The “superbug” can change the pH from near 1 to 4 or higher.  Antacids and proton pump inhibitors do not fix infection.  In fact, decreasing the acidic content of the stomach is a known mechanism of inviting H. Pylori into the gut (1, 5, 6).  Creating drugs that successfully treats the symptoms associated with reflux like proton pump inhibitors and antacids impairs the diagnostic process necessary to find out if H. Pylori has colonized the gut.  By the way, H. Pylori has been known to be linked to nasty things like stomach ulcers and stomach cancer (4, 8).   Studies have noted a 6 fold increase in stomach cancer with log term H. Pylori infection (4).  Masking the symptoms with an antacid or proton pump inhibitor may allow for this nasty superbug to colonize the gut for years increasing the risk for serious problems later in life.  Additionally, proton pump inhibitors are notorious for decreasing vitamin B12, particularly in the elderly (1).  Vitamin B12 is needed for protection of the nervous system as well as prevention against certain types of anemias (9).

Nasty little bug!

Another reason for reflux can be due to food sensitivities.  If you are eating foods that your body has a sensitivity to, this can lead to reflux conditions.  The reason for this, once again, is your stomach is not properly breaking down these foods.  Your body detects these foods as foreign invaders.  This creates an irritation and symptoms that can present themselves as reflux.

Food sensitivities can cause reflux/heartburn too.

Summary

Confused yet?  Our summary will clear it up for you.  The key points of this post are:

1).  After the question what (“What do I have?” – Gastric Reflux/Heartburn), always ask the question why (“Why do I have this problem?”). 

Just one brand of digestive enzyme with acid that will help break down food properly reducing the need for antacids and proton pump inhibitors

2). Consider a digestive enzyme with acidic supplementation if you have reflux.  Digestive enzymes with acidic supplementation increases acidic content in the stomach to digest food properly decreasing the chance for backwash into the esophagus.

3).  Longstanding use of antacids and proton pump inhibitors has consequences including infection and vitamin deficiency. 

4).  Consider a H. Pylori test or food sensitivity test if you’ve had chronic reflux or had long term use of prescription or over the counter medication for reflux.

*** Please Note:  We routinely evaluate and treat patients at our office for reflux.  We have non-invasive testing strategies for the “superbug”,  H. Pylori, as well as testing for food sensitivities.  We have natural and conservative treatments available for reflux and for “superbug” infections. For more info, call us at 708-532-CFIM (2346). ***

References

1. http://www.ncbi.nlm.nih.gov/pubmed/18924330

2. http://www.ncbi.nlm.nih.gov/pubmed/11478751

3. http://www.ncbi.nlm.nih.gov/pubmed/10466875

4. http://www.ncbi.nlm.nih.gov/pubmed/12047266

5. http://www.ncbi.nlm.nih.gov/pubmed/11403543

6. http://www.ncbi.nlm.nih.gov/pubmed/10627752

7. http://www.ncbi.nlm.nih.gov/pubmed/9626024

8. http://en.wikipedia.org/wiki/Helicobacter_pylori

9). http://en.wikipedia.org/wiki/Vitamin_B12

The weather is warming up and out comes the endurance athletes (runners, bikers and triathletes) again.  The old aches and pains re-emerge.  An endurance athlete that can’t participate in their sport anymore is kind of like a dog owner that’s lost their dog (depressed).  For more on that analogy, click here (http://thecfim.com/rest-fixes-bad-mechanics).

I wonder if they miss us as much as we miss them/

We will see posts on social media asking for treatment advice.  All the advice comes with good intent.  The intent is to help someone hurting.  The intent is to  keep the injured person active.  The intent is to keep the injured person enjoying something that they are passionate about (endurance sports). Some advice is better than others. Some advice is just flat out wrong.  Some advice is just humorous.

One of the topics sure to generate buzz is chronic IT Band Syndrome.  The IT Band is a dense band of connective (soft) tissue that runs down the outside part of the thigh.  It runs from the hip and crosses the knee joint.  There is even fascial (soft tissue) attachments to the pelvis.  The band meshes with fibers of the tensor fascia latae (TFL), gluteus maximus and gluteus medius (1).  The IT Band is a powerful stabilizer of the entire lower extremity.  The purpose of the band is to proper rigid support to the thigh bone (femur) during gait (walking) and to stabilize the shin bone (tibia) from excessive internal rotation (1).  The band has dense and strong fascial connections directly into the femur (thigh bone).

IT Band

Recent research has investigated the role and anatomy of the IT Band and fascia.  Research has recently found that dense connective tissue and fascia is extremely difficult to mobilize or deform with hands on manual therapies (2, 3).  We  have found that fascia and the IT Band is so dense and so strong that it is extremely resistant to stretching and other soft tissue mobilization techniques (Active Release, Graston, Sound Assisted Soft Tissue Mobilization, Gua Sha, Myofascial Release, Foam Rolling etc.).   For those that don’t know, the above mentioned soft tissue techniques attempt to reduce soft tissue adhesion and soft tissue restriction.

Soft tissues (muscles, tendons, ligaments, fascia, etc.) respond to repeated chronic stress by tightening/restricting/adhering.  Repeated stress overloads the tissues causing an energy crisis.  The cells and tissues cannot receive sufficient oxygen, cannot exchange waste products, and have trouble producing energy to fuel cellular processes.  The net result is the tissue shortens/tightens/restricts/adheres.  It would seem logical that methods to undo this process as those mentioned above would work for Chronic IT Band Syndrome; however, consider that the IT Band is extremely resistant to lengthening.  Undesirable results such as tissue tearing and inflammation would occur in order to create sufficient force to permanently deform/loosen/mobilize these tissues (3).

In fact, the majority of the benefit with soft tissue mobilization and lengthening methods are probably neurological (3).  In other words, the tissues of the IT Band aren’t lengthening like in other tissues, but the tolerance towards aggressive soft tissue methods increases.  The nervous system learns to adapt to the demands placed on the tissue.  We see this routinely with stretching.  The tissue lengthens during the stretch but length gains recede (1, 5, 6).  Research has consistently shown that the benefits of stretching are mostly neurological with the person adapting to the stretch (7).  Tissue lengthening via stretching is short lived (1, 5, 6).    Athletes with chronic IT Band Syndrome have probably tried aggressive soft tissue work and stretching and had some success due to neurological adaptations, but this hasn’t been enough to resolve the problem because the IT Band resists lengthening.

Look familiar? This stretch hasn’t worked too well either. Probably because the IT Band resists lengthening!

One of the best evidence based tools for chronic IT Band Syndrome is  glut strengthening.  Glut strengthening has been shown to be an effective tool by reducing pain in 22/24 runners given a 6 week program of hip abductor/glut exercises (8).  Additionally, the pain reduction correlated to improved strength of the glut/hip abductor muscles.    Eccentric control over the hip is a known mechanism to improve mechanics, increase tolerance to activities, increase tolerance to sports, improve sports performance and reduce pain.  Many of the chronic cases have tried some form of glut strengthening, to some benefit, but have not yet overcome the chronic pain.

Good entry level glut exercises that haven’t worked to this point either.

So here’s the deal, the patients have come to our office already having tried many of the “best” treatments available including soft tissue mobilization methods and glut strengthening with limited or no benefit.   What could they possibly receive in our office that would help?  What additionally could we offer?  Do they have to live with this chronic pain?

The best thing we could offer at this point is a fresh perspective.  Maybe the problem isn’t tight/adhered/restricted tissues.  Maybe the problem isn’t a strength problem either.  Maybe the problem is something else that no one has checked to this point.  Maybe the problem is the knee joint itself has lost the normal ability to go from one movement (flexion) to another (extension).

The knee joint looses the ability to extend (straighten), especially the last little bit (terminal extension).  As the joint looses the ability to straighten, the muscles around the joint respond by increasing tone (tightening).  The increased tone produces mechanical irritation at the knee that we perceive to be IT Band Syndrome based on the location of the pain, but the reason for this is completely different than muscle adhesions, restricted tissues, muscle weakness or muscle imbalances.  Increased tone to the IT Band with reports of knee pain is therefore an effect, with the cause being loss of normal joint motion, particularly terminal knee extension.  Restoring terminal knee extension is critical to reducing the pain, restoring function and getting the athlete quickly and safely back into their endurance sport.

If you’ve been hampered by a chronic case of IT Band Syndrome and have missed time away from your sport, please call our office at 708-532-CFIM (2346) for a consult.  A simple motion and exercise maybe all that’s needed to get you back running or biking or running/biking/swimming again.  ”Why Put Off Feeling Good?”

References

1. Michaud, T.C.  (2011) Human Locomotion: The conservative management of gait-related disorders. Newton, Mass:          Newton Biomechanics

2. http://www.ncbi.nlm.nih.gov/pubmed/18723456

3. http://www.rolfingtaichilondon.com/ARTICLES/fascial%20plasticity%20schleip.pdf

4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2614693/

5. http://www.ncbi.nlm.nih.gov/pubmed/20075147

6. http://www.ncbi.nlm.nih.gov/pubmed/10862546

7. http://www.ncbi.nlm.nih.gov/pubmed/16476913

8. http://www.ncbi.nlm.nih.gov/pubmed/10959926

The jokes are endless with poop!

Stool tests are especially helpful for many chronic health and chronic digestive conditions:  1). Gas 2). Bloating 3). Skin Problems (Urticaria, Hives, Eczema, Rashes, Psoriasis, Acne and others) 4). Crohn’s 5). Colitis 6). Irritable Bowel Syndrome 7). Chronic Headaches 8). Fibromyalgia 9). Chronic Myofascial Pain Syndrome 10). Adrenal Fatigue & Fatigue Syndrome 11). Constipation 12). Diarrhea 13). Chronic Pain.  Many doctors don’t routinely recommend this test despite many of the above mentioned conditions filling the waiting rooms of physicians across the US.  We don’t know why the test recommendation is not made.  Maybe the reason is the “poop perception.”  We don’t like to talk about this topic (poop) to begin with and especially not with our doctors.  Maybe the reason is because traditional medical training undervalues the importance of stool tests except in third world countries.  News flash, parasites, bad bacteria and other problems exist in this country as well and are not just a problem of third world countries.  Maybe it’s because it requires a little more work on the patient’s part to follow through with the test.  Either way they are PHYSICIANS!  They are supposed to recommend the best course of action regardless of the stereotypes.  The patient may not choose that recommendation, but they need to here it is the right course of action.

There is so much information and so much benefit  to getting a snapshot of the internal environment of the body, especially in chronic, unresolved health conditions.  You can’t find this info in blood, saliva or urine.

Our stool tests screen for:

1). Good Bacteria Vs. Bad Bacteria Levels in the Gut

2). Parasites

3). Harmful (Pathogenic) Bacteria

4). Yeast/Fungi/Mold

5). Digestive Markers

6).  Supplementation and Medication Strategies to Eliminate Microbes (Bad Bacteria, Parasites, Yeast, Fungi, Mold, etc.)

Too many of these guys are a real problem.

At this point you are thinking, so what happens when we capture the sample?  The test results typically come back within 2-3 weeks.   The test comes with a comprehensive print out of results.  We give the patient a copy for their records.  We then discuss the best treatment recommendations.  All our recommendations are patient specific based on the test results and patient preferences.  Some patients prefer natural and conservative treatment options which could include supplementation, dietary modification and nutrition/health counseling.  Some patients prefer referral back to a primary care physician or to a gastroenterologist for medical interventions.  Some patients need time to “digest” the results (pun definitely intended here).  Some patients prefer to do nothing with the results.  It’s always the patient’s choice here.  The bottom line is that THEY NOW HAVE A REASON FOR CHRONIC POOR HEALTH!  We just learned a heck of a lot about the  patient from their poop.

Dr. Thomas wrote an excellent piece on neck tension and exercise.  The pearl of the post is a simple way of gauging the amount of tension in the upper shoulders and neck while exercising, with a way to reduce the tension.  This simple method can help your athletic performance in the gym and on the playing field.  Check out his blog here (http://motionforlife.blogspot.com/2013/04/simplecheck-for-neck-tension-tension-in.html).

Please no yelling and no ruffling of feathers!

For those that don’t know, there is a huge battle raging across the nation.  This is a “turf war” for who controls the right to practice  needle insertion techniques (aka acupuncture).  Traditional Chinese medicine practitioners and acupuncturists have issues with physicians (medical doctors, osteopaths and chiropractors) practicing needle insertion techniques.  Physicians have issues with physical therapists practicing needle insertion techniques (aka acupuncture).  Physical therapists have issues with traditional Chinese medicine practitioners and acupuncturists attempting to limit them from practicing needle insertion techniques.  Some state practice laws for health care practitioners are conflicting.  Some state practice laws are ambiguous.  These debates could go on and on, but we won’t bore you with all the details.

Before we get too far into this debate, let’s define terms.  Acupuncture is the insertion of small, fine needles into the body

Acupuncture = Insertion of fine, thin needles to produce a desired therapeutic effect

to stimulate a therapeutic effect such as treating disease or reducing pain (1)  .  The concept was originally based on Chinese theories, but has been adapted into several styles (Japanese, Korean, Vietnamese, Western, Biomedical, and Dry Needling).  Each style has their own spin on theory and mechanisms behind why acupuncture works, but all styles have one overwhelming similarity and that is needle insertion to generate a desired therapeutic effect.  

Therapeutic effects from acupuncture may be reduction of pain, restoration of qi (“energy”) flow, decreasing global or local nervous system sensitivity, stimulating blood flow to an injured area,  reduction of trigger points (sensitive and tender areas within muscles and fascia), balancing of hormones and neurohormones, improving the homeostatic conditions of the body, inducing the body’s self healing mechanism,  etc.   Nowhere in this definition of acupuncture (needle insertion to stimulate a therapeutic effect) does it say who owns the right to practice it.  We all do.  Duly licensed and credentialed practitioners all own the right to practice needle insertion techniques (aka acupuncture).

Patients across the United States are demanding acupuncture.  Patients’ own personal views, opinions and biases ultimately select which style of acupuncture is best for them.  Practitioners should be able to respect that.  After all, the reason why every health care practitioner has the ability to practice their craft is because of the patient.  The patient has a medical or health care need to be addressed.  They select the health care practitioner.  The patient then empowers and entrusts the health care practitioner to help them.  Without patients and without a demand we wouldn’t be having this discussion.

Which style works best?  That depends.  All styles work.  They work for the right patient, at the right time, with the right practitioner.  If any one of those three (right time, right patient, right practitioner) isn’t present, then the chances for a successful outcome go down for any acupuncture practitioner or patient.

We all recognize and respect the lineage.  We recognize that the ancient Chinese were the first to use this healing modality.  We respect that there had to be a therapeutic benefit from needle insertion (aka acupuncture) or else it wouldn’t have lasted this long nor would there be a “turf war” over who owns the right to practice this modality.

Now that everything is out in the open let’s get beyond the needles, energy flow, trigger points and politics.  The common ground that needle insertion (aka acupuncture) practitioners have is that they seek to stimulate a therapeutic effect in the body.  Call the explanation of that effect what you will (Qi, innate intelligence, balancing of neurohormones, restoring homeostasis, gate control theory of pain, reducing global or local sensitivity, reducing trigger points, etc.)  The explanation (“why”) depends on the practitioner and patient.  The “what” (inserting needles into the skin for therapeutic benefit) is still the same.  The best way of looking at this is the coin analogy.   One side of the coin is Eastern Acupuncture  and the other side is Western Acupuncture.

Let’s dig a little deeper into some of the proposed mechanisms of how acupuncture work.  On initial examination, it would appear that there are no similarities.  On deeper inspection, similarities exist.  This is what we mean by going beyond needles, energy flow, trigger points or politics.

1. Energy Flow:  Traditional Chinese acupuncture explains the therapeutic effects of acupuncture by aligning the patient’s qi (energy).  When qi flows properly through the body, health is maintained.  When qi is interrupted, disease can set in.  Western theory explains the energy concept a little different.  Lesions in tissues induced by needle insertion send signals towards the spinal cord and brain.  These lesions trigger a cascade of electrochemical reactions in the body.  The electrochemical reactions can be observed with tools such functional MRI of the brain, PET scans and EMG/NCV (2).  We have clearly seen with our high priced imaging tools specific areas of the brain and spinal cord process these electrochemical signals differently when needles are inserted into the skin and subcutaneous tissues.  Think of the body as a battery.  A battery uses electrochemical reactions to create energy for a car to run, to power a flashlight, or keep your laptop powered on an airplane.  The body uses electrochemical reactions to make its normal processes work.  Maybe, just maybe these electrochemical reactions are the “qi” or energy flow that the ancient Chinese stumbled upon thousands of years ago.

Energy Pathways

2. Body Wall Relationships:  The ancient Chinese formed meridians.  Meridians are channels of energy that tie specifically to an organ (liver, gallbladder, spleen, kidney, etc.).  The thought was that the internal organs could be treated via tapping into the various points on the body.   A respected acupuncture historian, Professor Long-xiang Huang of the Acupuncture Research Institute of the Academy of Traditional Chinese Medicine in Beijing, states, “The most valuable discovery in acupuncture theory is the interrelatedness between the parts of the body surface, and between the parts of the body surface and the internal organs.  These are the immortal pearls of classic acupuncture.” (2)  Western medicine has its own take on the relationship between the body wall and the internal organs.  Western medicine instructs on the concept of referred pain.  In particular, organs of the body can refer pain to local or distant sites on the body wall (skin and subcutaneous tissues).  Some examples include the heart and gallbladder.  Patients experiencing a heart attack may complain of pain down the L arm as well as pain in the neck and jaw area.  Gallbladder referred pain from gallstones or other gallbladder pathology can occur in between the shoulder blades or into the tip of the R shoulder.  Please keep in mind the location of the pain is far away from the actual site of the problem.  The ancient Chinese were on to this long before Western medicine even existed, but both styles had a methodology for explaining the same concept of referred pain.  Sounding more and more like 2 sides of the same coin now isn’t it?

Areas of Referred Pain

3. Homeostatic Processes:   The ancient Chinese forwarded the concept of yin and yang.  This refers to the balance that exists in nature.  Normal processes are interrupted without balance.   These opposing forces should balance each other other out in nature and in the patient.  Perhaps, the best explanation for some of the mechanisms of Western style acupuncture is the methodology that acupuncture taps into the body’s homeostatic, self regulatory processes.  Needle induced lesions into the tissues stimulates many of the survival mechanisms of the body including the self healing mechanisms, restoring homeostasis, facilitating repair mechanisms such as antiinflammatory reaction, tissue regeneration and pain modulation (2).  These processes involves the nervous system, cardiovascular system, endocrine system and immune system.    Our body is always in a flux of breaking down vs. building up (catabolic vs. anabolic states).  This is analogous to yin and yang.  We need to have both states working well in our body to have homeostasis.  What you have are 2 concepts from 2 areas of the world that explain the similar idea of balance.

4. System of Diagnosis and Treatments:  Both Eastern and Western styles of acupuncture have a process to assess patients.  The Eastern style uses a patient history (question and answer session), tongue diagnosis, pulse diagnosis and palpation to find areas of the body for needle insertion.  The Western style uses a patient history, physical exam procedures, palpation, and other Western based methodologies (movement analysis, anatomy, neurology) to select points for needle insertion.  Both styles favor the assessment and the reassessment to guide the practitioner in the process of acupuncture point selection and obtaining a favorable outcome for the patient.   The main point we are trying to make here is that a system is in place in both styles to assess, reassess and modify treatment if needed.  These are similar concepts from 2 different parts of the world.   Are you getting the initial reference to the same coin with 2 different sides now?

5. Ah Shi – The Trigger Point: Classical Chinese theory recognizes the presence of Ah Shi points.  These points are sensitive and tender areas of tissue that are palpable.  These areas often presented as rigid or semi rigid bands.  The Western school of thought classifies these areas as trigger points.  Effectively, the Chinese discovered the concept of the trigger point and a created a system to treat it (acupuncture/acupressure)  long before the rest of the world.  Western science further advanced the concept of the trigger point with the classic work of Travell & Simons’ – Myofascial Pain and Dysfunction: The Trigger Point Manual (http://www.amazon.com/Travell-Simons-Myofascial-Pain-Dysfunction/dp/0683307711/ref=sr_1_3?ie=UTF8&qid=1365243415&sr=8-3&keywords=travel+simons+trigger+point).   Where you live in the world and how you think explain what you call it (Ah Shi or Trigger Point), but the end result is the same and that is that both styles identified the issue (sensitized, tender bands of connective tissue) and have a methodology to treat that tissue (needle insertion).  Just one more example of the point we are trying to make.

Got a “migraine?” Maybe it’s just trigger point referral from the neck into the temples, top of the head or above the eyes

We hope you’ve enjoyed this post.  Our intent was not to ruffle any feathers.  Please don’t send us any hate mail.  Feel free to share if you’re passionate on this subject.  Our intent was to critically discuss the methods, mechanisms and theories of acupuncture.  Our intent is to show that whatever form of  needle insertion that you the practitioner or you the patient choose, it can have huge affects on the body.  Clearly acupuncture works or else it wouldn’t have lasted this long and we wouldn’t be having this discussion right now.  Let’s get beyond the needles, energy flow, trigger points or politics.

*** Note:  If this post interested you and you are curious to know if our style of acupuncture (biomedical acupuncture) is for you, give us a ring at 708-532-CFIM (2346).  We use this style for general health conditions, chronic pain, acute pain,  headaches, fibromyalgia, stress relaxation, trigger points, myofascial pain and many other problems. ***

References

1).  http://www.merriam-webster.com/medlineplus/acupuncture

2). Ma, Y.T, Ma, M. & Cho, Z.H.  2005. Biomedical Acupuncture for Pain Management: An Integrative Approach

St. Louis: Elsevier.

Tacky=Yes! Humorous=Absolutely!

Think about it.  How many times do you get up from a chair, couch, sofa or bench over the course of the day?  How long do you sit over the course of a day?  How long do you sleep?  If you get up from a chair 30+ times a day, that’s 30 times it could be helping or harming you.  If you sit for 6 hours a day, that’s 6 hours that could increase or decrease your back pain.  If you sleep 8 hours per night, that’s 1/3 of the day that could produce or reduce your pain.  Again, simple recommendations can have profound effects.  Get the point now.

It seems counter intuitive, doesn’t it, that the patient willingly and voluntarily would reproduce their own pain by simply rolling incorrectly.  It seems even more suspect that they would perform this maneuver and recreate pain 10-20 times daily.  Even more shocking is that patients who have come for a second opinion have not been told that simple movements like this could help or harm them.  They haven’t been taught how to sit, stand, sleep or transition.   We don’t know why they haven’t been taught this.  Maybe their clinicians disregard these strategies as irrelevant?  Maybe their clinicians don’t know the proper postures and positions to be assumed during these movements?  Maybe the focus of care is directed elsewhere?

Let’s just focus in this blog on the transition from lying on your back or stomach to get into the sidelying position.  From there please check out our previous blog on how to hip hinge to get up from a bed or chair (http://thecfim.com/spine-sparing-strategies-hip-hinging).

If you watch a patient with back pain roll first thing in the morning what you will often find is twisting.  The twisting occurs from segments of the spine that are the most mobile.   Picture a hinge and think about it for a second.  A door swings open about a hinge.  The hinge is the mobile part to which the rest of the door moves around.  The same concept occurs in the spine.  The most mobile parts of the spine are the hinges to which the rest of the body moves around.  These areas of the spine are typically the lowest parts of the back.  These areas should be the most stable segments, not the most mobile segments.  When you move around with a hinge, the joints and soft tissues receive abnormal wear and tear that eventually contribute to degenerative changes and in some cases pain.  Remember though, this all happened because of a hinge (a segment of the spine with abnormal, increased motion).  The hinge was there long before the pain occurred.  Fix the hinge and you’ve got a great chance at improving the back pain.

Ouch! Too much rotation in the lower back!  Definitely a hinge segment(s) here!

One method to reduce the irritation and pain caused by the hinge is teaching patients how to roll.  Our best analogy is to “log roll.”  This method fixes the rib cage, torso and pelvis together while the patient rolls all in one motion over onto their side.  Disassociating this connection (rib cage, torso and pelvis) allows the patient to twist, creates the aforementioned hinge and can contribute to back pain.  So fixing the rib cage, torso and pelvis together and “log rolling” will temporarily reduce the pain first thing in the morning and anytime the patient gets up from a lying position.  A simple maneuver of moving as 1 unit by “log rolling” has profound effects.  When repeated over and over correctly, this maneuver reduces rotational loads to the spine (reducing back pain) and becomes a great core training tool.

Everything looks great. Ribcage, torso and pelvis are all aligned. No rotation here.

It’s funny to see the face of a patient that rolls over  improperly when corrected.  Initially, they’ll report high pain levels and show facial grimmacing.  When corrected, they’ll giggle, laugh, smile or sigh in relief and then immediately turn to you bewildered how something so simple could help them.

A little tacky, but you get the point.

Moments later you can see the light turn on.   They get a little upset that no one taught them this.  They get upset that a simple movement when executed improperly can be their undoing.  Sometimes, they are more mad than they are excited that they’ve now found an instantaneous method to reduce their back pain first thing in the morning and at night.  This process could be averted if there was just a little more recognition that simple strategies can have profound effects.

The light is on and they are mad as hell!

1). You get up fatigued.

Do some of these look familiar?

2). You rush to get out the door to work.

3). You have a nutrient deficient breakfast of fast food (McDonald’s) or doughnuts.

4). You fight traffic or have a long commute to work.

5). You need several cups of coffee, pop, caffeinated tea, energy drinks or other stimulants to make it through a day of work.

6). You have a nutrient deficient lunch of fast food or you pack a lunch of highly processed foods.

7). You feel the urge to nap in the middle of the day after lunch.

8).  You need more stimulants to prop yourself up later in the day.

9). You rush home from work either with traffic or a long commute.

10). You quickly check with your family before you rush to make and eat dinner or you rush to take the family out for a fast food diner that is nutritionally deficient.

11).  You can’t shut off your mind later in the day as the stress of work lingers.

12).  You prepare yourself and family for bed, but routinely can’t stop checking email or playing with your electronic devices (IPad, ITouch, IPhone, Droid, Tablet Device, Flat Screen TV’s, etc.).

13). You finally get to bed later than you should and can’t fall asleep for hours.

14). Your sleep is restless and not satisfying.

15). You repeat this scenario the next morning and day after day for years.

If this sounds like you, you more than likely suffer from some form of ADRENAL FATIGUE SYNDROME.  One of the

experts on the subject, James Wilson (ND, DC, PhD), estimates in his book Adrenal Fatigue: The 21st Century Stress

Syndrome (http://www.adrenalfatigue.org/adrenal-fatigue-the-21st-century-stress-syndrome-book) that “80% of adult Americans suffer some level of adrenal fatigue at some time during their life, yet it remains one of the most under-diagnosed illnesses in the US.”  To make matters worse, many physicians don’t even know that this condition exists.  It was never discussed as part of their standard medical training.

The Adrenal Fatigue “Bible.” An excellent patient-friendly read for those interested on the topic.

Our body has a normal response to stress.  The normal stress response impacts multiple organs in the body.  That response works well when running from a tiger or lion, but we don’t do that too often in our society.  We live in a society of repeated small stressors (see the average day list above) that tax our body’s capacity to respond to stress.  Gradually, repeated stress leads to chronic disease (heart disease, stroke, anxiety/depression, Parkinson’s, Alzheimers, cancer, high blood pressure, insomnia, diabetes, etc.).  Chronic disease is by far the most challenging health care issue that Americans face.  Chronic disease is costly.  Despite these comments, chronic disease is mostly preventable with awareness and lifestyle modification including identifying and managing stress.

You want some of this to occur if you are being chased by a tiger or lion. You don’t want this to occur without imminent harm present as chronic stress leads to chronic disease.

Adrenal Fatigue presents with vague signs and symptoms:

•Difficulty getting up in the morning

•Fatigue not relieved by sleep

•Craving salty foods, sugary foods or stimulants (caffeine)

•Lack of energy

•Increased effort to do every day tasks

•Decreased sex drive

•Decreased ability to handle stress

•Increased time to recover from illness, injury or trauma

•Mild depression

•Increased PMS

•Increased symptoms with skipped meals

•Less focused thoughts

•Hard time remembering things

•Decreased tolerance

•Don’t wake up till 10:00 AM or later

•Afternoon (after lunch) “blues”

•Feel better after evening meal

•Decreased productivity

•Light headed when getting up

*** Key Tip Off: Chronic respiratory infections with a longer recovery period ***

Only when you put the pieces together is the puzzle complete.  These vague signs and symptoms individually mean nothing, but when clustered together lead to high suspicion of adrenal fatigue syndrome.  Definitive diagnosis and treatment occurs with a six step process:  1). Step 1: Comprehensive Questionnaire 2). Step 2: Comprehensive Exam (Physical Exam, Orthopedic Exam, Neurological Exam, Vascular Exam, Special Tests) 3). Step 3: Specialty Lab Testing As Needed (Saliva Hormone, Blood and Urine) 4). Step 4: Formulate a Specific Treatment Plan 5). Step 5: Implement Patient Specific Recommendations 6). Step 6: Re-evaluate.

Saliva testing requires the patient to spit into test tubes several times over the course of the day (morning, afternoon, evening).  We can also capture times of the day when a person is extremely energetic and times of the day when a person is very fatigued.  The patient releases tissues and cells from their mouth into the tube.  The cells are where the reactions take place, not the bloodstream.  This test has the added advantage of giving us a more accurate picture of cortisol levels.  Cortisol is a stress hormone.  One of the key actions of cortisol is to assist with energy (energy creation, energy storage, energy utilization).  Clinically, we see 2 scenarios: 1).  Dips in cortisol and energy at the wrong parts of the day 2). Spikes in cortisol and energy at the wrong parts of the day.

Just Say No To Energy Drinks

We identify and treat this condition routinely in our office.  We’ve had success because we focus on more than just the symptom of fatigue.  We focus on the reasons why the fatigue is there in the first place including blood sugar regulation issues, hormonal imbalances, lifestyle modification to reduce stress, etc.  By the way, in the past several weeks we’ve heard of a local doctor recommending energy drinks to fatigued patients.  As if that’s the real problem?  Is the patient really deficient in energy drinks because they don’t consume enough of them?  Isn’t it funny that the more caffeinated beverages and energy drinks we consume the more fatigued as a society we become?  Please give us a call at 708-532-CFIM (2346) if fatigue is a concern so you don’t fall prey to the energy drink recommendation that could rob you further of the energy you crave.

One of the niches of our clinic is the endurance athlete.   We treat runners, cyclists, swimmers, and triathletes.  Treating the endurance athlete is something that we enjoy and something we do rather well.  Endurance athletes are by nature highly motivated people that genuinely enjoy their sport.  When injured, a big part of their life is missing.  It’s kind of like losing your dog!

Can’t imagine how empty our life would be if our dogs ran away…Kind of like an endurance athlete that can’t compete.

We hear all the time about endurance athletes that either voluntarily choose to rest or are told by their doctors/rehab professionals (athletic trainers, physical therapists, coaches, etc.) to rest when injured.  Most athletes will accept this recommendation without question, but should you accept the rest recommendation?  Pause for a moment and let it sink in.  Now reassess and continue reading.  We are challenging a huge stereotype here.  We know it.  We know there will be backlash when challenging a huge stereotype, but please hear our argument first.

REST NEVER FIXES BAD MECHANICS!  Many of the injuries that we treat in endurance athletes are due to repetitive bad mechanics.  When you rest, you NEVER  fix the mechanics that led to the injury.  You essentially “mask” the problem.  When you continue with your sport as most endurance athletes do, the pain may be gone as the overload to the tissue has been reduced temporarily, but the bad mechanics are still there.  These mechanics can again lead to future problems.   Would you rather fix the problem right the first time or have it recur?  

This is analogous to having the check engine light pop up on the dashboard of your car.  You can either find the reason why the the light turned on or just turn the light off without fixing the problem and hope for the best.

Finding out why this turned on is much better than turning it off and hoping everything will work out

Many doctors and rehab professionals (athletic trainers, physical therapists, coaches, etc. ) don’t understand this concept either.  Routinely, we get consulted as a second opinion for local endurance athletes.  We hear the rest recommendation far too much.  We prefer to fix the bad mechanics and have you modify the training temporarily, but not completely cease the activity (unless imminent harm can be caused).  This allows us to test whether the improved mechanics are reducing the insult to the tissues.  Besides, you’ve worked way too long, way too hard, and invested way too much of your time and resources to simply stop what you are doing altogether.

Let’s back up for a second and discuss our thought process.  First, formulate a hypothesis.  Our hypothesis is that the repetitive motion injury (plantar fasciitis, tennis elbow, shin splints, carpal tunnel syndrome, swimmer’s shoulder,  rotator cuff tendonitis/tendonosis, biceps tendonitis/tendonosis, triceps tendonitis/tendonosis, jumper’s knee, patellar tendonitis/tendonosis, posterior tibial tendonitis/tendonosis, etc.)  occurred  due to repetitive bad mechanics that causes overload to the affected & painful tissues.  The injuries that we are referring to aren’t from major trauma.  They are from “micro trauma” meaning small insults from bad mechanics over time contributed to the injury.  Second, test the hypothesis.  Let’s try some form of mechanical treatment (manipulations, soft tissue mobilization, therapeutic exercise, etc.) while having the athlete continue a modified training program.  Third, analyze the effect of the treatment on the given activity.  Did the mechanics in question improve to observation?  Did the athlete’s tolerance to their sport increase?  Did the pain level during and after the activity decrease?  Fourth, reassess whether you keep the current hypothesis or the need to modify it.  We can save you weeks to months of time away from training by methodically using this process.  We can logically find the problem and fix it by using this process.  We can save you months to years of suffering from the same recurring injury by doing it right the first time.

Technically, the recommendation for rest could fit the above listed paradigm, but when you question the athletes that have come into our practice it seems like it’s a knee jerk reaction from their rehab professional.  If it hurts, then don’t do it seems to be the logic.  The 4 problems with this sentiment is that:

1. The athlete has “lost their dog”:  They can’t perform something that they enjoy which significantly improves the quality of their life.  Part of their identity is missing.  Sounds like they’ve “lost their dog.”  If you get this recommendation for rest, it shows that the rehab professional doesn’t understand the mindset of the endurance athlete.  Understanding the mindset of the athlete  is critical in treating and managing athletes in endurance sports.

2). Re-injury is likely: Rest never fixed the mechanics that led to injury leaving open a window for re-aggravation.

3). It’s a knee jerk reaction:  The rehab professional went through years of school and training to come to the conclusion that rest is the only answer.  If this is the case, then why go to a doctor or rehab professional in the first place and what good is their years of training.  So much for the “sports medicine” training too right?

Many doctors or rehab professionals then send the athletes out the door one after the other while charging a $25 copay and $200+ evaluation fee.  Kind of sounds like a mill and a knee jerk reaction so that they can get more patients into their office without fixing the problem.  Trust us, it’s much harder and takes much longer to find the problem and correct it.  It takes a special skill set and mindset to identify and correct the overloading mechanics.  It takes outstanding communication with the patient to convey this message and a willing patient to follow through with the recommendation that rest is not the answer.   It’s much easier and lazier to tell someone to rest.  By the way, you could get paid the same amount regardless of how short or long you will spend with the athlete;  so, telling someone to rest can be a business move just as much as a patient care move as you can process more patients through the clinic by conducting a half ass*d evaluation and coming to the immediate conclusion that the athlete needs more rest while lining up the next patient in the next room to do the same thing.  Don’t be fooled.

If you see this guy run! These guys are out there people.

4). Hurt may not equal harm:  If you give the patient a corrective exercise to fix their mechanics, they might be sore.  Their soreness could be entirely different (quality, intensity, location, etc.) than the pain from the activity.  You won’t know unless you have them test the activity.  You may find that corrective exercise is working because the soreness is entirely different than the pain they came to the office with.  For example, the patient comes to the office with IT Band Syndrome (pain on the outside part of the knee) and the doctor or rehab professional gives them glut (but) strengthening exercise.  The patient may be sore in the glutes following the session and sore in the glutes when attempting to run, but the pain is in a different location, the quality (ache/soreness) is different that the stabbing knee pain from the IT Band syndrome, and the intensity of pain is different.  The initial problem and pain is better but a new soreness crept up.  The athlete could misconceive that they are getting worse when in fact this could actually mean that progress is being made.  You won’t know unless you have them continue with the activity (running) while you attempt to fix the mechanics (glut strengthening).   Take a look at a previous blog post on Rules for Corrective Exercise for more info (http://thecfim.com/http:/www.thecfim.com/rules-corrective-exercise).

After reading all this, you’re now thinking there must be a time when rest is good right?  The answer is yes, rest is good when appropriately timed and when used to prevent imminent harm.  If the athlete has a stress fracture or suspected stress fracture, please rest or perform “relative rest.”  Relative rest is switching the endurance exercise from one type to another to avoid overloading the affected tissues.  Switch from running to swimming or biking  in the case of a tibial (shin) stress fracture.  Switch from swimming to biking in the case of rotator cuff tendonitis/tendonosis that is leading to a degenerative rotator cuff tear.   If the athlete is severely over trained, modify their training programs to incorporate rest so that severe fatigue, sickness and injury is avoided.  These scenarios fit the category of appropriately timed rest to prevent imminent harm.  These scenarios do not fit the mantra that rest never fixes bad mechanics.

In summary, we hope you’ve read and enjoyed this post.  We are challenging an established stereotype.  Our view may not be popular, but it has served our endurance athletes well.  Telling an endurance athlete to stop can be counter intuitive and counter productive.  It’s like telling them their dog ran away.  Fix the problem by fixing their mechanics.  Rest never does that.

The last couple weeks we’ve had an influx of patients to our office that had concerns about corrective exercises.  Stereotypes and misconceptions exist in patients and even in rehab professionals (medical doctors, osteopaths, chiropractors, physical therapists, occupational therapists, athletic trainers, strength and conditioning coaches, personal trainers, etc.).  To be fair, the  problem could be the practitioner, the patient or both.  The point here is that we (rehab professionals and patients) need to be on the same page.  We (rehab professionals & patients) need a mutual understanding of the simple rules of corrective exercise.

1. Comprehensive Evaluation & Re-evaluation(s) are Needed:  By definition, a corrective exercise is a specific

exercise recommended to address a specific deficit or accomplish a specific goal.  Patients may ask, “So what is that

One component of an evaluation and re-evaluation is a movement assessment

deficit or what is that goal?”.   The basis for all corrective exercise is a comprehensive evaluation and re-evaluation.  Both must be done. The evaluation helps the rehab professional determine baselines.   The re-evaluation helps determine progress or lack there of.  The evaluation and re-evaluation(s) must be specific to the patient or athlete.  If the patient climbs stairs at work, it would be wise to test stair climbing in the assessment.  If the patient is a runner, it would be wise to incorporate a gait (walking) evaluation. The evaluation and re-evaluation(s) are the perfect time to discuss mutual goals, reasonable expectations and time frame.  The professional and patient must be on the same page.

A re-evaluation is required.  You can’t judge whether the exercise was successful unless a re-evaluation is scheduled.  This re-evaluation should take place days to weeks later.  Patients may expect that the corrective exercise should work immediately; however, often it is repetition over days to weeks that get the job done.   By the way, practice DOES NOT make perfect.  PERFECT PRACTICE MAKES PERFECT!  Re-evaluation(s) should take place several times to tweak the exercise(s) and coach form otherwise the patient will be “practicing” instead of performing “perfect practice.”   There is a scientific theory that is takes approximately 10,000 hours or 10,000 repetitions to be truly proficient in something.  Ten thousand times of practice won’t do it.  Ten thousand times of perfect practice will.  The point here is follow up is required so that the patient and rehab professional don’t waste time, money or energy.  

2.  Corrective Exercises Aren’t Easy:  We live in a society where the motto, “Your Way Right Away” applies.  We expect an immediate result.  We want immediate gratification.  We want things simple and handed to us.  It is very easy to take a pill (pain medication, anti-inflammatory, muscle relaxer, etc.) for your problem.  Its also very easy to take an elevator up and down when you only have to walk 2 floors of steps.  Maybe that’s why chronic disease (heart disease, diabetes, cancer, stroke, etc.) is at an all time high, because we don’t want to work to be healthy.  We want health handed to us.    So, telling a patient that exercise is the solution to their problems and the exercise may need to be repeated over and over again several times daily is a very foreign concept to some.  Patients also have a hard time grasping that when they have surgery, it can take months or longer to recover. “You mean that I won’t just walk off the table and feel just fine?”   It doesn’t work like that and neither does corrective exercise.

These thoughts lead into the topic of chemical versus mechanical pain.  If you are receiving a corrective exercise, you should have some component of a mechanical problem.  The only cure for a mechanical problem is to identify what those bad mechanics are and correct them via mechanical treatments.  Mechanical treatments include corrective exercises.   Chemical treatments like pain medication, anti-inflammatory drugs, muscle relaxers, etc. won’t fix bad mechanics.  The solution of taking a pill won’t work.  Patients will need to be educated on the importance of these exercises on their outcome.  A different mindset is needed.

Corrected exercises should load or unload the tissues appropriately.  The goal is to challenge the brain and the affected tissues to make adaptations to the demand placed on them by the exercise.  If an exercise is too easy, it may not be accomplishing the intended purpose.  Likewise if an exercise is too difficult, it may not be accomplishing the intended purpose.  Patients need to train at the most challenging level possible with perfect form and without compensation.  This isn’t easy!  Training movements in this fashion requires time, patience and attention to detail. It may also require a patient to move outside their comfort zone.   Patients may need to try movements or activities that are completely foreign to them.   It takes time to master these movements and activities.  Your body may not be used to the movements and soreness may occur.   Again, corrective exercises aren’t easy!

3. Soreness & Discomfort is Possible:  This is an interesting topic because many rehab professionals don’t broach this too well and many patients don’t understand this either.  Corrective exercise may make you sore.  They may be uncomfortable; however, hurt does not equal harm.  Hurt is the now or short term response.  Harm is the later or long term response.

Let’s put this into proper context.  Corrective exercise can do three things:  1). Make You Better 2). Do Nothing 3). Make You Worse.  What category do you think soreness and discomfort fit into?  Take a pause here and think for a second.  You’d be wrong to think that soreness and discomfort solely fits into the make you worse category.  You’d also be wrong if you thought that soreness and discomfort solely fits into the do nothing category.  Your wrong if you think soreness and discomfort fits into the make you better category.  You are right if you said that soreness and discomfort fits into all 3 categories.  It is true that some corrective exercises feel great.  The opposite is also true that some corrective exercises may make you sore or uncomfortable if performed right.   The key here is context.   One of the best ways of thinking about what is good and bad for you is the Traffic Light Analogy used in the McKenzie Method.

Recommending corrective exercises is like looking at a traffic light

Green Light  - Continue With Exercise Recommendations

During Exercise:  A). Pain and soreness may decrease, stay the same or increase temporarily. B). Pain may stay in the same location or centralize (moves closer to the joint where it originated) C). Baselines (range of motion, activity tolerance, strength, movement quality, etc.) may improve or stay the same.

After Exercise:  A). Pain and soreness decrease B). Pain stays in the same location or centralizes (moves closer to the joint where it originated from) C).  Baselines are improved.

It is important to note that peripheral pain (pain referred further away from the spine or into longer or wider area) is

The best way to describe centralization and peripheralization is to compare it to a thermometer

more challenging than central pain.  Think of this as a thermometer where peripheral pain is “warmer” on the thermometer meaning the condition is “hotter” having a larger referral zone.  Movements that reduce the peripheral or larger area of pain into a smaller area or back to the joint where the problem originated from are “colder” on the thermometer.  Please note that when moving pain from the peripheral or larger areas to central or smaller areas the patient may experience a temporary increase of central pain.  Context is important here as the patient may feel they are “worsening” when in fact the exact opposite is true.  Pain moved from a larger location or peripheral location into a smaller or central location which research supports as showing an excellent prognosis for a rapid and outstanding outcome.  Context and timing are important.  Even a great exercise (“green light”) may produce some discomfort and soreness during the movement but the long term response (the “after response”) confers a great chance for success.

Yellow Light  - Proceed With Caution If Needed

During Exercise:  A). Pain and soreness may be produced or increased temporarily.  B). Pain may stay in the same location or be  peripheralized  C). Baselines may not change or may worsen temporarily

After Exercise: A). Pain and soreness go back towards pretesting levels B). Pain returns to pretesting location.  C). Baselines remained the same as pretest levels (no improvement or no worsening).

In the yellow light scenario, clinicians and patients both scratch their heads.  Rehab professionals must now consider making changes.  Does the patient need a new exercise?  Does the rehab professional need to progress the force (more repetitions, more pressure during the reps, etc.)?  Do they need to change the direction of the force as in adding lateral, rotational or combinations of movements?  The patient needs to know that this is a trial and error process that requires evaluation and re-evaluation often times taking several visits to confirm an initial diagnosis and taking several visits to determine how to load the tissue properly.  The patient needs to know that although they hurt during the exercise, the pain did not peripheralize (get warmer or worse  on the thermometer), did not stay at high levels later on, and their baselines (range of motion, strength, movement quality, activity tolerance, etc.) did not change.  In essence, the patient is no better or no worse.  The rehab professional found out through testing that corrective exercise recommendations may need alteration.

A yellow light exercise may actually be a good thing as it could serve as a comparison for later testing.  For example, in the case of a back pain patient that needs to be able to lift 50 lbs from chair to ground levels.  2 sets of 10 reps increased the pan from 2/10 to 5/10 during. Pain remained in the same location and baselines remained the same at the time of testing.  The patient returned to our office 2 days later with pain levels a 2/10 with pain in the same location and no change in baselines.  We now know that we can comfortably progress the lifting exercise to his tolerance because the “after” responses (pain intensity, pain location, baselines) showed no changes.  Hurt does not equal harm.  This patient made progress during those 2 sessions despite a temporary increase in symptoms at the time of lifting.   He gained the confidence that he could perform a work related activity with minimal to no long term repercussions.  He learned that hurt did not equal harm.

Red Light  - Stop Immediately

During Exercise:  A). Pain and soreness is produced and increased during  exercise B). Pain location stays the same and worsens or peripheralizes during testing  C). Baselines get worse during testing

After Exercise:  A). Pain and soreness remains elevated above pretesting levels B). Pain location remains the same and worsened or remains peripheralized C). Baselines remain worse.

This is the stop category.  Pain and soreness are produced but there is not a therapeutic benefit from doing this.  Red lights require an open dialogue from the doctor and patient.  Was the exercise recommendation wrong?  Did the patient perform the exercise incorrectly?  Is the diagnosis accurate?  Is the patient engaging in activities that put them at risk?

4. Must Be Done Routinely in the Right Dosage and Direction:  The purpose of corrective exercise is to correct repetitive bad mechanics.  The only way those mechanics improve and remain that way are repetitively doing the right thing in the right dosage and direction.  Overzealous patients may do too much.  Overzealous doctors may recommend too much.    If the dosage too is too much, progress can be impeded.  If the dosage is too little, progress can be impeded.  Evaluation and re-evaluation(s) are key to determine the right dosage. Think of this as medication, where the “medicine” (exercise) is adjusted based on the patient response.  It may take more.  It may take less.  The recommendation may not need to change.  The only way to know is a series of evaluation and re-evaluation(s).

5. Additional Issues May Need To Be Addressed, Peel Backs & Progressions:  Sometimes during the course of treatment secondary issues come up and need to be addressed.  Some things that come to mind: 1).  A green light exercise may turn into a yellow light.  2). Activities, postures or positions that create fear and inducing avoidance may need to be addressed. 3). A clinician may have missed a site of referred pain. 4).  A patient may have  a new chief complaint.  5). The corrective exercise may need to be peeled back or progressed.  As you’ve figured out, corrective exercise is a process.  No shortcuts exist.  Evaluation and re-evaluation(s) need to be performed with the patient’s goals guiding the process and corrective exercise recommendations.  Please be aware that rarely do we make it through treatment without some form of modification.  Exercises may need to be progressed, regressed (peeled back), changed altogether or additional issues need to be addressed.  In our experience, this is the norm rather than the exception to the rule.

6. Corrective Exercises May or May Not Directly Work On Your Site of Pain:  The site of pain may not the source of the problem.  Patients think linearly.  It hurts me here, so that must be the source of the problem.  Rehab professionals often get fooled too.  The site of pain may not be the reason for pain.  Dysfunction in one area of the body can lead to problems elsewhere.  For example, we had a patient that came with a diagnosis of tennis elbow from her primary care physician.  Tennis elbow is pain in the lateral elbow at the soft tissue attachment of muscles that control wrist movement.  The location of pain fit, but the reasons why the pain was there didn’t fit.  Many of the standard test

for tennis elbow weren’t too provocative.  We decided to do a quick screen of the neck and found that certain neck movements could both exacerbate and reduce the pain.  In this case, the pain at the elbow was referred from the neck.  If we just focused on the elbow, we would have wasted time, energy and money.  Her corrective exercises were the specific neck exercises that reduced the referred pain.  We didn’t touch the site of pain to get her better.

All these areas can refer pain into the lateral epicondyle of the elbow

2 weeks later we had another case of tennis elbow.  This patient had a more classic history and exam findings.  We ruled out the neck first and then tested the elbow.  Our primary area to treat was the elbow.  We recommended a specific exercise to improve the strength of the wrist extensors (http://well.blogs.nytimes.com/2009/08/25/phys-ed-an-easy-fix-for-tennis-elbow/) and several weeks later as anticipated she was discharged without pain and full function.

A good local exercise for tennis elbow

The point here is that the assessment guides exercise recommendations.  Don’t be surprised if the site we treat isn’t the site of your pain.  If we are right, you’ll thank us for the time, energy and money saved.

7. KISS – KEEP IT SIMPLE “SWEETHEART”:  Patients are looking for answers.  Rehab professionals are trying their best to answer those questions.  Sometimes in our zeal, we give patients more than what they need.  Sometimes more is not better in the realm of corrective exercise.  Sometimes less is better.  Less is better because it helps test a hypothesis.  The hypothesis is that 1 specific corrective exercise can help improve the outcome.  We are looking for a cause-effect relationship with the cause (doing the exercise) generating the effect (a change in the clinical case).  We want to try to reduce or remove all the other variables (additional exercises, provocative activities, etc.) so that we can obtain the necessary information on whether it was the exercise or something else that caused the change.  Less is better because if you give patients several exercises it undermines the value of following the most important recommendation.   Less is better because the more  corrective exercises you give them greater the chance they have of performing the exercise or exercises improperly.  Less is better because  it allows for better compliance by reducing the amount of time needed to perform their program.  Less is just better!

What we find is that simple recommendations have profound effects.  Simple recommendations of how to sit, stand, sleep and transition (sit-stand, lay down-rolling over and rolling over to sitting up) are often left out.  Think about it.  How many times do you get up from a chair, couch, sofa or bench over the course of the day?  How long do you sit over the course of a day?  How long do you sleep?  If you get up from a chair 30+ times a day, that’s 30 times it could be helping or harming you.  If you sit for 6 hours a day, that’s 6 hours that could increase or decrease your back pain.  If you sleep 8 hours per night, that’s 1/3 of the day that could produce or reduce your pain.  Again, simple recommendations can have profound effects.  Get the point now.  Let’s just focus on 1 of these areas for sake of convenience, sit-stand.

If you watch a patient with back pain get up from a chair, they often initiate the motion by flexing their low back and rocking forward.  This is the exact mechanism that lead to their back pain, forward flexion/forward rocking.  It seems counter intuitive doesn’t it that the patient willingly and voluntarily would reproduce their own pain by simple getting up from a chair improperly.  It seems even more suspect that they would perform this maneuver of forward flexion and rocking 30+ times daily.  Even more shocking is that patients who have come for a second opinion have not been told that simple movements like this could help or harm them.  They haven’t been taught how to sit, stand, sleep or transition.   We don’t know why they haven’t been taught this.  Maybe their clinicians disregard these strategies as irrelevant?  Maybe their clinicians don’t know the proper postures and positions to be assumed during these movements?  Maybe the focus of care is directed elsewhere?

Regardless, a simple maneuver of moving through the hips (hip hinging) and lower body does have profound effects.  When repeated over and over correctly, this maneuver reduces compressive loads to the spine (reducing back pain) and becomes a great lower extremity training tool to build up the butt (glut) muscles.  The butt muscles are HUGE stabilizers of not only the back and hips but the entire lower extremity including the knee, foot & ankle.

Protective muscles for the spine and entire lower body

It’s funny to see the face of a patient that moves improperly during the sit-stand transition when corrected.  Initially, they’ll report high pain levels and show facial grimmacing.

When corrected, they’ll giggle, laugh, smile or sigh in relief and then immediately turn to you bewildered how something so simple could help them.

A little tacky, but you get the point.

Moments later you can see the light turn on.   They get a little upset that no one taught them this.  They get upset that a simple movement when executed improperly can be their undoing.  Sometimes, they are more mad than they are excited that they’ve now found an instantaneous method to reduce their back pain during the day.  This process could be averted if there was just a little more recognition that simple strategies can have profound effects.

The light is on and they are mad as hell!