Category — Corrective Exercise

Foam rolling has become a popular modality used both in warm ups and as a method to assist in recovery from hard training. Little is known about how foam rolling works but the main goal and reason for its use is to decrease muscular tension and improve range of motion, similar to the way in which massage is often used.

A recent study in the Journal of Strength and Conditioning Research by MacDonald and colleagues aimed to understand the effects of an acute bout of foam rolling on knee joint range of motion and muscular force.

Methods

The subjects, 11 healthy recreational resistance training males (ages 18-25) participated in the study and were asked to report to the lab on four different occasions, separated by 24-48hrs of rest, each occasion focusing on either baseline measurements or a foam rolling intervention.

• Test Day 1 – A Range of Motion (ROM) assessment was followed by 2min of rest and then the assessment was taken again at 2min and 10min post rest
• Test Day 2 – Muscle force production was measured using maximal voluntary contraction (MVC) and evoked muscle activation and was followed by 2min of rest and then the assessment was taken again at 2min and 10min post rest
• Test Day 3 – A Range of Motion (ROM) assessment followed by 2min of foam rolling and then the assessment was taken again at 2min and 10min post foam rolling
• Test Day 4 – Muscle force production was measured using maximal voluntary contraction (MVC) and evoked muscle activation and was followed by 2min of foam rolling and then the assessment was taken again at 2min and 10min post foam rolling

All test conditions were preceded by a 5min bike warm up.

Foam Rolling Protocol

Foam rolling was performed on a foam roller constructed from hollow PVC pipe surrounded by a neoprene foam of 1cm thickness. The subjects were taught to roll their quadriceps from origin to insertion for 1min. They then rested for 30sec and then rolled for another minute – 2minutes of total foam rolling.

Some Key Findings

• Foam rolling did not produce significant differences in either voluntary or evoked muscular force output
• Acute foam rolling significantly increased knee flexion ROM at both 2 and 10min post foam rolling

Practical Application

The increase in joint ROM is a promising finding of this study as improving joint mobility is often a goal of warming up for activity/training.  Additionally, athletes who lack joint ROM in certain areas may find foam rolling to be a beneficial modality to help assist with limitations. While most associate foam rolling with relaxation its application has been used significantly in warm ups over the past several years and if often followed with some form of stretching activity or mobility activity where the muscles are taken through a range of motion, held of a second or two, and then brought back to their starting position, this sequence repeating for several repetitions. As I discussed in a blog article 3 years ago, Stretching As A Part of the Warm Up: Can We Make It Work?, when these two modalities are followed by a more active/dynamic warm up that prepares the nervous system there does not seem to be the performance decrement that most research notes when stretching is immediately followed by a test of maximal power.

Interestingly there was not a decrease in force output of the muscle, as one would assume that foam rolling would cause a greater amount of relaxation in the tissue similar to the findings of other massage research (Wiktorsson-Moller, et al). McKechnie, et al. did find a similar result – improved ankle joint ROM without a decrease in power output – using a 3 minute massage treatment of either Petrissage or Tapotement to the calf musculature.

I do wonder if some of this has to do with the fact that in massage research the subjects are at the mercy of the therapist and the therapist can adjust their touch and depth of pressure to “meet the subject’s nervous system where it is at” rather than trying to force things and go too deep, too fast, and hoping that this produces the results they would like. Perhaps the density of the foam roller in this study was too hard or maybe the subjects leaned too aggressively into the foam roller and really pushed, as many do with the “no pain, no gain” approach that is often taken with foam rolling? Or perhaps there is just something about human touch that allows for more relaxation, comfort, and an ease of tension? Additionally, time may be an issue when it comes to decreasing muscular force, as indicated in Wiktorsson-Moller et al’s study which used a 7-15min massage protocol administered by a therapist and showed a decrease in quadriceps isometric force and hamstring isokinetic force. Additionally, Crane et al have shown that longer periods of time on one area (10min on the quadriceps alone) produced a positive influence on inflammation following an intense bout of exercise (HERE is my write up of that paper from last year).

The time piece is a critical element, in my opinion, as everyone adapts at different rates and their nervous systems ability to adapt may be related to a variety of factors – fitness level, stress, perception, nutrition/hydration, etc – which is why I find it odd that some therapists will perform a few passes on a muscle and expect things to be normalized in 2min. I believe that to be truly comprehensive you need to take a holistic approach, think big picture, and consider how you want to influence more than just a few muscles within a treatment session. So, perhaps the subjects in the study just needed more time in order to see a favorable result in terms of decreased muscle force output?

Wrapping up

This was an interesting study and shows some promise that foam rolling may have something beneficial to offer besides the anecdotal praises that it currently enjoys. We still don’t know how it exactly works, what it exactly does, and we don’t know all of the things that rolling your muscles on a piece of PVC may actually influence within the body. Regardless, it seems to do something and if that something improves a client’s ability to perform or feel better and does not have negative effects on health then I am all in!

patrick
patrick@optimumsportsperformance.com

I recently had the opportunity to attend two courses from the Postural Restoration Institute – Myokinematic Restoration and Pelvis Restoration.

The basic premise of the system that is taught by the Postural Restoration Institute is that the body is asymmetrical and, in order to optimize human function, we need to try and restore as much symmetry needed in order to have balanced reciprocal function (while appreciating the asymmetries of the body and acknowledging that we will not change them). Basically, we have a liver on the right side, the crural attachments on the right lumbar vertebrae are thicker than on the left, the right lung has three lobes while the left lung has two, etc (we can go on and on with these sorts of asymmetries), thus we tend to orient ourselves over the right leg which places us in a pattern of right mid stance, referred to as a Left AIC.

Left AIC

The main pattern discussed and the backbone of their system is the Left AIC (short for Anterior Interior Chain). The Anterior Interior Chain is a chain of muscles which connect the torso to the knee and consists of the diaphragm, psoas, iliacus, TFL, vastus lateralis, and biceps femoris. We have two AICs in the body, one on both sides, however the Left AIC tends to be more dysfunctional than the right. Additionally, individuals may find themselves in other patterns but underneath those patterns is always a Left AIC due to the natural asymmetry of the human body as discussed above.

In this Left AIC pattern the main findings include things such as:

• Anterior pelvic rotation on the left
• Increased hamstring length, tension, and tone on the left
• Pelvis rotated to the right side
• Right ischial tuberosity sitting lower than the left
• Left femoral head is not received as well by the acetabulum as the right is
• Right side is more in a position of adduction, internal rotation, and extension
• Left side is more in a position of abduction, external rotation, and flexion
• Decreased trunk rotation to the right side
• Decreased right apical expansion and left diaphragm opposition
• Increased left rib flare (poor left zone of apposition)
• Decreased left mediastinum expansion

All of these things are actually “normal” and are due to the natural asymmetry we all posses; however, some people – with proper training – can control this position better than others and thus perform at a higher level. Other individuals may not control this position well and end up compensating in such a way that they themselves in a position of PEC – short for posterior exterior chain – where they exhibit many of the things above on both sides, bilaterally.

PEC

The Posterior Exterior Chain consists of our latissimus dorsi, QL, Posterior Intercostals, Serratus Posterior, and Ilicostalis Lumborum.

Being in a PEC position is characterized by attributes such as:

• Stiff looking gait mechanics
• Bilateral hyperlordosis
• Both hips in a position of flexion, external rotation, and abduction (people tend to walk with their toes out)
• Butt gripping (tight gluteus maximus bilaterally)
• Flat and stiff thoracic spine
• Bilateral compression of the SI-joints
• Sagital plane dominant individuals who have lost optimal function in the frontal and transverse planes
• Pelvic floor in a descended position, bilaterally, causing the muscles of the pelvic outlet to be stiff and inflexible leading to issues with constipation
• Poor zone of apposition bilaterally
• In a state of hyperinflation, lacking the ability to exhale and allow the diaphragm to dome up

Goal of PRI

The goal is to use a battery of tests to determine what sort of position the individual is in and then what type of control they actually have. To do this, the Postural Restoration Institute has a number of tests – some are tests of position while others are tests of function – to help understand the person in front of you and make informed decisions about exercise prescription. To take it a step further, the tests are also used, in an algorithmic sort of way, to differentiate between individuals displaying one of these patterns versus individuals displaying one of these patterns but considered to be “pathological” and displaying a certain amount of ligament laxity – referred to as a  Patho Left AIC or Patho PEC. This information further drives exercise choices as those that are pathological may need a different set of exercises or exercise regression to ensure they are performing the movements in the right position and feeling the correct muscles working.

PRI can get extensive with the exercises as they have over 100 in their catalog although there are a few exercises that would be considered “big money” exercises for each of the possible patterns one may be in. If you understand the patterns and use the testing approach effectively you will understand which structures/muscles you are looking to facilitate and which you are looking to inhibit and can pretty much use any permutation of the “big money” exercises as long as they achieve the intended goal and improve the testing when you go to re-test, which should be done frequently to know if what you are doing is working and if you are helping re-position the individual.

Similarities with other Approaches

Whether it is PRI or any other system (DNS, FMS/SFMA, Janda, Osteopathic approaches, etc) there should be some similarities in the message as all of the systems are dealing with the human body. It is the similarities between all these things that I care the most about because it helps me see the big picture and be aware of more things when I look at an individual.

One thing PRI does is go heavy into the anatomy of the body with regard to how muscles function and they do a good job of differentiating between which attachments are moving and which are stable. For example, we can have femoral acetabular rotation (a femur rotating on a pelvis) and we can have acetabular femoral rotation (a pelvis rotating over a femur). This is similar to the idea of punctum fixum and punctum mobile in the DNS methodology. While some may consider looking at things like this as being a bit excessive, I truly believe that understanding these concepts can be extremely helpful to understanding function and programming exercise.

PRI has a large focus on breathing and talks extensively about the “zone of apposition” (ZOA) – the aspect of the diaphragm that apposes the chest wall. The ZOA is influenced by the position of the rib cage. When the rib cage is flared upward, ribs in external rotation, the ZOA is not in a position to function and allow for proper diaphragmatic breathing. In DNS this same position is referred to as on “open scissor position” where the rib cage is angled upward and the pelvis is angled downward (anteriorly tilted), causing increased erector spinae tone and a lengthened abdominal wall which posses a high amount of tension. Individuals with an inefficient ZOA or the open scissor tend to be more upper chest breathers, stuck in a hyperinflated position, and recruit the neck musculature (SCM, Scalenes, Levator, Upper Trap) to assist with respiration.

I see a bit of an Osteopathic influence in the PRI system which is cool because I have read a lot of Osteopathic texts. The whole approach to re-positioning the pelvis in PRI is similar to self Muscle Energy Techniques where the individual is using muscular force to drive the pelvis into a certain position (which is great because you don’t have to put your hands on the person for these techniques to be useful and can allow the client to feel empowered by performing the activities on their own).  The interesting thing is that the common pattern in PRI, the Left AIC, is opposite that of the common pattern in Wolf Schamberger’s text, The Malalignment Syndrome, which states that everything is happening on the right side (right pelvis in anterior rotation rather than the left) and this is similar to some of the other Osteopathic things I have read in the past. The instructor gave some answers as to why this is and in the end it comes down to a visualization thing as most of the other approaches were looking at anatomical landmarks with the person either supine or prone on the table and because of this they can be flawed as anatomical landmarks can change when someone lies down on the table (Schamberger does talk about some of these changes in his book on pgs. 43-44). Thus, PRI recommends tests of position and function rather than static tests of anatomical landmarks. The instructor of the course also talked about how the Muscle Energy Techniques used in those Osteopathic approaches achieved a similar result a lot of the time, even though their understanding of the position was incorrect, because they were activating the correct muscles to drive the pelvis into the correction position. Who’s right? Who’s wrong? Does it really matter? At the end of the day the goal is to make a positive improvement and if you did something that had a positive influence, even if your explanation or thought process wasn’t 100% correct, I don’t know if it matters all that much. Another thing that I would add is that the Osteopaths discussed breathing and the autonomic nervous system pretty extensively so perhaps their holistic approach achieved many of the similar results that those using PRI achieve. Regardless, there are a lot of similarities between these two approaches to pelvic movement and correction which is interesting to look at and be aware of. The Osteopathic similarities with PRI also show up with regard to the discussion on the diaphragm and viscera as the Osteopathic techniques on visceral manual therapy/massage discuss similar relationships between the diaphragm and the liver on the right side and the diaphragm and the spleen on the left.

Finally, the PRI patterns, particularly the PEC, is where I see some similarities to Janda and Travell and Simons. This pattern is very similar in appearance and function to the Upper and Lower Crossed Patterns from Janda. Many of the muscles which are discussed as needing inhibition in PRI (and in Janda) are also those that are either needed to keep us upright throughout the day (anti-gravity muscles) or those that help assist with respiration when the diaphragm is not functioning properly. So, it makes sense that things you want to inhibit in some of these patterns are the lumbar erectors (we live in a world of extension) and the glutes (particularly in the PEC pattern). Additionally, the vastus lateralis is a muscle which is part of the Anterior Interior Chain and one that can function significantly in these patterns to help provide stability. It comes as no surprise that this muscle is also one that is frequently riddled with trigger points, particularly in the lateral side under the IT-band (which lies over the vastus lateralis, biceps femoris, and is influenced by the TFL – all three muscles which are part of the Anterior Interior Chain).

Integration & Conclusions

I have enjoyed the courses thus far and look forward to taking more of them. I think that they underpin things I already do in practice very nicely and can fit well within the FMS model as another tool that can positively impact the results in some of the tests. Also, I have found that when there are a number of things going wrong in the FMS using some of the PRI approach can be helpful to reposition the individual and then retest to see what sort of improvements have been made. I have been using some of the exercises in my own warm ups and in the warm ups of a few people I have been working with (based on what we have found in testing) and the results have been very positive.

I don’t think any one system has all the answers and I don’t think any system will ever have all the answers as there are so many things that influence the body and so many things we don’t quite know. What I will say is that I really enjoy when different philosophies line up and share many similarities. The PRI approach is one more tool in the toolbox to help understand human function and their courses are some of the most fun I have had during a con ed course in a pretty long time.

patrick
patrick@optimumsportsperformance.com

The role of the Fitness Coach (or Strength & Conditioning Coach, or Coach of Physical Preparation, or whatever you want to call it) is to raise the athletes’ level of fitness to its highest potential in preparation for sports competition. With a variety of movement based rehabilitation courses available these days, many fitness coaches have gravitated towards them as a way to “branch out” and extend their services. However, I feel that, in the process of doing so, we (as a profession) have gotten away from developing fundamental fitness qualities in our athletes, as we have gotten so bogged down with focusing on only one aspect of their development – movement.

I certainly will never (ever) discourage a coach from taking more courses and advancing their learning and I do believe that it is important for coaches to educate themselves on various rehabilitation methods to allow themselves to effectively communicate with the medical staff and be a part of the solution when an athlete is injured or returning from injury. Just as I would encourage medical professionals to learn about basic conditioning methods so they too can discuss with the fitness coach and not hold athletes back, which can sometimes happen, because they don’t understand the possibilities of training when injured or preparing the body for sport when returning from injury. Additionally, I do feel that there is something that strength coaches may be able to gain from a number of these courses in terms of how they see things within an athletes movement, which may lead them to select a certain exercise over another.

However, many Fitness Coaches have gotten so far away from developing the fundamentals of fitness and focusing on movement that they actually have athletes who may move decently but lack basic fitness competency. What ends up happening is that as fatigue sets in during the competition the athletes “good movement” begins to break down and the athlete ends up in this vicious cycle of injury, rehab, competition, injury, rehab, competition, etc…This was part of the reason Charlie Weingroff, Joel Jamieson, and myself got together to record our Strength in Motion DVD – to show coaches how to combine a movement based approach with concepts that are essential to being a great strength coach and developing well-rounded athletes.

Requisite Competencies

Requisite competencies are the aspects of training that I feel are essential to develop in all athletes. These are the fundamentals. The basics. If you focus on only one area or aspect of these requisite competencies then you end up with a deficient athlete who lacks a well-rounded fitness base. The three requisite competencies, as I see it, are:

1. Movement Competency
2. Work Capacity Competency
3. Locomotion Competency

Movement Competency

Many fitness coaches live here and do a good job with this (as I stated earlier). In this area the key goal is progress the athlete to a level where they can move efficiently and fluidly in all three planes of motion, they have appropriate joint ranges of motion to satisfy the needs and demands of their sport, and they have basic competency of fundamental exercises – push, pull, squat, hinge, and lunge.

Work Capacity Competency

Work capacity is essential to general preparation for sport. This competency should be focused on developing a very robust level of fitness that can tolerate high amounts of work and allow the individual to be resilient when it comes to recovering from hard training or competition. Having a well developed aerobic system is a good starting point and how you develop this will depend on the methods you choose and, to a certain extent, the sport the athlete is training for – sports specific work capacity being the ultimate goal.

Locomotion Competency

Movement competency deals with how an individual performs movement statically while locomotion competency deals with how well the person propels them-self through space (how they loco-mote). One can loco-mote in a variety of ways and they should all be developed – crawling, walking, skipping, running, and jumping (plyometrics, hopping, leaping, bounding, etc). The goal of locomotion competency is to develop athletes so that they have a very large catalog of locomotion options that they can call upon when participating in sport.

Wrapping up

These are the fundamentals. They are not sexy by any means but they are an essential starting point when planning training. The role of the Fitness Coach should be to enhance all of these qualities and set the athlete up for success in their given sport. Focusing on only one component of the above requisite competencies ends up leaving athlete deficient and preventing them from attaining their highest potential. I know most coaches will read this and think, “I already know all that. We already do this stuff!”. But I would encourage you to really look at your program and think long and hard about whether or not you are doing the basics well. I think many believe that they do these things (when in fact they may only do one or two of them well) but they may be leaving some things on the table when it comes to developing requisite competencies.

patrick@optimumsportsperformance.com

A few months ago, in between seminars at the Boston Sports Medicine and Performance Group Conference, Charlie Weingroff and I sat down to discuss the topic of “Should Manual Therapy Hurt?”. We recorded our discussion for Laree Draper’s Movement Lectures Website.

For those interested in checking out the discussion, it can be found HERE for instant download as well as PDF transcript.

Patrick
patrick@optimumsportsperformance.com

I’d love to hear your thoughts on ‘reset’ therapies and window in which we have to affect the baseline pattern (ie how long, and how much, and how much step back do we expect) and expected rate of recovery in the ‘normal’ case. Let’s say for shoulder impingement or shoulder instability.
-Eric

Eric,

Thanks for the great question! For anyone that is not familiar with the term “re-set”, what Eric is referring to is the idea that when we are working with some individuals (mainly those in pain) you are trying to look for some sort of way to “re-set” their brain in order to allow them to progress forward with their rehabilitation and get back to being active and moving pain free.

Let’s start there…

When I think about a “re-set” I think about you, as the clinician or therapist, doing something to the client. This may come in the form of joint mobilizations, massage/soft tissue therapies, dry needling, etc. My friend and colleague Charlie Weingroff wrote a great blog article on manual therapy methods as a “re-set” in his blog – Putting Manual Therapy Into Perspective.

It has always been my thought processes that manual therapy (in my case soft tissue therapy mainly) opens the window. You place your hands on an individual’s skin, interact with their brain, and in some way work to change their perception about what it is they are feeling or experiencing. Basically, in my mind, you are attempting to use touch (which can be very powerful) to modulate the threat response. Once the window is open you have an opportunity to wedge a few pieces of wood under there or maybe a few books and buy yourself sometime to change their perception even more – most likely  with movement or more active therapies. If you simply open the window and then do nothing the window will just close eventually and the person will be back where they were before. This is where chiropractors who just crack their patient’s spine and then send them on their way leave a really bad taste in my mouth. The patient becomes reliant on the manipulation and has to come back frequently because they have not been taught how to build back their own confidence in their body when they window was open.

This is essentially the “re-set”. Open the window in some way, keeping in mind that not all therapies will work for all people (therapy is more “read and react” where you do something, see what the effect was, and then go from there), and then try and keep it open with some form of movement therapy to help put the patient/client in control of their own healing. This, I believe, is also where we can see some benefit from the Selective Functional Movement Assessment (SFMA) concept of first trying to work on the dysfunctional-nonpainful and/or functional-nonpainful patterns. A 2010 paper by Boudrea et al., actually discussed the concept of novel movement stimuli and its role in musculoskeletal pain disorders. One of the key points that stood out to me in the paper was that novel movement stimuli could be useful in enhancing neuroplastic changes in the brain as the patient feels that the new movement they are being taught is beneficial. In essence, the patient’s brain makes favorable changes with regard to perception of pain when movement that is new to them is emphasized. With the SFMA, when we exercises in patterns that are non-painful but dysfunctional we are basically choosing movements that don’t cause a threat response from the patient (because they aren’t movements they perceive to be painful) and because the pattern is considered to be “dysfunctional” any movement we choose in that pattern would challenge the patient as “novel stimuli”. Even with the functional-nonpainful patterns, I believe we can make large improvements in the client’s perception of pain because we can exercise in those patterns that are pain free and tell the brain “Hey, I am not that messed up! There are things I can actually do that don’t hurt!”

Just as I emphasized the power of touch above I will also emphasize that movement is just as powerful.

So, to re-cap, open the window, try and keep the window open by choosing appropriate movements, encourage the patient/client to take control of their own healing, and continually find movements that challenge the client’s brain to turn down the threat response. Those are my thoughts on the “re-set”.

How long, how much…Normal Cases?

It is hard to say anything about “normal” cases since each person is individual and each person adapts at their own rate. Additionally, this rate of adaptation is dependent on a number of variables such as their stress levels, which I wrote about in a previous blog article, and their general health. Let’s face it, people are becoming unhealthier and more unfit and not every problem that people have will be solved by some soft tissue work and exercise. People may need nutritional intervention, lifestyle intervention, better sleep, stress management, psychological intervention, etc. You can do all the great therapy you want but if the person is a walking inflammation soup on the inside it is either going to take really long to get the result you want or it is not going to happen at all. If you want really fast results you need to try and control as many variables as possible (which may not always be an option).

Being very general, I like to say that you should see some sort of result after one session and hopefully some more dramatic results after 3 sessions – people should know that you are the guy that can help them after that first session. Sometimes, depending on the individual and how proactive they are with the things I mentioned in the previous paragraph, I can make some really fast changes (like playing 3-days after having a muscle strain or making changes in a pain that someone has had for a very long time only a few sessions) but this is not always the case because people have a lot of things going on in their lives and, again, I can’t control all of those variables. My goal is always to attempt to restore the person back to normal function in the fastest time possible without compromising their health. That being said, there are three people I tend to see:

1. Those that I can help and seem to have the answers for.

2. Those that I can’t completely help but I can help manage their issue better than others might (meaning that they don’t want to take drugs or get a surgery but I can help “keep them out of the red”, so to speak).

3. Those that I can’t help because either I am not the guy for their particular problem, they have some other stuff going on that warrants medical attention, or they need to be in the care of a medical professional to help treat their problem.

So, again, being very general, if I can open the window and pick the right exercises I expect things to happen pretty quickly. I am very hard on myself in terms of how things progress with someone so if I am not seeing the changes that I want in the time that I expect to see them I am immediately thinking about what I am missing or what I need to consider further.

Hope that helps answer your questions!

Patrick
patrick@optimumsportsperformance.com

Reference

Boudreau SA, Farina D, Fall D. The role of motor learning and neuroplasticity in designing rehabilitation approaches for musculoskeletal pain disorders. Manual Therapy 2010; 15: 410-414.