My 2017 in Review: Top 5 Things I've Learned + My Top 10 Most Viewed Articles of 2017

            Before getting started I just want to extend my props to the people at The Vault Barbell Club and the staff of the Ontario Powerlifting Association for putting on a great meet at The Vault Barbell Open this past weekend. It was a pleasure to compete there and stick around to watch some of the other weight classes compete.

2017 was an interesting year on my part. I launched a website and guest wrote for other parties, launched my second cardiac (and first pulmonary) rehab program, dropped 24 lbs, got to be part of a review panel to review some of Western University’s Physiotherapy program courses and continued to help with the UW Kinesiology program (among other things).

                All in all I consider this year to be quite successful but along the way I learned some very useful tidbits of information and I definitely had some things I’d like to have done differently. In no particular order here are the most important things I learned in 2017 as well as a list of my top 10 most viewed articles.

The most important things I’ve learned (in no particular order) in 2017 are…

1) How great a 10 minute walk after a meal is

I credit Stan “the Rhino” Efferding for teaching me about this trick.

Some research out of Australia in people with Type 2 Diabetes showed that taking a 10 minute walk after each meal was more effective in improving insulin sensitivity, digestion, and nutrient partioning than doing a 30 minute walk once a day.

Now, I must confess, I don’t do a 10 minute walk after every meal every day – but I get them in as often as possible and I find them helpful, not only for the above reasons, but also as a means of recovery from intense training and also just some relaxing, leisure activity in the midst of a busy day. While the above research wasn’t done in a healthy population, when you look at the benefits of the 10 minute walks you can’t go wrong.

2) The importance of having the right amount of force in manual therapy

As I’ve written about before – manual therapy is not the high skill treatment technique that many people like to think it is. You aren’t breaking up the ITB or releasing adhesions. As such you don’t need to kill someone with force.

That said, and this is more anecdotal than evidence-based, I do believe you need to put in enough force to get patients to buy in to the treatment. This is also patient-based. Some people who are used to heavy massages may need more force whereas people who are tense may need a “soft” manual therapy (to quote Charlie Weingroff). The art is finding the right level of force.

3) The importance of slowing down your assessment & treatment

I was thinking about this when I first Skyped with my lovely and awesome friend Joletta Belton -  sometimes, even though we don’t intend to do so, we do tend to rush patients along subconsciously. In a busy clinic with tight booking schedules, it happens. I’m grateful to the people who pointed this out to me.

Towards that end I’ve really worked on hacking down (I hate to say minimalizing) my assessments & treatments to the most important things. As such I don’t feel as subconsciously rushed.

From an assessment perspective I highly value a good subjective (read these 2 papers for a lot of guidance on that). In the objective standpoint most special tests aren’t supported by the research and most assessments lack reliability and/or validity. Towards that end I still believe that a proper quadrant scan, active/passive/resisted/repeated movements, plus some functional tests will give you the vast majority of what you need to know to get started.

From a treatment standpoint many therapists use manual therapy to provide a “window of opportunity” to where active therapy done afterwards can be better. This year I’ve flipped my treatment order to where I do exercises & education first and use passive treatments to fill up any time in the session. Some may disagree with me but I do feel manual therapy has a place – especially when you are dealing with a patient who’s condition is highly irritable and/or has other medical conditions (e.g. recent MI, overall deconditioning) that prevent them from doing a ton of rehab exercise … and there’s only so much education you can hit someone with. That said manual therapy, in the grand scheme of evidence, should be a lower priority.

4) Pain Neuroscience Education (PNE) really needs to be tailored to the individual

Sometimes I harp a lot on how PNE is used. It’s supported in the literature and can be very helpful for decreasing fear, encouraging activity and improving outcomes both from a patient & provider perspective.

That said I hear of too many professionals either bombing patients with too much PNE at once and/or forcing it when the patient clearly isn’t interested. Research from the last couple years has shown that PNE can be received very differently by different people – some positively & some negatively. As such it needs to be relevant to the individual, done in small amounts (patients forget much of what they learn) and you should ask patients if they care to learn about it at all. 

5) The importance of down time & prioritization

Props to Stan Efferding (and my buddy Will Kuenzel) for this as well.

Earlier this year I got super ran down on 2 occasions to the point where (especially on the latter) I got super burned out and didn’t really care for powerlifting or even physiotherapy that much. My burnout came from a combination of running hard with work, finding a place to live, personal & family stuff, various sidebar projects (including one big one that’s under wraps), helping with 2 universities, and launching my site.

Through meeting Stan Efferding earlier this year and talking with him he emphasized the concept of trying to do 1 thing great at a time – be it business, lifting or family. In hindsight that’s the approach I should have been taking – focusing on 1 or 2 things at a time as opposed to trying to do everything.

Another change I’ve made this Fall is forcing myself to take more down time even if it means turning opportunities down.

With that are the top things I’ve learned in 2017.

My top 10 most viewed articles of 2017 (ranked in ascending order ) are ….

10) McGill Big 3 for Special Populations

9) Product Review – The Ultimate Pullup Program by Meghan Callaway

8) The Rehab Renaissance: The Good, The Bad, and Where We Can Improve in Bridging The Gap Between Rehab and Training

7) What to look for in a rehab professional

6) Simplifying the manual therapy process

5) What you may never have been taught in school about pain

4) Impinging on the impingement theory

3) When do biomechanics matter? – This is my personal favourite

2) Low Back Pain: What Are We Doing Wrong and What Can We Do Better

1) A Review of Core Stability Training in Rehab: Facts, Fallacies and Future Directions

The Rehab Renaissance: The Good, the Bad, and Where We Can Improve in Bridging The Gap Between Rehab and Training

                Earlier today I read a post by Nick Tumminello where he shared a link to a book entitled “The End of Physiotherapy” and discussed some of the fallacies trainers make by looking up to therapists. It made me think – where have we gone wrong in this bridging of the rehab & fitness worlds?

                As a Physiotherapist who does exercise programming for people with chronic conditions and some sports rehab, does some fitness consulting on the side, and competes in powerlifting … I’ve seen, worked with, and/or learned from all sides of the rehab & fitness continuum from people who can barely squat out of a chair to people who can squat over a grand. While I’m excited to see rehab & fitness professionals learning from each other this “Rehab Renaissance” (to quote Craig Liebenson) has its pitfalls which I will discuss in this article.

At a Push/Pull/225 Bench for Reps at a seminar with Stan "the Rhino" Efferding. 

Disclaimer: For simplicity’s sake, I am painting rehab & fitness professionals with a broad brush. There are people in both circles that do and don’t do some of the things that I’ve mentioned below so I apologize if it sounds like I’m stereotyping.

The Good: Bridging the rehab & fitness worlds has created a great knowledge boom in many ways…

I’ve often said – I’ve learned more about exercise coaching, cueing, progressing, regressing & modifying from personal trainers and strength coaches than I have from most PTs & DCs. It’s a sad state as many of the educational systems focus too much on manual therapy & modalities and not enough on exercise (I am working on that) so I, and many other rehab professionals, look to fitness professionals for guidance in that avenue.

In addition strength coaches are the foremost experts in building their clients’ fitness in order to enable them to tolerate & perform well at their desired sports. Learning how to progress someone in end stage rehab towards a desired sport is a must if you’re a therapist who works in orthopedics & sports rehab.

Conversely you have fitness professionals learning how to improve mobility & movement from rehab professionals. You can debate about the FMS all you want – but it’s got people looking at movement, how to assess it and how to improve it. While I disagree with the idea that there’s one right way to move, you gotta admit that it’s pretty tough to give someone a well rounded exercise program when they’re new to exercising and their hips, shoulders, knees & ankles are stiff as boards. Yes mobility work does get taken WAY too far (and I will write about this in a separate article) but an increased focus on mobility & movement, compared to what we’ve done in the past, isn’t a bad thing.

Lastly trainers have learned a lot from rehab professionals & biomechanists on how to modify exercise programs for people in pain – which isn’t a bad thing but can have issues as I describe below.

The Bad: this shift has also brought some less than desirable changes to our fields including

1) The biggest issue: managing people away from load

The over-cautiousness by some (not all) rehab professionals and the trainers that learn from them has lead to a “rehab purgatory” (to quote John Rusin and Craig Liebenson) where many trainers & therapists fall too far in the direction of trying to optimize every little movement, posture and muscle activation detail before ever loading someone & working the client towards the activities that are meaningful for them. This is problematic – especially for fitness clients who want to lose weight, look better, feel better & be healthier … not score a 21 on a FMS. Same goes for physical therapy clients who want to be able to go out for a walk in the mountains and don’t care about having perfect TVA activation or scapulohumeral rhythm.

Don’t get me wrong – as I’ve written about before some biomechanical variables matter a lot and can benefit from specific exercises & attention but one of the biggest biomechanical variables that needs to be managed is load. As Tim Gabbett said – methodically building the client’s workload tolerance to prepare them for their desired activities is one of the best things we can do for them.

2) Rehab & fitness professionals overemphasizing each others techniques and using questionable practices

On one end you see trainers doing a lot of corrective exercises to “treat” pain & dysfunction (and even some doing manual therapy) whereas on the other side you see therapists doing a lot of strength training movements with clients who aren’t athletes or gym junkies.

In physical therapy strength training (not referring to basic rehab exercise) has a place such as

-          In improving the health & function of people with chronic diseases and

-          In returning clients with pain to sports and/or the weight room

But I’d be wrong if I said that everyone in pain just needs to lift big weights and everything will sort itself out. Sometimes patients can’t do these exercises due to pain or a mobility limitation …. or its just not plain in line with their goals.

Side note: when working on this piece I was reminded by some words of wisdom from Jason Silvernail. While we are quick to criticize our own fields many (if not all) interventions by rehab professionals have a better risk/benefit ratio than opioids, unnecessary medical imaging, and many common orthopedic surgeries.

Regarding trainers & corrective exercise – some of the research done on the FMS as well as Hewett’s ACL research has shown that changes in “movement quality” are more due to changes in body awareness & motor control and less due to fixing tight, weak, immobile, or unstable joints & muscles. Sometimes correctives have their place – such as if someone can’t deadlift with a neutral spine due to super tight hips – but in many cases I believe exercise technique can be changed by simple coaching & cueing. Also a lot of the pseudobiomechanical variables that trainers (and therapists) try to assess & correct either can’t be reliably assessed and/or don’t correlate well with pain.

Manual therapy is not as high skill a technique as many therapists would like you to think but it does need to be done safely and I get concerned when I see trainers stretching clients far more forcefully than I (at 255 lbs) ever would.

Which brings me to …

3) Overstepping scope of practice

My biggest concern, on both ends, with the Rehab Renaissance is when personal trainers try to be physiotherapists & when therapists try to be strength coaches.

I have nothing wrong with fit pros working with people with pain but as Charlie Weingroff said

-          The client needs to be assessed to rule out medical issues AND

-          Trainers don’t treat pain, they don’t diagnose, they don’t treat the neck and they don’t do manual therapy

I’ve heard stories of personal training clients who had pain secondary to serious medical conditions that weren’t detected in time as the trainers tried to treat pain without referring out. In my experience in Intensive Care Unit I saw patients who didn’t have red flags detected until it was too late. You don’t want that happening to you.

As Greg Lehman said – the most important part of a physiotherapy assessment is to make sure pain is the problem, not pain secondary to something sinister.

On the flipside I do see therapists try to be wannabe strength coaches, which can also be dangerous if the lifts aren’t coached and programmed effectively, but to me that’s a much smaller issue than the other way around.

How we can improve: as with all my articles I like to offer some positive suggestions to improve the rehab & fitness fields. That comes in large part for mastering “the basics.” We know through the training & rehab research that

-          Well tolerated movement, exercise & physical activity are good and important

-          Activity should be progressed in a methodical way (i.e. Tim Gabbett style) to build up people’s activity tolerance while minimizing injury risk

-          Having good physical and psychosocial health (i.e. healthy body weight, proper sleep, minimizing stress) are huge

-          And that having positive beliefs about the body, whether you’re a high performance athlete and/or someone trying to get out of pain, are critical

These should form the framework for what we do regardless of whether you’re a rehab or fitness professional.

I hope this article has given you some thoughts on the Rehab Renaissance and where it can go from here.

On December 4^th I will be posting my last article of the year before the XMas/New Year’s break.

McGill Big 3 For Special Populations

By Eric Bowman in consultation with Dr. Stuart McGill

The original article was published for PT Perspectives on January 28, 2014.

If you have been around the rehabilitation or functional training world over the last three decades you’ve likely heard of the name Stuart McGill. Dr. McGill is a Professor Emeritus in Spine Biomechanics at the University of Waterloo who has authored the popular books “Low Back Disorders” and “Ultimate Back Fitness and Performance” together with several hundred peer-reviewed journal papers documenting research findings. In addition, he sees patients with painful backs ranging from everyday people to elite athletes.

The McGill Big Three core exercises have become popular with clinicians and personal trainers as they train the core muscles while providing less stress on the lumbar spine in comparison to traditional exercises such as situps, reverse hypers, and leg raises (1,2). While those exercises aren’t necessarily evil and can be applied & programmed properly many elderly people suffer from osteoporosis – a decrease in bone density predisposing people to fracture. Biomechanics research has shown us that osteoporotic vertebrae are more likely to fracture under end range, loaded, repetitive spinal flexion (3).

Here is a video of the McGill Big 3 (along with Stir The Pot) in their basic forms. Each exercise has progressions and regressions that are described in more detail in his books.

http://www.youtube.com/watch?v=kukmaW9CmSU

As with any training system or exercise, the McGill Big 3 must be tweaked to suit the needs of the individual. Elderly clients have other health conditions that must be accounted for when designing a training program.

Having worked with seniors who have cardiovascular disease, osteoporosis, and other conditions; I’ve developed some modifications to the McGill Big Three that are addressed in this article.

Concern #1: Hypertension

In many individuals blood pressure rises with age and isometric exercise is known to elevate blood pressure (4). For some individuals, a 10 second hold of a core exercise may rise blood pressure to levels of concern.

Solution: Do less more often. Instead of doing five reps of 10 seconds each, do more reps with shorter holds (e.g. 3-5 seconds).

Concern #2: Osteoarthritis

Osteoarthritis is one of the most common musculoskeletal conditions in the elderly (5).

Exercises such as the birddog aren’t always tolerated by seniors due to the kneeling position required to perform them. Kneeling is a risk factor for osteoarthritis (6,7) and some people with osteoarthritis experience pain when kneeling (8).

Solution: Perform the birddog standing against the wall, on a comfortable yoga mat, or supported by a chair. Be careful when coaching this exercise to ensure that the hips are extending and that the lumbar spine remains in a neutral position. To progress this exercise you can narrow the base of support and then add perturbations from the trainer/therapist.

Concern #3: Balance disorders

As we age our balance and proprioceptive abilities decrease, increasing our risk of falls (9). A fall in the elderly has a higher two year mortality rate than everything except for the death of a spouse (10).

I’ve dealt with trainers and Kinesiologists who shy away from the birddog and other core exercises for fear that they would lead to a fall. In reality these exercises just need to be modified a little bit.

Solution #1: Regressions

As outlined in Low Back Disorders, the birddog can be regressed in two ways. The first is to have the client extend either an arm or a leg (not both) and the second is to have the client lift one hand up a few inches and hold it in that position (1).

Solution #2: Gain a more stable base

Doing planks, side planks, and/or birddogs against the wall or against a stable chair can be a safer option for some individuals.

Concern #4: Cardiac Insufficiency

Supine exercise has been shown to decrease cardiac output (11,12). For individuals with angina, congestive heart failure, or other cardiovascular conditions; the curl-up may not be appropriate.

Solution: Switch to a front plank and have the client perform the exercise against a wall.

I hope this article gives you some thoughts as to how I modify Dr. McGill’s exercises for the populations I work with.

REFERENCES

1.       McGill, S.M. (2007). Low back disorders: Evidence-based prevention and rehabilitation (2^nd ed.). United States of America: Human Kinetics

2.       McGill, S.M. (2009). Ultimate back fitness and performance (4^th ed.). Waterloo, ON: Backfitpro Inc.

3.       Maquer G, Schwiedrzik J, Huber G, Morlock MM, Zysset PK. Compressive strength of elderly vertebrae is reduced by disc degeneration and additional flexion. J Mech Behav Biomed Mater. 2015 Feb;42:54-66. doi: 10.1016/j.jmbbm.2014.10.016. Epub 2014 Nov 11.

4.       Chrysant, S.G. (2010, September). Current evidence on the hemodynamic and blood pressure effects of isometric exercise in normotensive and hypertensive persons. J Clin Hypertens (Greenwich), 12(9), 721-726. doi: 10.1111/j.1751-7176.2010.00328.x.

5.       Michael, J.W., Schlüter-Brust, K.U., & Eysel, P. (2010, March 5). The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee. Dtsch Arztebl Int, 107(9), 152-162. doi: 10.3238/arztebl.2010.0152

6.       Fransen, M., Agaliotis, M., Bridgett, L., & Mackey, M.G. (2011, February). Hip and knee pain: role of occupational factors. Best Pract Res Clin Rheumatol, 25(1), 81-101. doi: 10.1016/j.berh.2011.01.012.

7.       Cozzensa da Silva, M., Fassa, A.G., Rodrigues Domingues, M., & Kriebel, D. (2007, August). Knee pain and associated occupational factors: a systematic review. Cad Saude Publica, 23(8), 1763-1775. Retrieved from http://www.scielosp.org.proxy1.lib.uwo.ca/scielo.php?script=sci_pdf&pid=S0102-311X2007000800003&lng=en&nrm=iso&tlng=pt

8.       Hassaballa, M.A., Porteous, A.J., Newman, J.H., & Rogers, C.A. (2003, June). Can knees kneel? Kneeling ability after total, unicompartmental and patellofemoral knee arthroplasty. Knee, 10(2), 155-160.

9.       Sturnieks, D.L., St George, R., & Lord, S.R. (2008, December). Balance disorders in the elderly. Neurophysiol Clin, 38(6), 467-478. doi: 10.1016/j.neucli.2008.09.001.

10.   Liebenson, C. (2013, October 3). Training the frontal plane by Craig Liebenson. Retrieved from http://www.youtube.com/watch?v=uVADBwPpzgk

11.   Cotsamire, D.L., Sullivan, M.J., Bashore, T.M., & Leier, C.V. (1987, March). Position as a variable for cardiovascular responses during exercise. Clin Cardiol, 10(3), 137-142.

12.   Takahashi, T., Okada, A., Saitoh, T., Hayano, J., & Miyamoto, Y. (2000, February). Difference in human cardiovascular response between upright and supine recovery from upright cycle exercise. Eur J Appl Physiol, 81(3), 233-239. 

What role do breathing exercises play in orthopedic rehab and in strength training?

                It seems like breathing is once again a hotly debated topic in the rehab & fitness worlds. Some think that breathing exercises are the greatest thing since sliced bread while others think they’re useless. My brilliant colleague Roderick Henderson posted a great video on the topic in early August and in this article I will give what I feel to be a balanced perspective on the topic.

Disclaimer: I will not be discussing breathing for people with cardiopulmonary disease in this piece – that’s another topic for another time.

Side note: as I was working on this article my brilliant colleague Adam Meakins put out a great article on breathing as well. If you haven’t read his opinion piece than give it a read.

                Believe it or not – I do see some useful applications for breathing exercises such as

1) A relaxation/recovery technique either as part of a post-workout cooldown and/or for a separate recovery session

2) To change patterns that are associated with pain

Anecdotally I have heard of people with rib and/or low back pain that find certain breathing techniques more or less comfortable than others. Anecdotally some people I work with who have rib pain find diaphragmatic breathing more comfortable than chest breathing. Some people I work with who have back pain that’s aggravated by extension find breathing more comfortable when emphasizing a 360 degree expansion of their belly (see video here by Chris Duffin for the technique https://www.youtube.com/watch?v=IZDVHVohtmE).

In those populations I have no problem with changing someone’s breathing technique to give them a way to breathe that’s more comfortable for them.

Side note: changes in pain with treatment can be due to a variety of factors so the caveat is that we have to be careful not to attribute changes in pain to changing a “breathing dysfunction¹.”

Side note #2: If you are a rehab professional who is working with a person who has pain with a given breathing technique you need to be cognizant to rule out any major orthopedic or medical issues that may be causing these problems including (but not limited to) a rib fracture or cancer. If you are a fitness professional DO NOT try to diagnose this stuff and please refer to a qualified professional – preferably one who understands lifting, pain science, and the biopsychosocial model. If you have trouble finding a good PT in your area that appreciates training message me – I’ll help you out as best I can.

3) To improve performance and/or comfort in a given exercise

If changing a person’s breathing patterns improves performance and/or comfort in a given exercise be it a squat, a deadlift, or an aerobic exercise session I have no problem with that.

In my article on core stability I discussed how bracing can be overdone and is only really relevant if you’re doing strength training or are in a lifting competition. This is more anecdotal than research based but I don’t know of any strength athlete/strength enthusiast that feels they can lift more in a relaxed state than in a “braced” state. For info on specific breathing & bracing technique I’m a big fan of Brian Carroll and Chris Duffin’s work.

Where we go wrong is

1) Assuming everyone in pain is in pain due to a breathing dysfunction and assuming that fixing people’s dysfunctions will cure everyone’s pain. Also the idea of a “breathing dysfunction” is problematic and without a definition as breathing, as is the case with many other movement variables, has a wide variation of “normal.”

2) Spending anymore than a few minutes of a personal training/S&C session on breathing when that time can be spent on more productive things.

So in summary there’s nothing wrong with giving people breathing exercises to help find less painful ways to breathe and/or improve exercise performance … assuming major pathology is ruled out. But understand that they’re not a panacea for everything and everyone.

Reference

1.          Hartman SE. Why do ineffective treatments seem helpful? A brief review. Chiropr Osteopat. 2009;17:10. doi:10.1186/1746-1340-17-10.

A Short List Of Truths About Persistent Pain Rehabilitation - For you, the patient

I was honoured when my good friend, colleague and former University of Waterloo & Western University classmate Nick Hannah (Facebook, YouTube, Instagram) asked me to help write an article with him on the truths of rehabilitating people with persistent pain. I've attached a link to the article here. I hope you read it, enjoy it and will share it.

Product Review - The Ultimate Pullup Program by Meghan Callaway

              Earlier this month I was touched when my fellow Canadian friend and colleague Strength Coach Meghan Callaway messaged me and asked me to review her new pull-up program "The Ultimate Pull-Up Program." Ever since I discovered her work a couple years ago I’ve became a big fan of her serious, no-nonsense approach to strength training and nutrition as well as her authentic personality. So, towards that end, when she asked me to review her program I was excited and could not say no.

Side note: before anyone says anything NO I am not an affiliate of Meghan’s and as such I am not getting any money from this.

The program consists of four progressive phases that start with very regressed versions of pullups and progress to (and even beyond) regular pullups. If you follow Meghan on social media you’ll see her doing some very advanced (and by her admission sometimes crazy) progressions of pullups and other exercises, some of which are included in the program as bonus content.

What amazed me about the program was the level of detail Meghan put in to describing each of the exercises and the various cues she uses to ensure proper performance as well as the amount of progressions and regressions available for each exercise. One of my hesitations in recommending people to do specific programs comes down to whether or not they can do the exercises properly but Meg has this taken care of.

One of the biggest themes in the book is that of creating full body tension in order to do pull ups as opposed to the traditional focus on just treating it as a back & arm exercise. This concept was first taught to me by my friend and mentor Dr. Stuart McGill and he learned it from the popular kettlebell expert & strength coach Pavel Tsatsouline.

As I was reading the book I also thought to myself that it makes a good overall strength training program for pullups and for progressing bodyweight exercises in general. I’ve often said bodyweight exercises can be quite effective but past a certain point you can only do so many reps of pushups & bodyweight squats before they quickly hit a point of diminishing returns.

            Overall I quite enjoyed the program and enjoyed reading it. I will definitely be taking a lot of these principles and applying them to my own training and that of the patients and clients that I work with.

The only two things I would have liked to have seen included in the program are

1) Some tips for fat loss for larger clients who may struggle to do pullups (or bodyweight exercises in general) due to their weight. Obviously being a bigger powerlifter I am biased.

2) Exercises and guidance for people who may lack the mobility to perform pullups (or any of the other exercises) properly.

I might be wrong – but I do feel the program is more intended for healthy people who are already working out and have a good base of fitness. Some of the exercises may not be recommended for people due to certain injuries and/or medical issues.

            All in all I think Meghan’s Pullup Program is one of the most well thought out and well written programs I’ve ever read and if you’re an avid gym goer who wants to improve your pullups I highly recommend it. The program is available at this link and will be available for a discount launch price until Friday at midnight. 

What to look for in a personal trainer or strength coach

            At the start of every year many people make resolutions to lose weight, start exercising, and improve their health & lifestyle. Some people may hire a trainer or coach to help them with their exercise & nutrition routines.

            Spending the vast majority of my time in the physical therapy world I am quite often given the task of recommending good gyms/trainers to some of the people whom I work with.

            As someone who’s trained myself for a lot of years I believe having a knowledgeable trainer or coach can save you a lot of time & hassle. At the same time personal trainers aren’t regulated like doctors or physiotherapists are and as such it’s difficult to know who to trust.

            In this article I give you a (non-exhaustive) list of what you should look for in a trainer or strength coach before hiring. For the sake of not making this a long article I’m not including some of the more basic “common sense” ones such as trainers showing up on time, not texting on their phone, and being professional.

Disclaimer: Some may argue that trainers & strength coaches are different professions. I’m just overlapping them for simplicity purposes. I’m not including coaches of specific strength sports (i.e. powerlifting, olympic lifting, strongman) or coaches of physique sports (i.e. bodybuilding, bikini, figure) in this article.

With that out of the way here are some of the traits you should look for in a fitness professional…

1) They should ask you about your medical history

This is the biggest thing right here. If you go in for an initial session and your trainer doesn’t ask you about your medical history, your injury history and your medications than you should immediately ask for a refund and head out the door.

With the rise of obesity and other health conditions it’s more and more common that trainers encounter clients who have various medical conditions and are taking medications. Some medications and medical conditions require special adjustments to the exercise program to be done safely. If your trainer doesn’t ask you these questions they’re just playing with fire.

Side note: I may get flack for this but I believe that training diseased populations (i.e. heart disease, osteoporosis, cancer, hypertension) should be left to people who have the requisite training (i.e. CSEP – CEP, CSPS, Kin or Physical Therapy degree) AND have worked with these populations AND keep up to date on the research.

2) They should ask you what your goals are and tailor the program towards your goals

The fitness industry is full of trends ranging from aerobics to bodybuilding to functional movement to kettlebells to CrossFit to powerlifting. While these all have a time & a place when done and programmed correctly I’ve seen too many trainers force their goals and their philosophy on clients. Your trainer should ask you what your goals are. If you ask your trainer “how is this helping my achieve my goal” and the trainer doesn’t have an answer than that’s a problem.

Side note: sometimes to achieve specific goals your trainer/coach may ask you to do things that you may not like to achieve your goals. For example if your goal is to lose weight your coach may recommend reducing soda consumption.

3) They should give you an individualized program

The major principles of training – specificity (SAID), overload, and fatigue management apply to everyone and almost every training program will include some squatting, hip hinging, pushing, and pulling (short of any medical or injury issues). That said training still needs to be individualized in terms of training volume, training frequency, exercise technique and exercise selection.

Training needs to be individualized to provide the most effective program with the lowest risk of harm. Some people can’t do certain exercises properly or painfree. Some people are really deconditioned and won’t tolerate a lot of training volume right off the bat.

As such a trainer or coach should be able to develop a program that’s customized to your needs, not a cookiecutter program or even worse the exact workout that your coach uses for him/herself.

Along with this a trainer should be able to modify your program if you’re tired, sick, sore, get injured, have pain with a certain exercise etc. Your trainer should be asking you questions like “How do you feel today?”, “How did you feel after the last workout?”, and “Did you get a good sleep last night?”

4) When performing exercises the trainer should be walking around, observing from different angles and coaching you to perform the exercise effectively

One of the important lessons I learned from Stu McGill is to observe an exercise from all angles and put the work into coaching. A trainer should be doing the same – not just counting reps or cheerleading.

Side note: some exercises and some people require more coaching than others. If you’re doing a simple exercise (i.e. seated calf raise) and/or you’re someone with good body awareness than you may not need as much coaching as someone else doing a more advanced exercise.

5) Your workouts should be progressive and have a direction. They shouldn’t be random.

A concern that I have with some training plans is that the workouts are incredibly random from day to day and don’t have a planned direction. The training principle of SAID – Specific Adaptation to Imposed Demand and the principle of Directed Adaptation state that training needs to be geared in a specific direction to achieve a specific goal.

For instance fat loss training needs to be built around maintaining a calorie deficit and preserving (or potentially increasing in some cases) lean muscle mass.

In another example building strength in certain lifts requires low rep training (for the most part, not all the time) in those lifts to build neural efficiency & technique and also requires higher repetition training to build hypertrophy in the muscles that support those lifts.

As such workouts can (and should) have some variety in terms of set & rep ranges and exercises but they should all be tailored a specific goal. If your training consists of 3x15 one week, hitting a 1 rep max the next week, and doing 5x5 the next week than chances are your training is so random that you aren’t going to be able to spend enough time to achieve one goal.

Following with that your trainer should be tracking your workouts to make sure that you’re progressing appropriately.

6) Your trainer shouldn’t be basing the effectiveness of your workouts based on how much you puked or how tired you are.

A concern that I have with the popularity of extreme workouts is that people base their effectiveness off of how tired they are or whether they puke or not. I am of the belief that the occasional *ss-kicking session is OK as long as it’s done safely – but if you leave each workout super sore, in a pool of sweat, and/or feeling like you’re going to puke than you need to consider working with someone different.

I hope this article gives you an idea of what to look for when hiring (or referring to) a trainer or strength coach. If you are having a hard time finding one in your area message me on Facebook or at my email ericccbowman90@gmail.com and I’ll do my best to help you to find one.

What to look for in a rehab professional

            As a powerlifter (and hopefully soon to be CSCS) who works in the health & fitness industry I cringe whenever I see powerlifters & strength coaches asking other powerlifters and coaches for injury & rehab advice. Your coach may be great at preparing you for the platform but unless they went to PT/Chiro/RMT/ATC school and have a solid understanding of pain science & the evidence they likely aren’t the people you should be seeing.

            That said I see a lot of powerlifters, strength coaches, and athletes in general who are reluctant to see a rehab professional as they may doubt the professional’s ability. In addition some (not all) rehab professionals aren’t very knowledgeable when it comes to weight training or athletics. This can make it difficult to find a good professional to work with.

            The purpose of this article is to provide a (non-exhaustive) list of things to look for in a rehab professional.

1) They don’t run you through an assembly line

I understand that I will piss a few people off by saying this but <30 minute assessment times & 10 minute (or less) treatment times for patients are ridiculous. These bookings, in most (but not all) cases, fail to provide adequate time to adequately assess, reassess & treat patients.

Bottom line – you should be looking at clinics that provide 40-60 minutes per assessment and at least 15-20 minutes per visit.

2) They understand pain science and the biopsychosocial model

Many rehab professionals are educated in the postural-structural-biomechanical model of thinking. This model basically claims that all pain is due to postural, structural, and biomechanical faults. The problem with this theory is two fold.

First of all many of the “biomechanical” faults that therapists & chiros cite (e.g. trigger points, joints being out of place, upslips/downslips/rotated innominates, hypermobile/hypomobile segments) either can’t be reliably assessed and/or don’t correlate well with pain.

Secondly, through decades of research, we know that pain is more complex and can be influenced by biological, psychological, and sociological factors.

Bottom line – if you ask your therapist about the biopsychosocial model & pain science they should be able to give you a half decent answer as to what they are.

3) They should understand lifting and athletics

If you’re not an athlete or someone who lifts weights feel free to skip this part.

One of the gripes I hear about PTs & chiros from strength coaches, trainers and lifters is that many of them don’t understand lifting weights or athletics and are overly cautious with their restrictions. You hear this all the time. “Don’t squat it’s bad for your knees.” “Don’t deadlift it’s bad for your back.” “Use light weight and do lots of reps.” “You’ll never run again.” The list goes on and on.

Now I will be the first to say that certain injuries and certain medical conditions can make certain exercises unsafe. But working with a rehab professional who understands how to train effectively & safely and also understands athletics will give you the most bang for your buck.

Side note: Your therapist may not have done every single sport or activity that you do but they should at least understand the general demands of each activity.

4) They should give you a thorough assessment & ask you about your general health, not just your aches & pains

One major concern I have with some (again not all) rehab professionals is when they start doing manual therapy and other techniques without giving you a thorough assessment and asking about your medical history to rule out red flags.

Some medical conditions – such as cancer, rheumatoid arthritis, osteoporosis, and others can make manual therapy techniques (and certain modalities) unsafe. As such your PT/chiro/RMT/ATC whoever should be asking you about your general health & ruling out red flags to make sure treatments can be done safely.

Side note: Sometimes as a patient you may have to do things you don’t like – such as taking a temporary break from training, modifying your training volume, and/or doing rehab exercises to help get better. But, at the end of the day you should be able to ask your therapist “how is this helping me achieve my goals?”  

5) They should be good at communication

“People don’t care how much you know until they know how much you care.” – Attributed to many people

Communication is key. As a patient you should feel like your story is being listened to and that your therapist is working towards your needs & goals. I’ve heard it said, both in PT and doctor’s clinics, that patients have less than 15-23 seconds to speak before they get interrupted. In my practice I open (almost) every assessment with “tell me your story” and let them have the floor. I found this gave me more useful information and insight into their condition than anything else did. As Peter O’Sullivan said “you won’t remember tick boxes but you’ll never forget a patient’s story.”

6) They should be evidence based & value continuing education

This is a no-brainer. If your therapist doesn’t value continuing education and making themselves better chances are he/she is more likely in it for the money than to help you.

7) They shouldn’t make you dependent on passive treatments

I’m sure I’ll also get some flack for this one but here goes….

Patients like passive treatments (e.g. modalities, manual therapy). The patients don’t have to do anything and they provide a short term (often placebo) benefit. While the odd modality is supported for the odd condition and manual therapy does have a place – if a therapist doesn’t give you some active methods to manage your pain (be it exercise, education, or both) that is problematic.

Side note: during my time in clinical practice I had times where I had to solely passive treat certain patients as they were in such pain they couldn’t tolerate much (if any) volume of exercise. But I made it known to the patients that this was a temporary thing.

I hope this article gives you some insight for choosing a therapist. If you have trouble finding a therapist email me at ericccbowman90@gmail.com and I’ll see what I can do. Tune in next week for “What to look for in a fitness professional.” 

A Review of Core Stability Training in Rehab: Facts, Fallacies and Future Directions

Updated May 5, 2018

               Over the last two decades one of the most popular forms of exercise in the health and fitness industry is core stability training. While the fad is slowly starting to die off a bit you can still go to many PT clinics or gyms and see people being told to pull their bellybutton in when doing exercises.

                I’ll confess, as a former student and current friend of McGill’s, the whole core stability concept (particularly the TVA/MF focus) has been a big thorn in my side for many years.

                So where did this start? Where did we go wrong? That’s what I will explain in this article.

                Before we get started I’d like to provide a definition of stability as stability means different things according to different people. The term stability has many meanings attached to it including control of movement, balance, stiffness or absence of movement, or structural stability. Webster’s definition of stability is

“ 1:  the quality, state, or degree of being stable: as

•       a :  the strength to stand or endure :  firmness

•       b :  the property of a body that causes it when disturbed from a condition of equilibrium or steady motion to develop forces or moments that restore the original condition

•       c :  resistance to chemical change or to physical disintegration”

ORIGINS OF CORE STABILITY – PANJABI

In the early 1990s a researcher named Panjabi first defined the concept of the neutral zone as “A region of intervertebral motion around the neutral posture where little resistance is offered by the passive spinal column^1,2.”

Panjabi proposed that a smaller neutral zone meant a joint was more stable. Panjabi recognized 3 contributors to spinal stability….

•       Active subsystem: Spinal muscles

•       Passive subsystem: Spinal column

•       Control subsystem: Neural^1,2

THE RESEARCH FROM AUSTRALIA ON THE INNER CORE

                In the mid to late 1990s Paul Hodges, Carolyn Richardson and other researchers compared people with and without low back pain (LBP) to see how fast their core muscles activate in response to various arm and leg movements. What they found was that the transverse abdominnis (TVA) and multifidus (MF) were slower to activate in people with LBP compared to people without LBP. No other muscles were activated differently between groups³.

                These studies created the idea that there is an inner core consisting of TVA, MF and the pelvic floor that contracts independently of the outer core. TVA was thought to increase spinal stability through its attachment to the thoracolumbar fascia. Drawing in or abdominal hollowing co-contracts the TVA and MF and increases intra-abdominal pressure³.

                A 1997 study by Peter O’Sullivan et al showed that core stability exercises improved outcomes in people with spondylolisthesis compared to GP care⁴. Hides et al showed that training the inner core decreased the risk of developing LBP⁵.

                As such it became believed that TVA and MF issues cause LBP, that everyone with LBP needs core stability exercises and that the inner core muscles are the most important muscles in spinal stability and low back health. Boom!! A new trend is born. Core stability exercises are still the most prescribed intervention for LBP.

What people who quote the research tend to miss is that Hodges et al’s research was cross sectional. As such we can’t tell if core muscle delays are a cause or consequence of pain. Pain can affect muscle activity and prospective research hasn’t found an association between baseline TVA function and LBP development⁶.

                In addition the average delay in muscle activation was 20-50 ms across studies which is negligible. Some researchers have questioned the legitimacy of measuring MF via surface EMG as there is potential for crosstalk from the erector spinae. In addition some research has shown activation delays in other core muscles in people with LBP⁷.

STUART MCGILL AND THE GLOBAL APPROACH

                In 2003 McGill et al measured the role of each muscle in spine stability and found that each muscle contributed fairly equally to spinal stability across various tasks⁸. His research also showed that drawing in decreased the activity of the outer core muscles and as such removed many stabilizing muscles from the equation⁹.

                By contrast bracing (or stiffening all of the muscles in your core) contracts all muscles and has been shown to increase TVA and MF activity, increase spinal stability, and increase ability to respond to perturbations when compared to drawing in⁹. A recent study found efficacy for bracing exercises in LBP¹⁰.

                Side note: some studies that claim to use bracing actually use hollowing or drawing-in.

                However, most tasks (including lifting up to 70 lbs) require 4-8% core muscle maximal voluntary contraction for sufficient spinal stability. This level of core muscle activity can be generated naturally and reflexively without bracing unless you have a spinal cord injury or other neurological condition⁹.  

                Bracing does increase compressive forces on the lumbar spine¹¹ and as such it may be appropriate for higher load tasks (ie heavy strength training) but it is “overkill” for day to day tasks.

PAIN SCIENCE AND THE BIOPSYCHOSOCIAL APPROACH

                Through the work of researchers such as Peter O’Sullivan, Kieran O’Sullivan and others we know of the link between psychosocial factors and LBP.

                A myriad of psychosocial factors are associated with the transition from acute to chronic LBP including stress, anxiety, depression, hypervigilance, fear avoidance, kinesiophobia, and catastrophizing^12,13.

                Some studies have also shown that some people with chronic low back pain have hyperactivity of their core muscles. The notion that the lumbar spine is unstable may cause these maladaptive beliefs and behaviours and may cause more focus on protection of the spine^12,13.

RECENT RESEARCH

                Studies in 2012 and 2014 have shown that core stability exercises were not superior to general exercise in improving outcomes^14,15. One important thing to note is that the general exercise protocols in many studies often included general core exercises (ie planks, birddogs etc). A study in 2017 showed core stability exercises provided better outcomes at 3 months compared to general exercise but no measures were made at 6 & 12 months and a 2018 review showed that core stability exercises were more effective than general exercises ^16,18.

                A 2013 systematic review found no correlation between changes in TVA and MF activation and clinical outcomes in people with LBP⁶. A 2017 paper showed that spinal stability in people with back pain didn’t significantly change after performing a motor control program or a general exercise program¹⁷.

PRACTICAL IMPLICATIONS

                Core exercises by themselves are not necessarily evil – it just depends on how they’re marketed. If they’re used as a means of movement and exercise that’s tolerated by the individual (assuming they are well tolerated) than that’s OK. If you say “you need to get your core working to keep your spine stable” you are more than likely delivering a nocebo effect.

                Drawing in in isolation (i.e. when lying on your back & lifting your legs/arms up) is OK but isn’t advisable when doing advanced core exercises, heavy lifting, or balance exercises.

To summarize this long article

•       Core muscle activity can be altered in people with LBP but it’s relevance to spine stability and LBP is questionable

•       The TVA and MF aren’t any more important to core stability than any other muscles

•       Exercises designed to focus on the TVA and MF haven’t produced any more favourable outcomes in LBP than general exercise

•       Doing draw-in exercises in isolation is OK but drawing in shouldn’t be used when doing advanced core exercises, lifting, or balance exercises

•       Bracing is appropriate when extra stability is needed (ie lifting heavy loads) but shouldn’t be used for day to day tasks

•       The belief that “your spine is unstable” may (in theory) cause issues like fear avoidance, hypervigilance and guarding which are associated with chronic LBP

References

1.          Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. J Spinal Disord. 1992;5(4):383-389; discussion 397. http://www.ncbi.nlm.nih.gov/pubmed/1490034. Accessed September 27, 2017.

2.          Panjabi MM. The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. J Spinal Disord. 1992;5(4):390-396; discussion 397. http://www.ncbi.nlm.nih.gov/pubmed/1490035. Accessed September 27, 2017.

3.          Hodges PW. Is there a role for transversus abdominis in lumbo-pelvic stability? Man Ther. 1999;4(2):74-86. doi:10.1054/math.1999.0169.

4.          O’Sullivan PB, Phyty GD, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine (Phila Pa 1976). 1997;22(24):2959-2967. http://www.ncbi.nlm.nih.gov/pubmed/9431633. Accessed September 27, 2017.

5.          Hides JA, Jull GA, Richardson CA. Long-term effects of specific stabilizing exercises for first-episode low back pain. Spine (Phila Pa 1976). 2001;26(11):E243-248. http://www.ncbi.nlm.nih.gov/pubmed/11389408. Accessed May 27, 2017.

6.          Wong AYL, Parent EC, Funabashi M, Kawchuk GN. Do changes in transversus abdominis and lumbar multifidus during conservative treatment explain changes in clinical outcomes related to nonspecific low back pain? A systematic review. J Pain. 2014;15(4):377.e1-35. doi:10.1016/j.jpain.2013.10.008.

7.          McGill S. Ultimate Back Fitness and Performance (6th Edition-2017) - Backfitpro. 6th ed. BackFitPro Inc.; 2017. http://www.backfitpro.com/books/ultimate-back-fitness-and-performance-6th-edition-2017/. Accessed September 27, 2017.

8.          McGill SM, Grenier S, Kavcic N, Cholewicki J. Coordination of muscle activity to assure stability of the lumbar spine. J Electromyogr Kinesiol. 2003;13(4):353-359. http://www.ncbi.nlm.nih.gov/pubmed/12832165. Accessed September 27, 2017.

9.          Grenier SG, McGill SM. Quantification of lumbar stability by using 2 different abdominal activation strategies. Arch Phys Med Rehabil. 2007;88(1):54-62. doi:10.1016/j.apmr.2006.10.014.

10.        Aleksiev AR. Ten-Year Follow-up of Strengthening Versus Flexibility Exercises With or Without Abdominal Bracing in Recurrent Low Back Pain. Spine (Phila Pa 1976). 2014;39(13):997-1003. doi:10.1097/BRS.0000000000000338.

11.        McGill SM. Low Back Disorders: The Scientific Foundation for Prevention and Rehabilitation. Champaign, IL: Human Kinetics; 2002.

12.        O’Sullivan P. Diagnosis and classification of chronic low back pain disorders: Maladaptive movement and motor control impairments as underlying mechanism. Man Ther. 2005;10(4):242-255. doi:10.1016/j.math.2005.07.001.

13.        O’Sullivan P. Common misconceptions about back pain in sport: Tiger Woods’ case brings five fundamental questions into sharp focus. Br J Sports Med. 2015;49(14):905-907. doi:10.1136/bjsports-2014-094542.

14.        Wang X-Q, Zheng J-J, Yu Z-W, et al. A Meta-Analysis of Core Stability Exercise versus General Exercise for Chronic Low Back Pain. Eldabe S, ed. PLoS One. 2012;7(12):e52082. doi:10.1371/journal.pone.0052082.

15.        Smith BE, Littlewood C, May S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskelet Disord. 2014;15(1):416. doi:10.1186/1471-2474-15-416.

16.        Coulombe BJ, Games KE, Neil ER, Eberman LE. Core Stability Exercise Versus General Exercise for Chronic Low Back Pain. J Athl Train. 2017;52(1):71-72. doi:10.4085/1062-6050-51.11.16.

17.        Shamsi M, Sarrafzadeh J, Jamshidi A, Arjmand N, Ghezelbash F. Comparison of spinal stability following motor control and general exercises in nonspecific chronic low back pain patients. Clin Biomech. 2017;48:42-48. doi:10.1016/j.clinbiomech.2017.07.006.
18.       Gomes-Neto M, Lopes JM, Conceição CS, Araujo A, Brasileiro A, Sousa C, Carvalho VO, Arcanjo FL. Stabilization exercise compared to general exercises or manual therapy for the management of low back pain: A systematic review and meta-analysis. Phys Ther Sport. 2017 Jan;23:136-142. doi: 10.1016/j.ptsp.2016.08.004. Epub 2016 Aug 18.