This post is for everyone. Technique Tuesday 8 explores hip hinging. Learn to move and lift correctly from the hips to avoid excessive pressure on the low back. I do want to mention that arching from the lower back to bend forward is not going to blow out your back, this is a natural movement. However, if you do it repeatedly, over and over again (due to work or any other reason) or you lift heavy weights with that posture, you could increase the chances of injuring your lower back. Here you go-
The thoracic spine (T-Spine) is an interesting part of the body. In recent times it has taken the brunt of the modern sedentary lifestyle of being hunched over on a chair and working on a computer for hours in a day for many months and years. These modern sedentary lifestyle changes and new work/office setups have had implications on our musculoskeletal system. What is interesting is that the T-Spine itself presents only with a few symptoms like mid back myofascial pain, stiffness, loss of mobility etc. However, other joints in proximity of the T-Spine are affected adversely due to this. Here is a list of problems we often see in an physiotherapy office that our closely related to an excessively stiff kyphotic T-Spine.
Shoulder impingement- An excessively kyphotic mid back places the scapula in a downwardly rotated, anteriorly tipping and protracted position. This position of the scapula has shown to decrease the sub acromion space in the shoulder when performing overhead activities leading to a common problem we see often; shoulder impingement/pain. Try this little test, try elevating your arm up to the maximum flexion elevation with a straight Tspine and shoulders pulled down and back and then with an excessive hunched over position. Which one feels better and which is worse? See the video below and try it yourself.
Neck pain- A kyphotic hunched over posture tips the head (weighing about 10-12 lbs approx.) anteriorly and extends our line of sight downwards to the floor. For compensation, we tilt the head backward which increases Cervical lordosis and causes upper cervical spine to go into extension to have a regular straight field of vision. This causes increase tone/tension in the cervical extensors often compressing the greater occipital nerve and other important cervical structures causing symptoms like neck pain, headaches, radiating symptoms etc.
Low back pain- An excessive kyphotic T-Spine pushes the thorax anteriorly and causes compensatory increase in the lumbar lordosis due to increased tension in the lumbar extensors causing pain at the low back. This is the classic presentation of the ‘Lower Crossed Syndrome’.
Breathing- Along with the above compensation, the thorax lifts up due to inability of the abdominal muscles to provide inferior stabilization (lower ribs flaring) decreasing overall chest expansion and causing poor breathing quality and control.
Furthermore, if you follow the joint-by- joint model of training by Cook and Boyle, you can see that the thoracic spine is meant to be mobile but has a tendency to get stiff.
So, here our some strategies/exercises we can use to maintain general T-Spine mobility. The angles drawn in the video are not exactly accurate and are used for demonstration purpose only-
Bench/chair thoracic spine extension with stick-
T-Spine extension on foam roller
T-Spine windmill rotation
Four point T-Spine rotation
Threading the needle
Closing thoughts, the mid back is meant to provide mobility but tends to get stiff and excessively kyphotic given our contemporary lifestyles. This can open the floodgates to a myriad of musculo-skeletal problems. It is paramount to keep working on its mobility.
Part deux of this blog is not really a course review but my thought on taking the Certified Mulligan Practitioner exam. To begin, I’ll say this, you don’t need to be a Certified Mulligan Practitioner (CMP) to be a good therapist. I know many physios who are great clinicians but haven’t taken the CMP exam. The Certified Mulligan Practitioner exam is a test to check your competency in Mulligan concept principles and application of techniques passing which you get the title CMP. Like I mentioned in the last blog, the Mulligan concept does not cover a whole lot on assessment/diagnosis. So the testing skips that part too.
What to expect in the test-
I gave the test back in 2010 and back then the test had two components. I have heard that the format has not changed a whole lot but don’t quote me on this.
Written Component- consisted of 50 MCQ’s. The Multiple choice questions which seemed tricky and often felt like they had more than one correct answer (they did not) was the easier part of the exam in my opinion.
The practical component- I believe was demonstration of 10-15 techniques (approx). Successfully passing the exam requires the test taker to be competent in each and every technique of the book and one would be asked to demonstrate any random 10-15 techniques covering all bases. This included everything- NAG’S, SNAG’S, MWM’S, SMWAM, SMWLM, headache SNAG’S, belt techniques, BLR, taping techniques etc. The practical component was conducted by two Mulligan Concept Teachers Association (MCTA) members; in our case one local from India and one from Australia.
Passing requires around 80% scores (approx) and attention to detail is important making sure one applies all the 7 principles of the concept when performing the techniques.
Is it worth it?
I can see why this question would cross someone’s mind. After all, one doesn’t need the title to practice in the profession or even to apply these techniques. You could just do the workshop/seminar course and still apply the concepts in your clinical practice. However, in my opinion it is worth it. Going through the extra grind has its advantages. I’ll give you not one but…. two!!
Early on in my career as a new grad, I always used my CMP credentials to bag better than average job opportunities and a little higher than average salary that a new physio would expect. To the new graduates starting their career in physiotherapy I’d say this, physio school will teach you the basics and how not to harm a patient but some of the curriculum is not up to date with the latest in the field and taking certifications will improve your overall clinical skills. It will also make you a more desirable candidate in the job market. Good physiotherapy offices value continuing education certifications and titles. CMP is a good title to have.
On becoming a CMP, you become part of the network of Certified Mulligan Practitioners. The database for a full list of CMP’s across the world can be found on the Mulligan website here.. This directory can sometimes be a good source of referrals for new patients/clients. I have had other mulligan practitioners refer patients who were around my practice and I have also had patients use this directory to find me directly. It can be quite a useful tool.
Hope this information helps. More course reviews to follow in some upcoming blogs. Lets keep the dialogue going. Until next time.
As we already know, the problem of glutes amnesia has reached epidemic proportions. Our lifestyle is not like what it used to be. More work gets done sitting on our behinds all day than ever before. Spend too long in sitting and we slowly start to lose the important movement of hip extension. In this blog post I would like to discuss two conditions that I have often seen in the past which can be directly or indirectly related to loss of hip extension (both lack of active control and loss of ROM). Seen in the general population and often perpetuated in runners. Lets begin-
Low back pain– while the causes for LBP could be endless, we will discuss the role of inhibited glutes and lack of proper hip extension in LBP. If we spend 8+ hours a day sitting on a chair (hip flexion), the glutes will be in an overstretched position and often inhibited. To add to those woes, the hip also gets stuck in a flexion position with classic ilicaus and psoas tightness. Now to maintain a upright posture and to compensate for tightness caused by excessive prolonged hip flexion which would put our trunk in a forward lean, the back extensors have to work harder to keep us upright. This often manifests as an increased lumbar lordosis (low back curvature). Prolonged time in this position can cause increase in tone of the lumbar erectors and could potentially cause low back pain. I see this often with recreational runners or those who are new to running. During running, if your hip do not go in to enough extension, the back begins to arch and the erectors being part of the posterior chain have to work extra hard. Remember the body is a great compensator but over time this catches up. This, I believe is often one of the common reasons why recreational runners come to see us for low back pain with running. If you are an athlete or a runner, this is not the best situation for running. Your glutes have lost their VIP status. No one likes weak glutes, unacceptable.
Plantar fascitis– I often find people with plantar fascitis have well developed calf muscles. It appears like its ‘calf raises’ day everyday for these folks however on further questioning you may find that they might not have been doing any calf strengthening exercises. If such is the case, I implore you to check for their active hip extension in walking or running especially during the midstance, heel off and toe off of the stance phase. This is the time when the leg should start to cross back behind the body due to hip extension. This is the primary movement that propels us forward. Now if the body lacks this crucial movement, due to weakness of the glutes max or tightness of the ilio-psoas etc the calf seems to become a more significant driver to push the body forward. Now multiply this a few thousand times a day (even more if you are a runner) over a few weeks, months or years and we have a overworked calf complex. As we all know, the calf exerts a pull on the plantar fascia (remember its a two joint muscle) and that irretates the PF blah blah, we all know this. So improving active hip extension and utilizing the full potential of the glutes is crucial to give the calf a break and in turn might relieve some stress of the PF.
The take home message is simple- Hip extension is a crucial movement for many daily activities and a lack of which might cause LBP or PF. When treating these conditions, don’t make the mistake of running after the symptoms like I have so often in the past. Here’s a little video to give you an idea of my thought process when analyzing hip extension in running.
(PS- this is not the only thing I look for, I’m only focusing on Hip extension here).
The week ahead is long and there is much to do, its only Tuesday. So we like to keep it short and sweet on #techniquetuesday. Today we discuss the plank. Plank is a great core exercise but often faulty techniques negates the true benefits of the exercise. In my mind, the true purpose of the plank is to engage the core to brace and protect a ‘neutral’ spine. However, I often find when performing a plank that the hold time supersedes good form. There’s a lot of excessive arching, ribs flaring out, more than desired hip flexion, cervical extension etc all for the sake of getting that extra 30 seconds. Here are some example-
Excessive lower back lordosis and cervical Extension
Excessive hip flexion
Try this instead-
Remember, the spine is not perfectly straight so a little ‘natural’ arching is acceptable. A cue I often use is to gently pull the front rib cage down towards the feet, I’m not a big fan of the cue ‘drawing the belly button towards the spine’ because it interferes with normal diaphragmatic breathing (which is important for proper core engagement).
If the plank off the feet/toes is hard, regress it to ‘off the knees’ like this-
Got a long drive ahead of you that you are dreading? Feel stiff and achy sitting all day. Below I present to you some simple exercises, stretches and strategies that you should try and incorporate if you know you would be behind the wheel for a few hours. Make them a non negotiable part of your drive (safety permitting) and more likely than not, your body will thank you for it.
Here you go-
1. While driving
(Disclaimer- do not take your hands of the wheel for more then 2-3 seconds and never both together, driving safety comes first. Do not let these exercises distract you from the primary activity of driving, I do these often and they are like second nature to me. Only perform them if you feel comfortable to do so safely depending upon your traffic conditions. Practice them at home or work first and then incorporate them carefully while driving. If you still feel unforgettable, avoid this and try the strategies in step two).
2. Take breaks often and move
Try holding the stretches in the above videos for about 30 seconds and repeat 2-3 times. For neck, wrist, back exercises that are not stretches, try about 10 repetitions. Although you ‘might’ feel some discomfort due to staying in one place for some a few hours, none of these exercises should cause pain. If they progressively increase pain and/or discomfort every time you do it, STOP. DO WHAT YOU CAN.
Always remember, the body is not meant to sit in one position all day and ‘motion is lotion’ for your body. Consult your physio if you have pre existing conditions as some of these exercises might not be right for you.