Are Dead Bugs Poison for your back?

Dead bugs are a common exercise prescribed for lower back stabilization.

Pictured above, it involves the actions of both hip flexion and shoulder flexion.

I have mentioned in my previous posts that while most people, measure hip flexion range of motion within normal limits, they  lack the ability to flex the hip without compensating into the pelvis and lower back.When we consider this fact, stabilization in the lumbar spine would not be possible for many to achieve. For those individuals, this exercise would be a harmful waste of time.

To determine if this is the case in your patient, place them in supine or sidelying, gently palpate just above ASIS or just below PSIS, and have the patient slowly flex their knee toward their chest. At the point in the range of motion when the ASIS or PSIS begins to move, is their uncompensated hip flexion range of motion.

Beyond that range they will be achieving motion in their pelvis which could lead to SI problems or motion in their lumbar spine leading to pathology there. 

For me it is about 70 degrees.

Every time I sit, squat or lift my leg higher than 70 degrees of flexion, I am getting motion in my lower back. This explains why sitting for a period of time aggravates my back. 

If I performed  Dead bugs as outlined above, it would aggravate my back.

Uncompensated motion needs to be restored or range of motion for the needs to be limited or modified before any exercise is prescribed; otherwise the exercise may be contributing to our patient's problem.

Post Script:

While the focus of this entry was on the hip, it is important to note that a patient performing dead bugs may also lack shoulder flexion that is compensated for with back extension.

Stabilization versus Mobilization deciding how to treat

Location of pain is often not the location to mobilize

Look at L4 in the following video and note when movement occurs at that segment.

For this patient any and all ADL’s that involve the slightest amount of trunk flexion, including but not limited to; dressing, brushing teeth, doing dishes, cooking, and reaching for items all elicit mobility and pain to the L4 region where he has a HNP.  Even if we teach him to perform a full squat to retrieve an item off of the floor he will still elicit motion to L4, secondary to his severe limitation of trunk flexion without compensation (movement) to his lower back.

98% of pain is caused by hypermobility or excessive motion which causes, inflammation, more pain and greater instability as our stabilizing core muscles shut down by 1% for every cubic centimeter of inflammation. It is why surgeons fuse joints, we brace body parts, and doctors cast broken bones.

Unless there is a blunt trauma hypermobility is caused by hypomobility elsewhere. To adequately treat pain we need to stabilize the area hypermobility and mobilize the area or areas of hypomobility.

Recently, I evaluated a shoulder patient who was considering another RTC surgery secondary to pain and inability to play tennis. Like the above LB patient in the movie,  when observing almost every PROM of that upper extremity including, forearm supination, he presented with early and excessive movement (hypermobility) and crepitus at the Glenohumeral  joint. He would compensate for a lack of motion in the forearm and humerus with hypermobility at the GH joint.

Treatment for this patient was to stabilize the shoulder while mobilizing up the kinetic chain. The rationale for this is there will now be attenuation of movement forces through the system and a delay or elimination of motion at the Glenohumeral joint. Post mobilization of the the forearm, there was no motion at the shoulder with full supination only at the forearm where it should be. Post mobilization of the structures around the humerus early motion of the GH joint was delayed or eliminated. 

Note I did not mobilize this patients shoulder but provided stability in the GH joint where he was hypermobile and mobility to the structures of  forearm and humerus that were hypomobile. 

What the Heck is the ARMS Release Technique

What the heck is the ARMS Release Technique?

No. It is not a technique to treat someone’s arms.

ARMS is an acronym for Active Release with Manual Stability.

The ARMS release technique is a mobilization technique that utilizes the Therapy Principle that states you need to have stability in order to have mobility.

This ARMS technique evolved from: PNF developed by Maggie Knott and Dr. Herman Kabatt, Functional Mobilization developed by Gregg Johnson and used by the Institute of Physical Art, and as stated before, the Therapy principle that the human body needs to have stability in order to have mobility.

It was discovered when I was unsuccessful in mobilizing a sacral restriction on a patient using the techniques that I had been taught.

I was presenting at an inservice, I was embarrassed and flustered as no matter the technique that I tried,  I could not release that damn Right Sacral Base.  In the my moment of panic I recalled my Orthopedics Professor in PT school stating “You need to have stability in order to have mobility”.

I applied a stabilization force to this patient’s abdominal core based on PNF principles.  As my force to the patient’s abdomen increased the restriction completely released. To my shock and amazement, I did not even need to perform any other type of mobilize.

I hypothesize that restricted tissue; aka. Hypertonic tissue, dysfunctional tissue, trigger point, knotted muscle may be caused by a protective mechanism for instability elsewhere. 

I think this may be why some releases, dry needling, and injections are only temporary in their results.

To view an example of The ARMS Release Technique being performed on a finger click:

http://www.youtube.com/watch?feature=player_detailpage&v=ONBmgLewr0w

The Benefits of the ARMS Release Technique include:

• The ARMS technique involves patient movement during the treatment.
• It is less painful than other release techniques
• The Patient is in control and therefore will not move in a manner that will cause them harm.
• The patient is performing re-education and stabilization as they are releasing.
• Because the patient is performing; exercise, neuromuscular re-education and release, 97140, 97112, and 97110 will always be appropriate to bill. Depending on the movement that the patient performs 97530, 97535, and 97116 may also be appropriate.  
• It can be used to release any and all Connective and Nerve Tissue

When I showed this technique to a renowned PT and educator, he encouraged me to teach it to others. I have chosen to do so. 

Increase Dorsiflexion by Treating toes?!

How would you treat this patient, what do you notice?

I think that we all agree that this patient lacks dorsiflexion, especially since his knee is not in full extension causing his fibular head to be off of the ground. When the knee flexes with dorsiflexion it is compensation for a lack of dorsiflexion.

What would you treat?

If you asked me this question 5 years ago, I would have said the following:

•        Mobilize the gastroc/soleus
•        Mobilize the talus
•        Manipulate the talocrual joint

All of the above are valid answers, non of them are correct. 

Today, using the principles of Diagnostic Motion Evaluation (DME) I would say mobilize; the proximal phalanx, and the metatarsal 2 and 3.

How do I know this?

The rule of Diagnostic Motion Evaluation states that in an open chain activity the therapist should begin evaluating for motion distal to proximal.

This picture reveals lots of motion (hypermobility) into extension of the toes, another compensation for a lack of dorsiflexion.  You can actually see a dent in the skin between the base of the phalanges and the metatarsals.  The restriction to motion is definitely not in the toes.

There is no lifting of the metatarsals into dorsiflexion and that is where this person’s restriction is.

 Notice the difference in motion of the metatarsals in this picture:

Before using DME I would waste valuable time treating valid structures that could cause dysfunctional motion. Now I can easily find dysfunction that is inhibiting motion or causing pain.

The link below shows a patient who I restored full dorsiflexion, simply by treating her big toe. By the way she happens to also have Cerebral Palsy.

www.sigproed.com/res_before_after.html#neuropatient_dorsifexion

Learn this invaluable technique at our upcoming NY classes register now at

http://www.sigproed.com/live_seminars.html

Sitting is like smoking-unfiltered-menthols-while-easing-cheese-coated-lard-and-screaming-at-your-spouse bad

“Sitting is like smoking-unfiltered-menthols-while-easing-cheese-coated-lard-and-screaming-at-your-spouse bad. “ A quote I love from AJ Jacobs in his book Drop Dead Healthy.

He goes on to document research that shows that sitting puts you at risk for the following:

•   Heart disease
•  Diabetes
• Obesity
•  Cancer including colon and ovarian

Sadly, studies show that even regular gym going can’t fully undo the harm of sitting. A study conducted by the University of South Carolina and Pennington Biomedical Research Center compared heart problems in men who spent more than 23 hours per week sitting and those who sat for less than 11 hours. The sitters had a 64 percent higher chance of fatal heart disease. Of those studied many were exercisers a t the gym

Jacobs fails to mention the physical maladies, we see as Therapists that caused either directly or indirectly  as a result of prolonged sitting.

1.  Back Pain: The vertebrae are constructed to provide equal weight bearing about 3 points. When most individuals sit position themselves in flexion causing increased weight bearing to the front of the vertebrae which in turn squishes the malleable discs posterior. This in turn leads to degeneration, bulging, and ultimately herniation of a disc .
2.  Breakdown and decubiti: Because most people do not distribute their weight about the 6 potential bases of support, they bear weight on their Ischial Tubs or their sacrum leading to the breakdown of the skin
3.  Neuromuscular Deficit: When we sit in flexion or with our legs extended to compensate for a chair that is too low or too high. We do not weight bear into the bottoms of our feet and our pelvic floor. This contributes to a decreased stimulation which will decrease proprioception. Proprioception is the sense that tells our body where it is in space and is an integral component of balance. Research shows that proprioception decreases with age and there is a significant.

The reason that sitting so bad from a biomechanical standpoint is that in most people sitting reinforces the flexion components at your hips, pelvis and spine.

The reasons being:

1.  Chairs are the wrong size for most people. There are many varieties in the size of people, but when it comes to chairs, there is a one size fits all mentality. It is like having every person on earth wear a size 5 shoe.

2. Most people lack hip flexion. If you told this to me 5 years ago, I never would have believed it to be true.  I mean most people can easily bring their knees to their chest.  The fact is that neither I nor most patients can bring their knees to even 90 degrees of flexion without compensating up the kinetic chain.

Take the following test:

1.  Stand holding onto a stable surface with one hand.
2.  Take you free hand and place your fingers just above your ASIS on the same side as your body.
3.   Raise the leg that is on the same side that you are palpating.
4.  Stop when you begin feel your ASIS  move into your fingers.(This is the point when your innominate begins to move into posterior rotation).

At the point just before your ASIS begin to move should be the height of your chair.

For me this is about it is about 80 degrees.

Any height that is lower than that level will cause your innominates to posteriorly rotate and you will be weight bearing on your coccyx and sacrum versus your pelvic floor. This will also alter the force of gravity acting on your vertebrae and move the weight bearing onto your discs posteriorly.

What can we do? Studies show that we on average spend 56 hours a week sitting.

Here are some tips:

1.  Raise the height of your seat to the level just before innominate rotation. In my case I am now sitting on pillows so that the angle of my hips is in 80 degrees of flexion.  If the chair raises great, if not add pillows.
2. Straddle the chair. Take the above test again but this time abduct and externally rotate your hips. Notice you can now go lower without innominate rotation.
3.  Mobilize the structural restrictions in your thigh.

Ø  If you begin to rotate between 0-30 degrees palpate the circumference of tissue in the entire lower 1/3 of your thigh.
Ø  If rotation began between 30 and 60 degrees palpate the middle 1/3.
Ø  Between 60-90 degrees the upper 1/3.

Goto www.sigproed.com for a list of resources and our upcoming classes