One of the most common types of stress-related headaches is called a cervicogenic headache. This type of headache is the result of referred pain from boney or soft tissue structures in the neck. When your upper trapezius goes tense from stress and one of the attachment sites of the trapezius is the base of your skull, what do you think the end result could be? That’s right. A cervicogenic headache. When it comes to special testing such as XRays or MRI, there is no clear relationship between degenerative changes of the discs or cervical vertebrae and headaches (Ylinen et al 2010). As a result, most of our assessment comes from functional and palpation testing of the cervical joints and soft tissue. Conservative management of neck and headache pain often includes passive therapies such as the many specialized soft tissue techniques that we offer at OrthoWell Physical Therapy. But what does the research say about exercise-based interventions? Do neck exercises help cases of cervicogenic headache? According to Ylinen et al 2010, they certainly do. The strength group performed one set of 15 reps (in four directions) of cervical resistance training using rubber bands, upper extremity dumbbell exercises, and neck stretches 5x/week in combination with 4 hands-on physical therapy treatments. The control group performed only daily neck stretches, cardio 3x/week, and no physical therapy. What they found, at a 12 month follow-up, was that headache pain decreased by 69% in the strength group and only 37% in the control group. A more detailed analysis of the study can be found at the Theraband Academy website. In conclusion, the evidence-based combination of hands-on physical therapy, exercise, and patient education would be the best approach to resolving cervicogenic headaches.
As most of you know, a very important part of our practice is the treatment of soft tissue dysfunction. This may be in the form of a muscle “knot”, chronic scar tissue, or post-surgical stiffness. We have many names ie “the doctors of knotology” and “the Marquis de Sade” to name a few. In spite of the many terms of endearment, at OrthoWell, we get our patients better- Faster! because of our approach. A very important part of your recovery has to do with your home program. Every conditioning program should include stretching, strengthening, cardio, and a close fourth should be self-massage and/or self-mobilization. Many of you have experienced “the twins” (my double tennis ball massager) as well as the foam roller. It is important to address your chronic “knots”, scar tissue, and muscle sensitivities in order to promote optimal tissue dynamics and to prevent future pain syndromes related to poor tissue dynamics.
The following video highlights our foam rolling strategy for your lower extremities. Each muscle group should receive 5-10 passes along the foam roll. The amount of weight you impart upon the roll will be dictated by your tolerance. Yes, this should hurt! Only mild to moderate pain, nothing severe. Use your arms and opposite leg to control the pressure being applied. Try to identify key areas along the way that may need additional passes. Yes, over time, the pain will subside and your pressure will increase. Consistency is the key. Ideally, stretching and self-massage should happen daily. Here is a run down of what is happening in the video.
1. In the first part of the video, I am treating the quadriceps. Longer muscles need more attention. Perform 5-10 passes each at the upper end, middle, and lower end of the muscle.
2. Turn 45 degrees and perform the same treatment at the junction between the quadriceps and iliotibial band(ITB). Pay close attention to the lower end near your patella.
3. Turn another 45 degrees and, in the same manner, treat directly along all three aspects of the ITB.
4. Next, turn over and treat your upper glute area. Cross one leg over the other as shown. The leg that is crossed is the side you are treating. Perform 5-10 passes.
5. Move down to the hamstrings and treat the upper, mid, and lower ends. Place your opposite leg on top of the treatment leg in order to impart more pressure.
6. Next, treat the calf muscle. Place the opposite leg on top for more pressure. Treat the entire length of the calf. You can also perform an up/down ankle movement in order to help glide the stiff tissue while imparting pressure onto the roll.
7. Finally, treat the inner thigh or adductor muscle group. It may be easier to use the 6” roll to treat this area effectively. You can purchase a white 6” roll which is the same material as the 4” or you may purchase the black roll which is firmer than the white.
So what are the BEST evidence-based Core exercises?
Evidence from random controlled trials of people suffering from low back pain show that core stabilization exercises result in significant improvements in pain and function(5,7) . However, the most effective combination of which muscles to target and which stabilization methods to utilize are still debated(1-11). One technique that has been suggested is abdominal hallowing or “drawing-in” your navel to activate the transversus abdominis (TrA) muscle. This technique has been shown to increase the cross-sectional area of the TrA(10), however, many exercise scientists are now advocating a method called “abdominal bracing”(demonstrated in my last post) in which ALL the abdominal muscles are recruited instead of just one(11). It should be the goal of core exercises to activate as many torso muscles as possible in order to ensure spinal stability and to prepare our bodies for the dynamic and often complex movements that occur during our daily activities. So what does the research say about which exercises activate which muscles the best?
Numerous studies have used EMG to determine the greatest electrical activity of torso muscles during various core stabilization exercises. In Escamilla et al(3), they used surface or skin electrodes to compare exercises such as traditional crunches, sit-ups, reverse crunches, and hanging knee-ups using straps to exercises using an Ab Roller/ Power Wheel and a device called the Ab Revolutionizer. What they found was that the activation of the upper and lower rectus abdominis(the “washboard” muscle) as well as both the internal and external obliques was the greatest with Power Wheel roll-outs and hanging knee-ups with straps. Because research indicates that the internal obliques are activated in the same manner(within 15%) as the tranversus abdominis(3), we can assume that these results apply to the TrA as well. The activation was least with a traditional sit-up! In Okubo et al(8), they used both surface electrodes and intramuscular fine-wire to compare curl-ups, side planks, front planks, bridges, and bird dogs. What they found was that the TrA was activated the greatest during front planks with opposite arm and leg raise and that multifidus activation was greatest with bridging. Although core stabilization exercises should be performed in multiple planes of motion, these two studies highlight the enhanced activation that occurs during “face down” exercises such as front planks and roll outs.
The functional progression of exercises as well as training in all planes of motion are important aspects of OrthoWell’s core stabilization program. Our program will uncover your weaknesses and maximize your strength by progressing through successive levels of difficulty in all directions of movement ie anterior, posterior, lateral, and rotatory. Optimal development of the “local” system ie your functional neutral position and bracing technique(my last post) should occur before attempting to train the “global” or big muscle system. Unfortunately, most people over-train the global system and need to be re-educated. So be patient as we take you by the “core” and steer you in the BEST, evidence-based direction.
The following videos are examples of some of our functional progressions for each plane of motion(sorry for the occasional “sideways” view). I demonstrate a particular exercise and then follow with an exercise of progressive difficulty. Functional progression is very individualized and requires skilled observation to determine competency. Many thanks to two of my peers, Mike Reinold,PT and Eric Cressey for being very helpful in this regard.
Anterior Core Stabilization Exercises
Anterior/Posterior Core Stabilization Exercises
Posterior Core Stabilization Exercises
Lateral Core Stabilization Exercises
Rotatory Core Stabilization Exercises
1. Allison GT, Mo4444rris SL, Lay B. Feedforward responses of transversus abdominis are directionally specific and act asymmetrically: Implications for core stability theories. JOSPT. 2008; 38: 228-237.
2. Ekstrom RA, Donatelli RA, Carp KC. Electromyographic analysis of core trunk, hip, and thigh muscles during 9 rehabilitation exercises. JOSPT. 2007; 37: 754-762.
3. Escamilla RF, Babb E, Dewitt R. Electromyographic analysis of traditional and nontraditional abdominal exercises: Implications for rehabilitation and training. Physical Therapy. 2006; 86: 656-671.
4. Faries MD, Greenwood M. Core Training: Stabilizing the Confusion. Strength and Conditioning Journal. 2007; 29: 10-25.
5. Hall L, Tsao H, MacDonald D. Immediate effects of co-contraction training on motor control of the trunk muscles in people with recurrent low back pain. Journal of Electromyography and Kinesiology. 2007; 19:763-773.
6. Hides J, Stanton W, McMahon S. Effect of stabilization training of multifidus muscle cross-sectional area among young elite cricketers with low back pain. JOSPT. 2008; 38: 101-108.
7. Hodges P, Kaigle A, Holm S. Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: In Vivo porcine studies. SPINE. 2003; 28: 2594-2601.
8. Okubo Y, Kaneoka K, Imai A. Electromyographic analysis of transversus abdominis and lumbar multifidus using wire electrodes during lumbar stabilization exercises. JOSPT. 2010; 40: 743-750.
9. Stanford M. Effectiveness of specific lumbar stabilization exercises: A single case study. Journal of Manual and Manipulation Therapy. 2002; 10: 40-46.
10. Critchley, D. Instructing pelvic floor contraction facilitates transversus abdominis thickness increase during low-abdominal hollowing. Physiother. Res.Int. 7:65–75. 2002.
11. Kavic, N., S. Grenier, S.M. McGill. Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine. 29:1254–1265. 2004a.
So why is it that 80% of people at some point will experience low back pain? Is it that we were never meant to evolve from knuckle dragging or is there a better reason? The answer to this question has more to do with common sense than with evolution. What do you think would happen to your car if you didn’t put oil in the engine? Common sense. Right? So why is it difficult for some people to understand the importance that proper posture, body mechanics and exercise play in spinal disorders such as neck and low back pain, herniated discs, and sciatica? Let me explain. First, let’s think of the discs in between your vertebrae as water balloons. When you squeeze one side of the balloon, the fluid will move in exactly the opposite direction. Right? However, physics tells us that when a pressure is exerted on a closed system, the pressure is equal in all directions . This would be true for a “healthy” system. So, yes, when the disc is healthy and strong, the pressure exerted on the disc is the same in every direction. However, what if one of the “walls” of the system is weaker due to chronic overuse and microtrauma? Think about the daily sloucher at the computer.
The more we are slumped, or flexed forward, the more stress that occurs to the back part of the disc. Remember, if we pinch the front, the fluid moves toward the back. In this regard, evolution is cruel, because the back part of the disc is the thinnest and the most susceptible to trauma. Bingo! The origins of a bulging disc. Why is it that some people with low back pain have an MRI and it doesn’t show a bulging disc? Oh, and by the way, radiologists use the terms “bulging”, “herniated”, and “protruded” interchangeably. Some even go as far as saying “there is bulging, but no herniation”. Huh? The proper medical terms would be protrusion, extrusion, and sequestration. I hope you’re not totally confused now! So what if the radiologist report says “only mild bulging” of the disc? Does this mean that the disc is definitely not the origin of the pain? Absolutely not! Although there is no clear relationship between the extent of disc protrusion and the degree of clinical symptoms, the periphery or annulus fibrosis of the disc is highly innervated. In fact, Bogduk in 1981 reported that “nerve fibres were found up to a depth equivalent to one third of the total thickness of the anulus fibrosus”. Edgar in 2008 confirmed this deep penetration of sensory nerves into the disc. Therefore, any trauma or even “mild bulging” to the peripheral layers of the disc could elicit pain. Kuslich confirmed that probing and electrical stimulation to the annular fibers could produce local LBP, but not leg pain. However, Ohnmeiss discovered that partial or full thickness anular tears, with or without disc bulging/herniation, can reproduce sciatica symptoms in about 60% of properly screened patients with chronic lower back pain . So then, what is sciatica? It is referred pain down your leg from a pinched or irritated nerve or from a traumatized disc or facet joint. The facet joints are the “winglike” structures in the picture below and, as you can see, the spinal nerves exit the spinal canal right next to the disc. Hersch showed that injection of an “irritant” such as saline into the facet joints of the spine can cause LBP. In addition, McCallwas able to reproduce sciatic symptoms with facet joint injections. It has also been well documented that a protruded disc can cause a “pinched nerve” and associated sciatic symptoms. Ouch!
So what does all this evidence mean for you? It means that the source of your low back pain is not always definitive. It can be multifaceted. In most cases, a thorough physical therapy evaluation will determine your neural sensitivities and functional impairments. Common sense tells us that avoiding postural stresses will place the body in an optimal position to heal. Appropriate manual therapy such as joint & soft tissue mobilization and manual traction as well as evidence-based spinal stabilization exercises should alleviate and prevent reoccurrence of symptoms. These will be the topics of the next two blog posts. So stay tuned!
