Functional Fitness and Chiropractic- Body weight

Jeffrey Sergent DC

Jeffrey Sergent DC

2004 Michigan State University- Environmental Science

2008 - National University of Health Science

Post graduate training

300 plus hours Diplomat, Rehab American chiropractic Council

McKenzie Mechanical Diagnosis and therapy, A-C

Dynamic Neuromuscular Stabilization, DNS, Clinical A-C, Certified Exercise Trainer

Functional Movement Systems I and II

Movnat certified trainer

Selective Functional Movement Assessment

Primary Spine Practitioner - University of Pittsburgh -Current

Functional exercise and ChiropracticPurpose of today's lecture is to give focus on what ailments enter our office, giving clinicians a background of the current training methods and theories and how it impacts our patients

This will not make you an expert in crossfit, oly lifting, powerlifting

This will give you a lens into evaluating, treating and mindset of our training and fitness patients.

We will take time to go through the exercises on form in preparation to helping our patients take away the “hammer” and keep them active.

Agenda Definitions - Work out terms, rehab terms

Exercises - Fitness/Rehab, both? Body weight exercises

Common faults

Clinical evaluation

Rehab and treatment of common conditions

Ice breaker Think of your schedule for monday.

Patient vs Doctor view Psychologically informed practicePerceptions of athletes can be skewed. They are not super humans

The thoughts that athletes have about experiencing pain:

Game ending, Fitness ending,

The words we use matter.

Patient one30 year old, female, US Triathlon team

Presented with Severe neck pain

Thoughts: can not work out and train, has to cancel her training center visit and appointments can not make it to nationals, can not make it to worlds, get kicked off team

Intervention: discussed how much she had been training (she’s resilient), showed her what she could do, create an rehab program that went through the changes and put her injury as a gift

Patient 2 52 year old male, self proclaimed “Crossfitter”, started on weight loss journey 3 months ago. Started because he was overweight, hypertension and close to being diabetic.

Presented with Lower back pain

Thoughts: all his hard work is for nothing, he is going to gain all the weight back, getting back to workout is never going to happen.

Intervention:

The Lancet – Low back series 2018

● MSK disorders are number 2 leading cause of disability world wide

● Guidelines recommend self-management, physical and psychological

therapies, and some forms of complementary medicine, and place less emphasis on pharmacological and surgical treatments; routine use of imaging and investigations is not recommended

The Lancet – Low back series

● The evidence:

● Little prevention evidence exist

● Exercise and education best evidence

● Ergonomic alone – ineffective

● “Non-evidence-based practice is apparent across all income settings; common problems are presentations to emergency departments and liberal use of imaging, opioids, spinal injections, and surgery “

The Lancet – Low back series

Exercise Therapy

Spinal Manipulation

Behavioral Therapy

The Lancet – Low back Serie

● Overall:

● Spend more = worse outcomes

● Patient Centered Care for best outcomes

The Lancet ● Low back pain● Published: March 22, 2018● What low back pain is and why we need to pay attention● Jan Hartvigsen, Mark J Hancock, Alice Kongsted, Quinette Louw, Manuela L Ferreira, Stéphane

Genevay, Damian Hoy, Jaro Karppinen, Glenn Pransky, Joachim Sieper, Rob J Smeets, Martin Underwood on behalf of the Lancet Low Back Pain Series Working Group

● The Lancet, Vol. 391, No. 10137

● Prevention and treatment of low back pain: evidence, challenges, and promising directions

● Nadine E Foster, Johannes R Anema, Dan Cherkin, Roger Chou, Steven P Cohen, Douglas P Gross, Paulo H Ferreira, Julie M Fritz, Bart W Koes, Wilco Peul, Judith A Turner, Chris G Maher on behalf of the Lancet Low Back Pain Series Working Group

● The Lancet, Vol. 391, No. 10137● Low back pain: a call for action● Rachelle Buchbinder, Maurits van Tulder, Birgitta Öberg, Lucíola Menezes Costa,

Anthony Woolf, Mark Schoene, Peter Croft on behalf of the Lancet Low Back Pain Series Working Group

● The Lancet, Vol. 391, No. 10137

JAMA 2018 Physical activity guidelines for Americans

Guidelines for kids

● 3- 5 year: Active through out the day

● 6-17: 60 minutes or more per day○ Moderate to vigourous

Adults ● 150 -300 minutes per week

moderate intensity● Or● 75-150 vigorous or equivalent

combination of moderate and vigorous

● AND● 2 or more strength days per week● Older adults need to focus on

balance as week

Current state of careMusculoskeletal conditions are on the rise. Low back pain being the highest increase in visits.

They are taking up more visits to the ER and PCP than ever before. From 8/100 visits to 13/100 over the last 10 years.

MSK super market: PCP, PMR, Surgeon, ER, Pain management, PT, DC, LMT, LAC, ATC, ND, Rolfing, Personal trainer, Google, devices, Reiki…. The list goes on

Who do they chose and why?

Exercise and Chiropractic SMT: Best short term outcomes (better than exercise alone)

Exercise: Best long term outcomes

SMT + exercise = “perfect marriage”

LBP guidelines,Joint pathology, Tendonipathy guidelines around the world require “Promoting functional Restoration”

Having an understanding of what our patient are doing outside and how we can promote a life of exercise is key and the “golden ticket” to long term success for our patients.

Healthcare 3.0Patient centered care

Doctor treats with the best evidence

Patients and Doctor form a team

Chiropractors can lead this!

Movement primary care

Focused on conservative management- chiropractic adjusting, nutrition and exercise.

Closed Chain/open chainOpen chain: O-I

One primary joint

On stationary other mobile

Isolated joint motion

One plane of mov’t

Non - functional

Closed Chain: I-O

Multiple joints axes

Both segments move simaneoulsy

Multiple joint movements

Multiple planes of movement

Significant functional oriented

In respect to joints:

Closed chain- Distal aspect of extremity is fixed

Open chain - proximal aspect of the extremity is fixed

Karel LewitIf breathing is not normalised – no other movement pattern can be” Karel Lewit, MD

Cylinder

Inferior drawParachute effect

Definitions Exercise programming

1. EMOM- Every minute on the minute: scrutinies the power of recovery

5 push ups, 10 squats every minute for 10 minutes

2. AMRAP- As Many Reps/Rounds as Possible. Pushes endurance, power and mental strength

12 minutes of 8 back squats and and push press

Definitions...3. RFT : Round for Time. Completing a given number of rounds of a circuit as fast as possible. Short rest helps develop timing and muscle endurance

Eight rounds of 15 KB swings, 10 KB clean ans press and 5 KB Snatches

4. Chipper: One round series of exercises, usually with high reps, to be completed in the fastest time possible. A high volume, muscle building grind

100 wall balls, 75 body weight squats, 50 push ups, 25 pull ups

Definitions Workout5. Ladder: One or more movements, increasing or decreasing with workload overtime

1-10 reps of goblet squats super set(no to minimal rest) with 10-1 reps of pull ups

6. Tabata: Do eight rounds of high intensity intervals, alternating 20seconds effort with 10seconds rest. Fast eviscerating finisher

20 seconds of assault bike for max calorie

Workout definitionsMetCon - Metabolic conditioning-

Dynamic training of challenging and cardio sessions

As opposed to traditional trunning of cardio training, long runs on the treadmill or elliptical

Body weight exercisesCommon ones

Push up

Pull up

Air squat

Burpee

Core

Push up“Ideal push up”

Armpit line/nipple line - can do a T test - arms to T, bring them in front,then retract back

Toes “dug in”

Push through full hand and torque through elbows on raise

Neck retracted or neutral

IAP through out movement

Push up Common mistakes

-Can not retract scapula and protract/elevate to push up

Rx: Scap stabilizer strength/motor control/T spine mobility

-Shear of the lower back

Rx: Anti shear exercises/core endurance/T spine mobility

- Distribution of weight through the hands transfer to outside of hand

Rx: Scap stabilizer strength/motor control

-Neck is a “noodle” or looking at abs

Neck endurance and Core endurance exercise, Scap stabilizers

Pull up

Ideal pull up

Grip - shoulder width apart

Shoulders pact

Elbows in front of body

Try to pull hands “in and down”

Hollow position- seals up energy leaks- feet pointed, glutes/core tight

Attack bar with chest

Pull ups common mistakes -Grip

Too close lots of elbow/brachioradilius primary mover (important but not driver)

Too wide allows for elbows to flare, causing protraction/elbow

Caved position of the chest- thoracic flexion and protracted shoulders

Neck extension

Feet crossed

Pull up- rehab treatment Scap stabilizers strength

Grip strength- can you hang the amount of pull ups you want to do?

Core endurance

Full external rotation/supination of the UE, supination

Air Squat -not loaded Foot placement - slightly greater than shoulder with apart, slight external rotation

Foot tripod- 3 triangle of the foot

Elongate through spine, keeping neck retracted

Knees travel to the mid foot, over foot

Arms stabilize the body as counterweights

Hip travels to 110 ish degrees with no butt wink, below that is okay

Tibia is parallel to spine angle at the bottom

Triangle position of the foot

1st metatarsal

5th metatarsal

Calcaneous

Increase surface areaIncrease ground reactive forcesBetter position

Air Squat - common mistakes

Toes flaring up- Stiffness in foot joints and muscles

Knee valgusity - Hip strength vs. ankle mobility

Quad dominance - Hip strength vs. ankle mobility

Forward flexion - Hip strength vs. ankle mobility

IAP loss

BurpeeSquat down to 100 degrees

Place hands on the ground shoulder width apart

Lower chest and thighs to the ground

Jump feet up to hands

Jump vertically with full hip and knee extension

Combining the rules of push up and squat

Common faults of the burpeeShearing of the spine

Core endurance and anti shear training

Hip impingement- feet too close together

Cue different or hip strengthening

Hands too far apart leads to protraction of the shoulders

Shoulder stabilization, thoracic spine mobility

CoreSit up

A traditional sit-up generates at least 3,350 newtons (the equivalent of 340 kg) of compressive force on the spine. The U.S. National Institute for Occupational Safety and Health states that anything above 3,300 newtons is unsafe.

PlankPlanks

Common faults

Neck looking at abs

Shoulders not centrated

2 minutes max

UE Pathology - Examination

Rule out cervical spine

Elbow 44%

Wrist 38.5%

Shoulder 47.5%

Neuro exam and MDT exam key

Cervical spine : physical examArm Squeeze

“..squeezing with the hand [simultaneous thumb and fingers compression, thumb from posterior (triceps muscle) and fingers from anterior (biceps muscle)] of the examiner, the middle third of the upper arm, elicited local pain”-Eur Spine J (2013) 22:1558–1563

The test was considered as positive when the score was 3 points or higher on pressure on the middle third of the upper arm compared with the other two areas (difference between results in middle third of the upper arm area and in the acromioclavicular joint and subacromial area).

Shoulder exam 180 deg of passive range of motion

Active Shoulder Abduction

180 degrees of shoulder abduction

Pass shoulder moves through range of motion with no pain

Fail: elbow flexion, shoulder hike, “ concaving” of teres and infra

SCAP STABILIZERS● Serratus anterior● Lower trap ● Rhomboid● Levatorscap● Latissumus dorsi

OTHER MUSCLES THAT CROSS THE SHOULDER JOINT● 2 heads of the bicep● 3 heads of the tricep● Pect major● Pect minor● Coracobrachialis● Deltoid ● Teres major

SUPRA SPINATOUS INFRASPINATOUS

TERES MINOR SUBSCAPULARIS

Generalities of TendinopathyPresentation:

History of overuse or load recently

Pain is point variable 1-2 fingers width

Hurts to weight bear

Change direction painful

Moderate to severe pain

Swelling

Tendon pathologyContinuum model of tendinopathy

1. Reactive a. Young 15-25yrs oldb. Uncommon painful

2. Degenerativea. Older than 30-60 yrs oldb. Rarely present clinically

3. Reactive on degenerativea. Older 30 plus yrs oldb. Common in practice-painful

Tendinopathy- Cook et. al. Tendinopathy

Tendinopathy TreatmentDuring the reactive-degenerative stage: Tape, Adjust, biofreeze, Nutrition

These are not very resilient, can be aggravated by exercise

Isometric exercises 45sec hold x5 with 2 minutes in between, 2-3 x daily

Start affecting other parts of the chain

Take away painful events and movements.

Rest is NOT best.

Tendinopathy treatmentOnce the pain has reduced add in isotonic movements: eccentric and concentric

Evaluation: as load increases pain should decrease

If you load to early, the patient will let you know

Rule of thumb is 3-4/10VAS during exercise and no worse the next day

Last, Get patient ready for sport or athletic endeavor

Fix Mechanics, this can be through Manual muscle testing, functional movement screen, or other pertinent movement assessment

Shoulder exam Shoulder flexion: 180 degrees of movement

Pass: able to move through pain free with no elbow flexion

Fail: elbows bend, shoulder hikes, pain

Serratus anterior: Manual muscle test

Test through range of motions

Empty can test:

Standing at same time

WALL ANGEL ● This is a gross motor and range of motion test● Use goniometer for more exact quantification

Standing UE multi segment testPatient hands out in front :

Test Wrist extension - shoulders at 90, elbows at 0.

Patient then takes wrist through flexion and extension

Clinician is looking for compensation through chain and obvious difference

Test supination and pronation - Shoulders at 90, elbow at 0, wrist at 0

Patient takes forearm through supination and pronation,

Clinician is looking for compensation through chain and obvious difference

UE -rehab and correctionsManual therapy -

Subscap - compression through range of motion

Flexor group - stripping into wrist

Latissimus Dorsi - End range motion

Thoracic spine manipulation

UE Rehab Breathing

Serratus anterior activation drill

Hitchhiker rows

Serratus wall walks

Eccentric closed chain rotator cuff movement

Planes of motion Sagittal plane

Frontal plane Transverse plane

Breathing Hook lying

Triple flexion

Seated

standing

Cervical retractions Open Chain Variation

McGill Sit up with retraction

Patient supine with hands under back

Raise head and torso off ground

Serratus anterior Elbows and knees

Dolphin position

Wall position

Contralateral positioning

Hip rehabManual therapy

Abdominal trigger point therapy

Psoas

Hip strength exercisesLow oblique sit half kneeling sit back

Banded - Lateral walks, monster walks, air squats

Counter weights

rehab quadrupedQuadruped advancements

Bird dog - contralateral movement of the

Arms and legs

Bear stance- lift the knees slightly off the

ground

Rehab to performanceDeadlift

Barbell, Kettlebell, dumbbell

-Neck retracted

-shoulders retracted

So much more and not enough time...Thank you! For your participation

jsergent@mmtmke.com

262/546/4696