Spring is here! Well, at least it is in California. I love spring. The word alone suggests movement, and movement equals change. The NCCPT Transform Me challenge is over. A lot of people made great efforts to transform their bodies. Watch for the winner on our Social Media and featured in the next NCCT Newsletter.

Chris Gellert, PT, CSCS, has written two informative CEU articles on the Spine. I’ve always been fascinated by the spine. It is our electrical system. Without it we can’t move. In fact, I always consider the spine first, in any exercise or movement that I perform. Chris has a few excellent CEU courses on our site as well. Go here to learn more:.

Don’t forget about our affiliate www.ProFitJobs.com. You’re able to post your photo, resume and video for employers looking for personal trainers, yoga, kickboxing or group exercise instructors, sales or front desk staff and a variety of

other health and fitness jobs. If you’re looking for personal trainers you can still use the locator system (Find a Fitness Professional) or go to ProFitJobs.com and post the job. If you’re certified through us, go to ProFitJobs.com and complete your profile. Either way, the site will automatically notify you when a job or resume that matches your description is listed... and it’s free!

Our Featured Personal Trainer of the Month is Mike Calarino, who demonstrates your past doesn’t have to be your future.

Should you eat before you work out? I guess it depends on what you’re trying to accomplish? Performance, weight-loss, fat loss... Some compelling arguments to eat in the article “Why you should eat before morning workouts.”

Please “Like us” on Facebook when you can at Facebook.com/NCCPT stay tuned for the Transform Me winners and as always…

Stay fit,

John Platero

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by dotFIT experts

You’ve heard it before: “Eat your breakfast.” Should you eat in the morning? And what if your goal is weight loss? How does breakfast affect

your ability to burn fat at the gym?

One of the interesting things about the fitness world is the prevalence of fitness myths. Some of these seem to make sense and may be based upon an incomplete understanding of the human body and metabolism while others outright ridiculous. This article will look at one such myth, whether one should eat prior to morning workouts.

We’ll start by looking at the rationale behind this plan of attack. Eight to 12 hours may pass between dinner or an evening snack until waking. During this time, the body is still operating and using calories, but no food or energy is going in. When you awaken, your body is in a “fasting metabolic state”. In other words, it has entered an energy-conserving mode (slowed metabolism) and is using body fat stores as the primary energy source due to the decreased level of muscle and liver glycogen.

Eating begins to bump up your metabolism thus breaks this fasting state (hence the word used to describe the morning meal, “break- fast”). The myth states that since glycogen, a preferred fuel source for muscles, is low, the body will use its fat stores to a greater degree. So far the myth appears to make sense.

There are several related myths that tie into this idea, and it is worth looking at them first, as they are often used to build the flawed case for the topic of this article:

The Myth: Working out first thing in the morning on an empty stomach will maximize fat burning, since muscle glycogen (stored carbohydrate) is low.

Insulin is bad and stores fat. Fat is not made out of nothing. Insulin, a hormone, is not responsible for creating fat out of thin air and depositing it in your trouble areas. Is it possible that people gain weight because they are simply eating too much? Of course. Insulin is just a guy doing an essential job inside the factory that is the human body. Like working an assembly line that keeps running until someone turns it off, insulin will store things, including amino acids, in muscle, and will keep storing even if it’s already got more than enough. But the point is someone is in charge of that assembly line and can choose to turn it off or slow it down by not overeating.

Low intensity exercise uses more fat than high intensity exercise. As a percentage of calories burned, yes…this is true. But the total calorie burn per minute is low. At rest you are burning the greatest percentage of calories from fat. As soon as you pick up the pace, CHO (carbohydrate) begins to make a greater contribution. Knowing this, does walking lead to more fat loss than running stairs for the same allotted time? No. At higher intensities, even though the percentage of fat used is lower, the total calorie burn and daily fat burn will be higher. Higher intensity exercise is associated with an increased calorie and fat burn for many hours after the session. This is called exercise post oxygen consumption (EPOC).

Food eaten in the evening will end up as fat on your body. If that were the case, then if you ate nothing all day but one apple before bed, it would turn to fat and you would gain weight. There is no enzyme in the body that is time sensitive and forces calories eaten after 7 pm to be stored as fat. If you consume fewer calories than you burn, you could set your alarm for 1 am, get up and eat a meal, go back to bed and still lose weight.

As long as you maintain a calorie deficit, you will decrease fat stores and lose weight.

Let’s get back to the initial topic of maximizing calorie burning with exercise to increase weight loss. Performing high-intensity cardiovascular exercise has the most significant contribution to calorie burn. At higher but still aerobic intensities, one can burn twice as many calories (and fat) as cardio done at a lower intensity. Plus you have the benefit of EPOC (the increased calorie burning after intense exercise).

There is an old saying that “fat burns in a carbohydrate flame”. In other words, the body needs glucose (from carbohydrates) to prime the fat burning processes. With less than adequate glucose available to keep the machinery running, exercise intensity (and therefore calories burned) can’t be maximized. A clear example of this is when an endurance athlete “hits the wall”. Their performance suffers or ceases not because they ran out of fat stores, but due to a lack of glucose to keep fat burning efficiently.

So, here it is: if you do not eat before you train/exercise, you decrease your body’s ability to maximize fat burning. And NOT just because your workout wasn’t as good as it could have been if you had more energy, but because you end up burning fewer calories all day. Why do performance athletes eat their biggest meal before training and consume a pre-workout snack? So their energy systems are full, allowing them to train at maximum intensities. Ultimately they will end up burning more calories all day (during the session and the subsequent recovery process) when compared to a less energized workout. Imagine being fully energized when you train or exercise and many more calories you will burn!

Weight/fat loss is determined by your daily caloric deficit

Exercise itself does not burn a great amount of fat no matter how long the activity. It is the contribution of exercise to a person’s total daily energy expenditure (TDEE), including the intensity, that affects fat loss. In other words, exercise simply adds to your daily calorie needs, and as long as you don’t consume more to compensate (keeping your intake below your needs) the body must draw on its fat stores and you’ll lose fat.

If you break the fast before you go to the gym, the body has the potential to perform better, enhance recovery and burn more calories. The higher the intensity of your workout (which you can now perform thanks to having filled your energy stores with a pre-workout snack), the more calories from fat you will use throughout the day in order to fill your energy deficit. The energy or calorie deficit, not the workout or when you eat, determines how much weight/fat you lose.

Make sure you don’t add calories.Just time them properly.

We’re not suggesting you add calories to your daily intake. Simply adjust the way you distribute your calories throughout the day. Spacing meals properly has added benefits, such as using more calories to digest each meal (after a meal the body has work to do in digesting and absorbing food), and a steady stream of nutrition (enhancing recovery and energy) as well as controlling hunger. Your first meal of the day breaks the fast and “fires up” the metabolism, so the sooner you do this, the better.

Getting the most out of your trainingEating before exercise is mandatory for performance athletes in order to enhance each training bout, recovery, and the final outcome. Therefore, ingesting part of your daily calorie allotment before exercise is a practice everyone should do. Proper pre-activity feedings can

1. Fill energy stores before a workout (not by adding dai-ly calories, but by redistributing them)

2. Break the fast to boost metabolism and con-tinue a constant flow of nutrients

3. Increase workout performance: high intensity train-ing burns two to three times more fat immediately post-ex-ercise, thus greater total fat throughout the day

4. Enhance recovery to improve maintenance or growth of muscle which also adds to your metabolic rate

5. Increase daily non-exercise movements by never staying in a less energetic/fasting state beyond rising in the morning (i.e. having more energy makes you WANT to move more)

It takes calories to burn more calories, but don’t add extra calories – simply take the total daily calories you are allowed and distribute them properly throughout the day based on your activities.

Early morning trainingIn light of recent research regarding the benefits of ingesting a pre- & post-training snack containing protein, carbohydrate and low fat in a quick digesting form (e.g. dotFIT™ bar or shake), it would be a mistake not to have something prior to your workout. It is now VERY clear that immediate pre- & post-activity nutrition intake dramatically improves exercise-induced results, even when all else is equal (total daily diet, training and supplements). Skipping these important feeding times cannot be made up for at other times of the day. This immediate timing is crucial to maximize recovery and results, and any advantage is lost if meals are missed or delayed.

When training first thing in the morning, nothing changes as it relates to your pre/post-training nutrition. Simply ingest a dotFIT snack or shake 10-40 minutes before you train and repeat the snack immediately post-training.

Although liquid delivery allows for the quickest absorption (e.g. dotFIT shakes/mixes), all dotFIT foods meet the quick digesting criteria for taking advantage of the pre/post “metabolic windows”. It’s during these windows that nutrient sensitivity/uptake is highest, maximizing recovery including muscle building.

Remember, do not add calories, simply redistribute them.

Learn more about dotFit and the dotFit experts

Many people associate strength and success with a stream of situations that do or should go right. In some instances, however, it is the broken pieces that forever shape your future, relegating the past to a mere memory.

Born in New York and raised in New Jersey, Mike Calarino grew up in a broken home. His mother worked two jobs to support her three children, while his stepfather battled alcohol addiction. In turn, sports became a refuge for Mike as early as the seventh grade, especially after meeting his best friend, Steve. Mike says, “Steve was an outstanding basketball player and very competitive. From then on, I did everything possible to be better than him.” Mike worked on his jump shots and running sprints from dawn to dusk, gradually falling in love with sports.

In high school, Mike continued to play various sports—football and wrestling came naturally

to him. His short and stocky but strong body was a blessing, though it would later become a weakness. From thinking that his strength alone would get him through wrestling matches easily, Mike eventually realized the importance of technique. Once he put some passion, hard work, and a change of mindset into the sport, Mike became a pro high school wrestler and started winning matches.

Featured Trainer:

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Upon graduating from high school in 1998, Mike joined the United States Marine Corps for three years and, soon after, began attending college part-time while working full-time. He graduated from Brookdale Community College in New Jersey and went on to pursue a Bachelor’s degree from the University of Phoenix. Even during this period, sports played a big role in Mike’s life as he played in basketball leagues and continued to weight train. For Mike, sports and college are what built his entire foundation, though he did not yet realize the impact it would later have on his professional life.

In 2005, Mike started working as a heating and air systems installer. One day, a friend called him about a job opportunity at the gym where he worked out, saying how Mike would

be a great fit. All it took was one scheduled interview and the rest was history. In the midst of this, Mike did his own research on NCCPT and became certified on his very first try.

Mike is now celebrating nearly a decade of doing what he loves: training people, playing sports, and now competing in his first flag football tournament. As for his own clientele, Mike focuses on all types of people at various stages of training. His most memorable client story started two years ago with a man named Harry. When the two first met,

Mike says, “Harry was timid, out of shape, and scared to death of being pushed—and I was determined to change Harry’s life.” Mike spent the next two years transforming Harry mentally and physically, mainly through the use of metabolic conditioning. Mike says, “Metabolic conditioning uses exercises designed to burn calories during the workout and maximize calories burned after the workout,” which he also uses on himself in conjunction with traditional bodybuilding. Harry is now looking and feeling better than ever, making Mike’s job even more rewarding.

Mike states that his personal fitness philosophy “…has always been to have fun and give the clients an amazing workout.” As for what the

future holds, Mike’s goal is just to be the best trainer that he can be and to reach as many people as he can. More importantly, he hopes to start a family soon.

Mike Calarino and many like him have proven that your past does not necessarily have to be your future. Sculpting your body is one thing, but sculpting your life is a whole different story. For more information on Mike Calarino or to connect with him personally, visit mcalarino@workoutworld.com

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Understanding the ScienceBehind

Both Movement and DysfunctionBY CHRIS GELLERTPT, MMUSC & SPORTSPHYSIO, MPT, CSCS, AMS

Understanding the ScienceBehind

Both Movement and Dysfunction

The spine is a complex structure, comprised of nerves, connective tissue, bones, discs, muscles and other essential integrative components. Whether it’s getting out of a chair or car, lifting or carrying items, some 29 muscles around the pelvic girdle and lumbar spine, provide stability. In this article, we will review the anatomy of the spine, common injuries to the lumbar spine, functional assessments and training strategies to work with clients with previous injuries.

Figur

e 1.

Sit to

stan

d

Figure 2. Lifting items

Basic Anatomy of the Spine

The spine is divided into three primary layers (internal, middle and outer).

1. Internal layer: Consists of the vertebrae of the spine, the spinal discs, and ligaments and series of small muscles that connect, one vertebrae to another. The discs and ligaments perform two important functions: they stabilize the spinal column, and they provide the brain with information about the exact position of every joint and vertebrae in the spine.

2. Middle layer: There are four important muscles within the middle layer, which provide stability for the lower back. Two of these muscles comprise the back, while the other two are abdominal muscles. The

Figure 3. Internal layers of spine

Figure 4. Multifidi

Figure 5. Quadratus lumborum

muscles of the back are called the multifidus and the quadratus lumborum. The stabilizers that come from the abdominal region are called the internal oblique as well as the transverse abdominus.

3. Outer layer: This layer is the thickest. Composed of large, thick muscles, which aid in assist in transitional movements, creating and sustaining muscle contraction. The outer layer is known as erector spinae.

Biomechanics of movement When we look at how the spine bends, flexes and rotates, there are several structures that directly produce these movements and are also affected.

Flexion and extension of lumbar spine During lumbar flexion, the veterbrae and the intervertebral foramen in the back (posterior) separate, creating tension and stress on the posterior annulus and posterior longitudinal ligament. This forces the nucleus populous backward. Making the disc vulnerable to bulge or herniate. During extension, the opposite motion occurs. During side bending or lateral flexion, there is opening on the contralateral side and narrowing on the ipsilateral (same) side.

As the trunk rotates, there is tension developed in the outer annulus where the annular fibers become taught (tight). While the other half of the annular fibers slacken. At the joint, the side rotated towards approximates while the other side opens (gaps).

Figure 6. Erector spinae muscles

Figure 7. Source: Hamill and Knutzen

Common injuries and causes of lumbar spine There are different types of injuries the ankle can sustain. The most common are lumbar osteoarthritis (DDD), disc injuries, and spinal stenosis. In this next section, we will review each condition providing a deeper understanding of each.

3.1 Lumbar osteoarthritis (DDD) Mechanism of injury/pathophysiology: Is termed the wear and tear arthritis because it is thought that the articular cartilage breaks down because of an imbalance between mechanical stress and the ability of the joint to handle the given loads. The following are factors that can influence the development of DDD; excessive weight, repeated repetitive stressors, and muscle imbalances.

Sign and symptoms: patients will typically describe as a deep ache in the morning that eases or decreases as the day progresses. During evening, the lower back stiffens once again.

3.2 Spinal stenosis Pathophysiology: A narrowing within the vertebral canal coupled with hypertrophy of the spinal lamina and ligamentum flavum or facets as the result of age related degenerative process commonly seen in older individuals (Geenvay & Atlas 2010).

Figure 9. Lumbar degenerative changes

Figure 8. Trunk rotation

Risk Factors: Poor posture, excessive weight, muscle imbalance between flexors and extensors.

Sign and symptoms: Results in vascular compromise, bilateral pain in lower extremities particularly in back, buttocks, thighs, calves and feet. Pain is increased with spinal extension and walking. Pain decreases with spinal flexion (bending).

Medical treatment: Conservative therapies initially and if unsuccessful, decompression

laminectomies may be required. In a long term study by Atlas, S et al (2005), 148 patients, Who either had surgery or underwent conservative care (physical therapy), were followed for 8-10 years. Results: Patients undergoing surgery had worse baseline symptoms and functional status than those initially treated nonsurgical.

4. Disc injuries Mechanism of injury: Injury to the disc, typically occurs as a result of a combined motion such as lifting with twisting. This motion places increased stress on the disc causing an injury. Per the research and my 15 years of clinical experience, most individuals suffer from a bugling disc or herniate disc. This is confirmed by an extensive examination by both the physician and physical therapist, an MRI, symptoms and objective findings. The four types are listed below.

Four types of disc injuries:

1. In Protrusion or bulge, there is change in the shape of the annulus that it causes to bulge beyond its normal perimeter.

2. In Prolapse disc (herniation), the ligamentous fibers give way, allowing the nucleus to bulge into the neural canal. The disc is still contained by the outer layers of the annulus and supporting ligamentous structures.

3. Extrusion is where the disc protrudes through the annulus but is contained by the posterior longitudinal ligament (PLL).

Figure 10. Spinal stenosis

Thickened ligamentum flavum

Hypertrophy of facets

4. Sequestration is where the nuclear material/free floating piece of the nucleus has partially separated from the

remaining nucleus, allowing it to be free in the neural canal and moves into the epidural space.

Etiology/Risk Factors: Over-stretching of the annular rings occurs as a result from a combined trunk rotation and

unilateral side bending, placing the disc in a vulnerable compromised position.

Repetitive compressive forces, micro-trauma or one single movement at end

range(flexion) with low load will stress the posterior spinal musculature and disc.

Sign and symptoms Loss of trunk motion/mobility, decrease in trunk strength, central/

radicular pain, possible parasthesias and painful referred pain peripherally, inability

to perform activities of daily living. Usually worse in the sitting position or rising.

Medical treatment: During the acute stage of injury, patient education, rest, and NSAIDS are recommended. Certain positions such as flexion and combined flexion with rotation are avoided to decrease intervetebral pressure.

Common assessments There are several ways to assess a client with our without a spinal injury. It is important to assess can the client maintain neutral spine in a static position, can they maintain neutral spine when their center of gravity is altered. Three effective assessments are the quadruped test, four point plank test and side plank test.

1. Quadruped test

In the quadruped test, ask the client to place their hands and knees in an all fours position. The first part(3A), as the client to extend one leg up, hold, the repeat on other side. Then with second part(3B), ask the client to alternate opposite arm with opposite leg. Observe if the client maintains neutral spine where the vertical arrow is, do they hyperextend their spine, excessively rotate their hips or sag?

Figure 11. Herniated Disc

Herniated nucleus pulposus

Figure 12. quadruped exercise

2. Four point (plank test)

Four point plank tests spinal erectors and paraspinal muscles. Ask the client to assume in the position in figure 13 below, prone with arms bent to 90 degrees (similar to a push-up). Then instruct the client to lift their entire body off the ground or surface while toes are in the extended position. Time them for the length of time they maintain neutral spine (without hips sagging or spine flexing).

2.1 Grading for both test is as follows: Normal: Able to lift pelvis off and hold straight 15-20 second count Good: Able to lift pelvis off but has difficulty holding spine straight for 15-20 seconds Fair: Able to lift pelvis off but has difficulty holding spine straight for 10-15 seconds Poor: Able to lift pelvis off but cannot hold for 1-10 seconds Trace: Unable to lift pelvis off the table

3. Side plank test

The side plank test challenges the quadratus lumborum and external obliques.

Ask the client to position their body is in side-lying position with the knees straight, while bending the bottom elbow at 90 degrees. Then instruct the client to lift their entire body off the ground, while keeping the legs straight. Time them for the length of time they maintain neutral spine (without hips sagging or spine flexing).

Training strategies and programming for lumbar injuries

With any injury, the most important thing to remember is the type of injury, healing time and prior level of function of the client. Let’s begin with ankle sprains.

Lumbar osteoarthritis (DDD) Recommendations for training: Joint protection, Aqua or pool therapy is an excellent intervention

based upon the buoyancy principle. Closed chain exercises such as lunges, ball squats, stretching, core strengthening and aerobic exercise(i.e. walking, and recumbent bicycle) are safe and effective. Particular emphasis should focus on glute and hamstring strengthening to improve sagittal stability.

Figure 13. Four point bridge test

Figure 14. Side plank test

Spinal stenosis Recommendations for training: Anatomically and biomechanically, flexion based exercises open the neural foramin. Perform flexion based exercises such as; knee to chest, prayer stretch and reverse abdominal crunch. End of range extension based exercises should be avoided as they close the neural foramin (ie. cobra pressup).

Lower extremity stretching should focus stretching hamstrings, hip flexors and quadriceps. Yoga and Pilates can also be effective to improve a client’s flexibility and core stability. Progressive resistance training exercises such as lat pulldown, seated mid row, seated reverse flies, and horizontal leg press are all safe to teach a client with lumbar stenosis based on science.

Lumbar disc injuries Recommendations for training: Obtain medical clearance from M.D. and communicate with client’s physical therapist prior to exercise training. Emphasis is on strengthening of “core,” abdominals, trunk muscles/lower back, and functional strengthening. Avoid combined rotational with side bending exercises, as well as hyper flexion and hyperextension motion. As these two motions place shearing forces on the disc.

Summary The lumbar spine a complex unit that is comprised of a multitude of ligaments, tendons, connective tissue, muscles that synergistically initiate and correct movement, and stabilize when an unstable environment. Understanding the anatomy, biomechanics and weak links of the spine, common injuries and evidenced based training strategies, should provide you with the insight to better understand and work with clients with these kind of injuries more confidently.

READ THE ARTICLE? TAKE THE QUIZ! EARN .1 CEU’S BY CLICKING HERE! ENTER THE COUPON CODE: ARTICLE1504

FOR $10 OFF YOUR TEST

About the Author:

Chris is the CEO of Pinnacle Training & Consulting Systems (PTCS). A continuing education company, that provides edu-

cational material in the forms of home study courses, live seminars, DVDs, webinars, articles and min books teaching in-depth, the foundation science, functional assessments and practical application behind Human Movement, that is evidenced based. Chris is both a dynamic physical therapist with 15 years experience, and a personal train-

er with 19 years experience, with advanced training, has created over 10 courses, is an experienced international

fitness presenter, writes for various websites and interna-tional publications, consults and teaches seminars on human

movement. For more information please visit pinnacle-tcs.com

REFERENCES

Atlas, S, et al, 2005, ‘Long-Term Outcomes of Surgical and Nonsurgical Management of Lumbar Spinal Stenosis: 8 to 10 Year Results from the Maine Lumbar Spine Study,’ SPINE vol. 30, number 8, pp. 936–943.

Beattie, P, 2009, ‘Current Understanding of Lumbar Intervertebral Disc Degeneration: A Review With Emphasis Upon Etiology, Pathophysiology, and Lumbar Magnetic Resonance Image Findings,’ Journal of Orthopedic & Sports Physical Therapy, vol. 38, no. 6, pp. 329-337.

Colby, L, & Kisner, C, 1996, Therapeutic Exercise: Foundations and Techniques, 3rd edition, F.A. Davis Company, Philadelphia, pp. 279-280, 431-452, 482- 508, 525, 600-618.

Genevay, S, & Atlas, S., 2010, ‘Lumbar Spinal Stenosis,’ Best Practice Residential Clinical Rheumatology, vol. 24, issue 2, pp. 253–265.

Hamill, J, & Knutzen, K, 1995, Biomechanical Basis of Human Movement, Lippincott Williams & Wilkins, Philadelphia, pp. 16, 20, 164-165, 223-225, 289-290

Lee, D, 2004, The pelvic girdle: an approach to the examination and treatment of the lumbopelvic-hip region. 3rd edition, New York, Churchill Livingstone, pp. 48-53.

Magee, D, 1997, Orthopedic Physical Assessment 3rd edition, W. B. Saunders Company, Philadelphia, pp. 362-366.

Oatis, C, 2004, ‘Kinesiology The Mechanics & Pathomechanics of Human Movement,’ Lippincott Williams & Wilkins, Philadelphia, pp. 8, 37-40, 45-51, 68-70, 81-88, 101-103, 113-115, 125-128, 149-150, 153, 516-520, 523-527, 776.

O’sullivan, P, 2005, ‘Diagnosis and classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism,’ Journal of Manual Therapy, vol. 10, pp. 242-255.

Are you dealing with clients that desperately want to lose weight but find it impossible to stick with healthy eating habits?

Have you lost clients because they haven’t seen fast enough success in their weight loss?

You already know a great deal about physical side of

losing weight … through exercise and proper nutrition. But the missing link in almost every fitness curriculum and is THE MOST IMPORTANT PART…getting your mind on your team!

This program will change your life for the better, and then you can help your clients to do the same!

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By Chris Gellert PT, MMusc & Sportsphysio, MPT, CSCS, AMS

.1 CEU

Article!

32

The spine is a complex structure,

comprised of nerves, connective tissue, bones, discs,muscles and other essential integrative

components. Specifically, the cervical spine is a vulnerable area

that is commonly injured due to fall, trauma, motor vehicle

accident, stress, as well as poor ergonomic setups, which all lead

to pain. In this article, we will review the anatomy of the neck,

common injuries to the cervical

spine, functional assessments and

training strategies to work with

clients with previous injuries. Neck pain from poor posture

Neck pain due to trauma

The learning objectives of this CEU article are to:1. Review the functional anatomy and biomechanics of the cervical spine and how it moves.

2. Be able to understand the difference between cervical whiplash, cervical osteoarthritis, cervical radiculopathy and cervical disc injuries, with respect to mechanism of injury and medical treatment of each condition.

3. Understand how the evidenced based research on how to train clients who either have or had a history of cervical whiplash, cervical osteoarthritis, cervical radiculopathy and cervical disc injuries

4. Be able to design individualized periodized training programs, and understand recommended vs. contraindicated exercises for each lumbar dysfunction that are practical and integrative in nature.

Intervertebrel Disc

Atlas

Axis

Lordosis7 Cervical Vertebrae

Kyphosis12 Throacic Vertebrae

5 Lumbar Vertebrae

5 Sacral Vertebrae

3 - 5 Coccygeal Vertebrae

33

1. Basic anatomy

When we look at the neck, there are seven bones (vertebrae) that are part of the supportive column of the spine. Within the cervical region, there are several key anatomical structures that include; spinous process, transverse process, and facets, which are an articular surface within the bone that allows gliding of bones to occur. In ddition, there is a disc between each two bones, that provides cushion and support, which is surrounded by an annulus, which is made up thin, type I collagen fibers, which protects the disc.

There are over 700 muscles in the human body. Each with a specific function and task. The primary muscles that support the neck are the upper trapezius, scalenes, levator scapula as seen in figure 5. Per the research and Vladamir Janda, the upper trapezius, scalenes and levator scapula are considered postural muscles, that tighten ver time. Whereas, the rhomboids, middle and low trapezius, weaken over time, and are called phasic muscles.

Lastly, each bone has two peripheral nerves that function to sense (interpret) information as well as produce movement (motor).

Neck pain from poor posture

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2. Common injuries and causes of cervical spine

There are several types of injuries the cervical spine can sustain. The most common are cervical whiplash, osteoarthritis, disc injury including pinched nerve (radiculopathy).

2.1 Cervical whiplash

Mechanism of injury/pathophysiology: The term “whiplash” commonly refers to symptoms and signs associated with a mechanical event such as a sudden acceleration and deceleration ofthe neck. Usually seen in a motor vehicle accident (Bono et al 2000).

Sign and symptoms: In the acute phase, there is complaints of localized sharp pain, and pain that either travels up or down the neck. The individual’s muscles are guarding, swelling of neck musculature with accompanying spasming. This makes any type of movement painful and difficult. Patients may also experience dizziness, immediate or shortly thereafter the accident.

2.2 Cervical osteoarthritis (degenerative disc disease)

Mechanism of injury/pathophysiology: Is termed the wear and tear arthritis because it is thought that the articular cartilage breaks down because of an imbalance between mechanical stress and the ability of the joint to handle the given loads. This biomechanically creates decreased space between the vertebra and possible bone spur (calcium deposit) develop seen in figure below. Factors that can influence the development of O.A. include; excessive weight, repeated repetitive stressors, and muscle imbalances. Figure 6. Osteoarthritic/degenerative spine

Figure 5. Muscles of the neck

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Sign and symptoms: Pain in the a.m. described as “achy” and stiff that decreases as the day progresses, and worsens or become more fatigued by the end of the day.

2.3 Cervical radiculopathy (due to a pinched nerve)

Mechanism of injury/pathophysiology: This is where the cervical nerve root is being compressed, resulting in inflammation, creating local to peripheral pain (arm). Irritation to the nerve root can result from mechanical derangement in or about the intervertebral foramen. The most common causes are a muscle pinching on a nerve, joint (two bones) compressing the nerve or a disc pushing on the involved nerve.

Sign and symptoms: Individual will describe pain as sharp, achy, burning located in the neck, Shoulder, arm or chest, depending upon the nerve root involved. Individual will also complain of vague pins and needles that come and go in the whole hand and possible weakness (Greathouse 2010).

Medical mgt: Patients may be advised by their physicians to take NSAIDs, have x-rays taken that reveal no abnormalities, advised to rest and follow up with a physical therapist. Per the research, manual therapy combined with mechanical traction has superior results(Young 2009).

2.4 Cervical disc injury

Mechanism of injury/pathophysiology: A single incident, or motion that involves a combined movement of cervical flexion, rotation with side bending repeated over and over may be the direct cause for a cervical disc injury (Starkey, C., & Johnson, G., 2006). The lumbar is more at risk for sustaining a injury to the annulus and disc due to size and biomechanical structure, than the cervical region.

2.5 Types of disc injuries:

2.5.1 In Protrusion or bulge, there is change in the shape of the annulus that it causes to bulge beyond its normal perimeter.

2.5.2 In Prolapse disc (herniation), the ligamentous fibers give way, allowing the nucleus to bulge into the neural canal. The disc is still contained by the outer layers of the annulus and supporting ligamentous structures.

36

2.5.3 Extrusion is where the disc protrudes through the annulus but is contained by the posterior longitudinal ligament (PLL).

2.5.4 Sequestration is where the nuclear material/free floating piece of the nucleus has partially separated from the remaining nucleus, allowing it to be free in the neural canal and moves into the epidural space.

Sign and symptoms: Most cervical disc herniations occur posterolaterally, which explains the neck and unilateral arm symptoms that most patients complain of. They will also complain of constant sharp pain, numbness, and possible weakness (Starkey & Jones 2006).

Medical mgt: Patients receive a thorough examination, x rays may reveal degenerative changes such as disc space narrowing or osteophytes present. A MRI is the most useful test in evaluating the integrity of the soft tissue and structures of the cervical spine.

Common Assessments:For safety and based on the clients past medical history, length of time from injury and general health, I would recommend the following assessments. First, examination of their posture from all planes. This provides invaluable information about muscle guarding, muscle imbalances and possible compensatory patterns. Second, I would look at range of motion of their upper and lower body. Specifically, looking at the quality and manner they move. Is it smooth, juttering, shaky, guarding? Another assessment I would look at isfunctional movements such as a squat or a lunge, which tells you about the entire kinematic chain, from the foot to the neck.

3. Training strategies and programming for neck injuries

With any injury, the most important thing to remember is the type of injury, healing time and prior level of function of the client.

3.1 Whiplash injuries

Whiplash injuries can take a long to heal ranging from 3 months up to one year in duration (Gargan 1994). There is considerable research that states that those who suffer a whiplash injury, often experience ongoing pain and disability for an extended period after their car accident (Kamper et al 2008).

Figure 7. Side view of faulty posture

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3.1.1 Recommendations for training: Based on evidenced based research, physics and my personal experience having suffered a motor vehicle accident in 2009, I would avoid having a client perform any overhead motion, such as shoulder press, kettle bell exercises, squats with barbells on the upper trapezius and performing any unsupported exercise as seen in the figure below. These exercises biomechanically cause increased compression force affecting the entire spine, potentially creating an injury and pain to the client.

3.1.2 Clients would benefit from a personalized program that consists of program design that meets their fitness goals and medical history. Specifically, exercises that target the posterior musculature, focusing on rhomboids, mid and low trapezius, low back extensors, and posterior deltoid. These will unload the neck biomechanically and improve posture and stability. Core strengthening should begin statically and progressed dynamically per the client’s ability to maintain form. Functional lower extremity strengthening should also be included and again, personalized.

Figure 8. Unsupported exercise

Figure 7. Seated mid row exercise

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3.2 Cervical degenerative disc disease (DDD) or Osteoarthritis

Recommendations for training: Training should focus on self-stretching of the upper trapezius and pectorals, which are commonly tight. Strengthening should focus on weaker, phasic muscles(rhomboids, low trapezius), also strengthening the latissimus dorsi, medial deltoids, rotator cuff. Core strengthening should always play an integral role in your program design. Lastly, cardiovascular conditioning should be personalized and tailored to the goals of the client. Based on evidenced based research and physics, avoid having a client perform any overhead motion, such as shoulder press, kettle bell exercises, squats with barbells on the upper trapezius and performing any unsupported exercise. These all place unnecessary stress on the cervical spine. These exercises biomechanically cause increased compression force affecting the entire spine, potentially creating an injury and pain to the client.

3.3 Cervical radiculopathy due to pinched nerve

Recommendations for training: Prior to training a client with a history of cervical radiculopathy, talking with the client’s physical therapist may serve as both an opportunity to learn more about the client and an excellent marketing opportunity. Building a relationship with a physical therapist takes time, encourages dialogue and most importantly, is another avenue to help clients post therapy.

Training should consist of targeting the weaker rhomboids, mid and low trapezius and back extensors. Core strengthening exercises should always be included, but do not directly load the cervical spine. Technique, quality of exercise and personalization, should be the priority with the program design.

Avoid having a client perform any overhead motion, such as shoulder press, kettle bell exercises, squats with barbells on the upper trapezius and performing any unsupported exercise. These all place unnecessary stress on the cervical spine. These exercises biomechanically cause increased compression force affecting the entire spine, potentially creating an injury and pain to the client.

3.4 Cervical disc injury

Recommendations for training: Prior to training a client with a history of cervical radiculopathy, talking with the client’s physical therapist may serve as both an opportunity to learn more about the client and marketing opportunity. Building a relationship

39

with a physical therapist takes time, however, encourages dialogue and most importantly, is another avenue to help clients post therapy.

Training should consist of targeting the weaker rhomboids, mid and low trapezius and back extensors. Core strengthening exercises should always be included, but do not directly load the cervical spine. Technique, quality of exercise and personalization, should be the priority with the program design.

Avoid having a client perform any overhead motion, such as shoulder press, kettle bell exercises, squats with barbells on the upper trapezius and performing any unsupported exercise. These all place unnecessary stress on the cervical spine. These exercises biomechanically cause increased compression force affecting the entire spine, potentially creating an injury and pain to the client.

Gaining more knowledge on the foundation and application science, improves confidence, skillset and most importantly, the delivery, and attainment of optimal training for your clients.

SummaryThe neck is a complex unit that is comprised of a multitude of ligaments, tendons, connective tissue, muscles that synergistically initiate and correct movement, and stabilize when an unstable environment. Understanding the anatomy, biomechanics and weak links of the neck, common injuries and evidenced based training strategies, should provide you with the insight to better understand and work with clients with these kind of injuries more confidently.

About the Author:Chris is the CEO of Pinnacle Training & Consulting

Systems(PTCS). A continuing education company, that provides educational material in the forms of home study courses, live seminars, DVDs, webinars, articles and min books teaching in-depth, the foundation science, functional assessments and practical application behind Human Movement, that is evidenced based. Chris is both a dynamic physical therapist with 15 years experience,

and a personal trainer with 19 years experience, with advanced training, has created over 10

courses, is an experienced international fitness presenter, writes for various websites and international

publications, consults and teaches seminars on human movement. For more information please visit pinnacle-tcs.com

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References

Bono, G, 2000, ‘Whiplash injuries: Clinical picture and diagnostic work-up,’ Clinical and Experimental Rheumatology, pp. 22-27.

Delee, P, 2010, ‘Orthopedic Sports Medicine,’ Saunders Elsevier, pp. 658-661.

Gargan, M.F., & Bannister, G.C., 194, ‘The Rate of Recovery Following Whip-lash Injury,’ European Spine Journal, vol. 3, issue 3, pp. 162-164.

Gifford, L, 2001, ‘Acute low cervical nerve root conditions: symptom presentations and pathobiological reasoning,’ Manual Therapy, vol. 6, issue 2, pp. 106-115.

Greathouse, D, ‘Radiculopathy of The Eighth Cervical Nerve,’ JOSPT, vol. 40., no.12, pp. 811-817.

Kamper, et al., 2008, ‘Course and prognostic factors of whiplash: A system-atic review and meta-analysis,’ Pain, vol. 138, pp. 617-629.

Starkey, C., & Johnson, G., 2006, Athletic Training & Sports Medicine. American Acade-my of Orthopedic Surgeons. Jones and Bartlett Publishers. Boston. pp. 530-540.

Young, I, et al., 2009, ‘Manual Therapy, Exercise and Traction for Patients with Cervical Radic-ulopathy: A Randomized Controlled Trial,’ Physical Therapy, vol. 89, no. 7, pp. 632-640.

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