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The BRACING Series: No. 6

By Sean M. Wheeler, M.D.

Screen Shot 2017 10 04 at 10.13.39 PMIn this series, we're going deep into the theory of bracing muscles and their role in body stabilization, and in doing so we've departed from the received wisdom of the scientific community, which has a poor (though developing) understanding of back pain.  I wrote my book, UPRISE, to push this community into new paradigms of thinking so that together we can cure chronic back pain.  This blog aims to not only explain the thought shift introduced in the book but to expand upon it as the hypothesis evolves into new territory.

One example would be the idea of "Bracing Deficiency" described in articles four and five of this series, which moves beyond the central themes of Uprise to give the condition more specificity and, finally, a name.  Theories such as this one and the proprioception theory of back pain (to be discussed in this space in the coming weeks) are meant to do what theories throughout the history of science have done: lead to more research.  If no theory is introduced, then there can be no wave of research activity in its wake to prove or disprove that theory.

In the absence of a theoretical underpinning, deciphering the results of completed research can sometimes lead to suspect interpretations of the data.  Take, for example, the study released in the December 2016 issue of the scientific journal, Spine.  In it, researchers evaluated the influence of weightlessness on muscular fitness by studying six astronauts stationed for six months at the International Space Station (ISS).  The astronauts underwent three MRIs of the spine: one prior to their trip (an average of 214 days prior), followed by an "immediate" MRI within two days of their return, and a third MRI more than thirty days later (on average, 46 days).  They did strength training on the ISS using a resistance exercise device to simulate the action of squats, deadlifts, bench/shoulder presses and rowing to keep large muscle groups strong.  After their return, they were given cardio, resistive weight training, and functional exercises focused on balance, proprioception, agility, coordination, and power.

Researchers found the astronauts' deep muscles in the spine decreased in size by an average of 14% from the first MRI to the second and that after six weeks of post-trip training those muscles were still on average 5% smaller than pre-trip.  The conclusion, as reported by Gizmodo, was a show stopper: extended space travel could cause irreversible back damage.  The analysis was widely reported, no doubt leading some mothers to announce to their kids, "Well, you're not going to be an astronaut!"

This conclusion indicates that even those at the highest levels of science (NASA) don't understand how the back works.  The astronauts were able to maintain the strength of larger muscles through simulated resistance training while in space, but the smaller bracing muscles responsible for stabilizing their spines atrophied due to their state of weightlessness, in which the bracing muscles were never obliged to fire.  Upon their return, the rehabilitation of the astronauts (and this applies as well to non-astronauts who have a major surgery, pregnancy or an extended period of inactivity) should have been guided by two fundamental principles of bracing muscle theory: one, that the body will naturally compensate for weak bracing muscles in the spine by engaging the hamstrings to take over the role; and two, that bracing muscles are endurance muscles which take far longer than six weeks to return to form (six months is more like it).  The rehab needed to encourage stabilization that minimized the use of the hamstrings and needed to continue for longer.  In this case, the third MRI was done much too early to have any real diagnostic value.  Ultimately, this lack of understanding may explain why astronauts are four times more likely than the rest of us to have a lumbar disc herniation.

NASA, if you are reading this, give me a call

We have much to discuss.

 

Dr. Sean Wheeler expert back pain doctorBy Sean M. Wheeler, M.D.

A recent guideline issued by the American College of Physicians discussing low back pain, and the use of opioids and their lack of effectiveness in treatment, has brought a focus on yoga as the first listed treatment alternative to opioids, and often the only one mentioned in media coverage of the guideline. 

Now many back-pain patients, intimidated by the image of themselves squeezed into yoga pants in a class with seasoned yoga practitioners, are deciding to just stretch more at home, perhaps in the belief doing so will alleviate their pain.

As a back-pain specialist, I've come to recognize the relationship between flexibility and back pain is a complicated one. 

Yoga is a group of physical, mental, and spiritual disciplines, today with a wide variety of Yoga practices and goals, including versions in which stretching is the primary focus.  Yoga as a physical discipline is our focus here.   

Choosing the correct yoga class for your specific needs is paramount.  To accomplish this, you must first understand where you rank within the Stability  Hierarchy – your body’s bracing capability – which I break into four levels:

  • Flexible and Stable
  • Inflexible but Stable
  • Inflexible and Unstable, and
  • Flexible and Unstable

Patients in the best position are those who are both flexible and stable.  They're the ones who have either worked very hard to maintain both attributes, or are young and have never been seriously injured.  To climb into this category is a worthy and attainable goal for most of us if approached correctly; those already there can start with any yoga class they choose.

The next level are patients who are inflexible but stable.  This includes the young adults who are involved in sport but have never been flexible; the middle-aged "weekend warriors" who've stayed active on a part-time basis; or the athletes with past injuries they never completely overcame.  This group needs to add flexibility to the stability they have achieved or maintained, and for them, a stretching-based yoga like hatha yoga would be very helpful.

A third group, the largest by far, has become sedentary or injured and now is both inflexible and unstable.  Many of my patients are unaware they are in this group; they think they're in the inflexible but stable group and will attempt to gain flexibility on their own.  While flexibility is important, it should only be achieved in coordination with the effort to gain stability.  Patients with chronic low back pain caused by weak bracing muscles of the lumbar spine [the definition of unstable] often have tightness in the hamstring muscles, which tighten in an essential act of compensation to stabilize the lumbar spine.  Attempts to stretch these hamstrings in isolation are counter-productive and could lead in the long term to disc degeneration and arthritis [see No. 5 in my "Bracing Series" for a more in-depth explanation].  Patients in this group must often start with physical therapy to strengthen their bracing muscles in isolation with the hope of transitioning into a yoga class that focuses on positions and poses.

The last group – flexible and unstable – is unfortunate though small, consisting mostly of those who have always been very flexible and have become weak in their bracing muscles.  Yoga is not helpful for this group, which already focuses way too much on what they're good at--flexibility.  These patients often need intense physical therapy followed by a transition to Pilates instead.

To recap our four categories:

        STABILITY HIERARCHY
HIERARCHY STAGE GENERAL CHARACTERISTICS YOGA RECOMMENDATION
Flexible & stable Those who work at maintaining both body attributes, and the uninjured young Any yoga physical discipline
Inflexible but stable Young adults involved in sports who have never been flexible, middle-aged “weekend warriors”, and athletes unrecovered from past injury Stretching-based, such as hatha yoga
Inflexible & unstable Sedentary and/or injured Physical therapy before transitioning to yoga
Flexible & unstable Flexible with weak bracing muscles Yoga not helpful

For my patients, I integrate into our TuneMe system the physical aspects of yoga which enhance stability and flexibility, even though I understand the practice of yoga at its higher levels involves elements of eastern spirituality, which as a Christian I personally reject.  I encourage my patients to continually evaluate their position within the Stability Hierarchy, and to use yoga for improving their body stability, as suggested above.

The BRACING Series: No. 5

By Sean M. Wheeler, M.D.

In my preceeding column in this series, we discussed the gap between the way we've learned to move throughout our lives and the ability of our bracing muscles to stabilize us enough to execute those movements.

As we grow, stability leads to coordination.  If we get injured or become sedentary, however, we lose our stability but not our coordination.

This gap between the stability we should have to move the way we do and the stability we currently have is called a bracing deficiency.

The inevitable result of this “bracing deficiency" is that our bodies must compensate or cover for our weakening bracing muscles, a process which leads to a further weakening of the bracing muscles and still more compensation. This deficiency can only be addressed with a dedicated focus on strengthening the bracing muscles in isolation.

Your body's compensations resulting from bracing deficiency occur without negotiation as the body must be stable.

For example, the hamstrings take over when the bracing muscles of the lumbar spine weaken, in an unconscious effort to stabilize the lower back. As this becomes ingrained, the hamstrings over time adjust to their new role, a job they can do better by remaining shorter and tighter, thereby causing a loss of flexibility.

A second way the body compensates for bracing muscle weakness in the lower back is by tightening the joint capsules of the lumbar spine. This process gives the spine a little more stability but takes away some of its motion. Both of these compensation scenarios are reversible.

By reclaiming the strength and endurance of your bracing muscles, you can recover from these two forms of bracing deficiency.

A third compensation scenario, however, is not reversible:

If the compensations last for years, the body will begin to build bone around the joint in an attempt to stabilize it. This bone growth is known as arthritis. Some forms of arthritis are inflammatory, but most cases of it are a form of body stabilization.

A spine which is stabilized by its bracing muscles is a spine which maintains its motion, which materially decreases the chance of experiencing chronic pain.

In contrast, a spine stabilized by inflexible action muscles, joint capsule tightening and, eventually, arthritis, achieves the "stabilization" effect through immobility. The result is a higher incidence of chronic pain.

These body compensations change the way you move, interact, play and age--in short, they change the way you live.

I see patients all the time who have bracing deficiency, patients who believe that joining a gym will somehow remedy their deficits. They begin to exercise their action muscles as a cure-all and get hurt as the compensations and lack of stability can't support their new level of activity.

I treat their pain and direct them to specialized physical therapy to re-focus on their bracing muscles to close the bracing deficiency.

This week's bracing muscle exercise targets the small muscles of the feet.

Though flexibility and mobilization of the feet are also a priority, this exercise is designed to improve endurance in the small muscles of the feet by creating oxygen debt.

When you perform the exercise in the video, remember to "dome" the foot for at least 30 seconds to achieve a prolonged decrease in blood flow in the muscle.

Do this exercise several times throughout the day.

Good luck.

Apr 07 2017

Byron Nelson

The legendary Mr. Byron Nelson with Dr. Sean Wheeler, 2005The legendary Mr. Byron Nelson with Dr. Sean Wheeler, 2005

By Sean M. Wheeler, M.D.

As the Masters golf tournament approaches each year my thoughts turn to Byron Nelson.

As a ‘marginally’ famous back pain and sports medicine doctor, I often get to care for patients who are actually famous.

I have pictures and mementos from these patients, but I only have one that hangs in one of my patient rooms.

I met Lord Byron, as he was known to the golfing world, through a friend and saw him a few times as a patient.

He was the consummate gentleman.

I would ask him about his life and he would answer as if it was unimportant and then stop and ask me about my life as if it was much more interesting than his.

I brought my kids with me on one of our visits and it was very important to him that they got a picture with him. Each visit would end with him asking to see my golf swing followed by a few suggestions.

When I told him that I was moving back to Kansas City he went into his house and retrieved a framed picture off of his wall of him and Tom Watson (a Kansas City native) practicing at the Masters. Dr Wheeler GolfDr. Sean Wheeler’s shot heads into Rae’s Creek

I always felt that Mr. Watson should have this picture but I have never had the opportunity to give it to him.

A couple months later I received a call from his wife asking if I would be able to come to the Masters with them and take care of him for the week. Stunned I asked for details and then asked if this would include going to the Champion’s Dinner.

This is the dinner hosted by the previous year’s champion for all the previous champions. It is extremely exclusive. They assured me that this was possible.

I had been a volunteer at the Master’s tournament the few years before that and had played the course a couple times, but this was an entirely different deal.

Byron Nelson had played in the second Master’s tournament in 1935. He had won the 1937 and 1942 tournaments. In 1945 he had his legendary season where he won 18 tournaments including 11 straight at one point.

He then had raised enough money to buy a ranch that he and his wife wanted and he retired in 1946.

Two weeks before we were set to leave for the tournament I called his wife to set some final arrangements and she informed me that he had fallen sick and was in the hospital.

The trip was off and I was disappointed, but hoped that, even at age 94 maybe we could go back the next year.

I sent him some Kansas City BBQ during the summer and got a nice letter back, but the handwriting was much shakier.

Then in September of 2006 I learned from the news that he had died.

The world lost a golfing icon that day.

Many may have thought that they lost a great golfer from 60 years previous. What they really lost was a great soul who happened to play golf.

I remember the day that his wife called and asked for assistance at the tournament most of all.

It was as if the history of golf reached out to me personally. Invited me in.

When I watch the master’s on television I often feel the same way.

I think we all do.

The BRACING Series: No. 4

By Sean M. Wheeler, M.D.

Many patients who suffer from chronic pain, particularly in cases involving the lower back, do so because they have developed a condition I label "Bracing Deficiency", in which the body's network of bracing muscles no longer provides the underlying stability to move in the ways in which we've grown accustomed.

From early childhood into adulthood, body stability and coordination develop in a virtuous partnership; the uncoordinated child slowly becomes the stable, coordinated adult. 

However, after an injury or sedentary period leads to the loss of strength and endurance in our bracing muscles [which, maddeningly, atrophy quicker than the action muscles that move us], we don't go back to being uncoordinated to match our loss of stability.  The coordination is still there, but its partner, bracing stability, has quietly left the building, leaving us in a state in which we move with the defined neuromuscular patterns developed over a lifetime, without the underlying bracing stability to safely do so.

The more pronounced the Bracing Deficiency, the more likely an immediate return to exercise will cause injury.  Many of my pain patients come to me believing in a cycle of recovery in which they receive treatment for their pain then simply return to their routine.  They remember a time when they were fit and feeling great, being "normal," doing their thing.  It's all good, they insist.  "I won't be the person who goes back to the gym then two weeks later has to quit because I've re-injured myself."

Then they have to suffer through my nagging reminders about the importance of bracing muscle strength and its impact on stability, a message which doesn't keep pace with their vision of a seamless return to peak form.  I concede that if they break an arm and have to go in a cast for six weeks then, sure, once the cast comes off they can get back to normal activities.  But a quick recovery of this type isn't in the works for areas of the body which require bracing/stabilization, which include the lower back, hips, feet, ankles, shoulders and neck.  

A recovery from chronic trouble in these areas must begin with weeks to months of bracing muscle exercises to shore up the Bracing Deficiency to the point where your stability and movement patterns are more in line. 

In this Bracing Series, we introduce exercises to strengthen select bracing muscles to ensure body stability as you move.  While the exercises may strike you as basic--even trivial if you were expecting to sweat--they are essential to a full recovery without re-injury.

As demonstrated in the accompanying video, this fourth exercise strengthens a muscle in the calf called the soleus, which stabilizes the ankle and, to a lesser extent, the knee.  

When performing this exercise, the key is to keep the knee bent, as a much stronger muscle in the calf [the gastrocnemius] will take over if you allow your leg to straighten. 

Hold the raised position for twenty to thirty seconds on each leg.  You multi-taskers can even do these while brushing your teeth if you like.  

Good luck.

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