The BRACING Series

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.

 

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.

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.

The BRACING Series: No. 3

By Sean M Wheeler, M.D.

The simple exercises that target the small gluteus bracing muscles from the STABILITY Series No. 1 and No. 2, may at first appear as exercises meant for the very old or very weak, or as exercises done only until one is ready to go back to the gym for a "real" workout.

I'm here today to disavow you of this mistaken assumption.

Let me start with a story.

I have a middle-aged patient who is a record-setting weightlifter for his age and weight-group. He's in another universe of strong, like guys on ESPN2 named Magnus who fling beer kegs for prize money.

He came to see me with pain in the back and knee.

We found that his small bracing muscles of the gluteus were weakened and his compensation for this weakness was causing his pain.

I had to deliver this diagnosis to a professional power-lifter, and he wasn't easily persuaded.

I described bracing muscles and explained that rather than actively lifting the weight, these muscles instead stabilize the legs for walking hills and stairs, for jumping down, or for squatting, as he does to pick up the barbell.

Bracing muscle weakness destabilizes the leg, which can lead to pain in the knee, hip and back.

Finally, he experienced a breakthrough when he realized that while squatting down to pick up the bar he had to deeply concentrate to keep his left knee from buckling in.

He was compensating by actively pushing his left knee out as he bent down and stood back up with the weight, and he'd been doing it throughout his career.

After this realization, he spent the next several months working on some of the exercises I present in The STABILITY Series.

If small bracing muscles were strengthened by lifting weights, anyone with all of my client's years of experience and training would have developed strong and capable bracing muscles and wouldn't need to compensate by pushing the knee out.

Now, he starts every workout by doing his stabilization exercises, before working to strengthen his action muscles.

The goal is to view stability exercise as an entirely different type of exercise, and prioritize the stabilization workout as necessary and the weightlifting as secondary.

Proper bracing muscle stability allows action muscle strengthening without injury.

Weightlifting by itself doesn't provide stability, only strength.

As you watch and engage with these exercises, remember that they are designed to strengthen these bracing muscles that provide stability, and you should do them for as long as you are active, whether you choose to do a strength workout separately or not.

Stability Exercise #3: Deep Bracing Muscles of the Spine

This exercise is for the bracing muscles of the spine.

Be aware: this exercise is much harder to master than the gluteus exercises described earlier in this Series.

The first step is to locate and isolate the bracing muscle without compensating with the surrounding action muscles.  This may require spending days doing only the muscle-finding part before progressing to the actual exercise.

In the effort to find these muscles, make sure that you are not tightening your hamstrings or rotating your pelvis.

If this exercise proves too difficult to execute, you may need to consult with a physical therapist or other professional.

Good luck.

The BRACING Series: No. 2

By Sean M Wheeler, M.D.

Spine stability is an inherent component in the design of our bodies.  

We gain spinal stability throughout childhood and early adulthood.

As infants, we can only stand once we achieve the stability to do so.  As toddlers, we crawl until we gain the strength in our bracing muscles to walk and then to run

With spinal stability comes a smooth daily coordination and balance for each of us, that demonstrates the power and inspiration of the human body, similar to the awe many experience in watching a professional athlete.  Our ascent to stability continues until derailed by injury or by a shift from an active life to one that is more sedentary.

Back pain often accompanies a sedentary lifestyle. In a futile attempt to sidestep the pain,  we stand and walk differently.  We avoid using the very muscles designed to stabilize the spine - the bracing muscles

And now our back hurts. 

Once the bracing muscles are no longer doing their job, they rapidly atrophy.  These muscles weaken, the spine destabilizes, and the spiral of chronic back pain deepens.  

In research studies observing the effect of weightlessness in outer space on different muscle groups, astronauts were tested for muscle strength before and after a two-week trip into space.  Researchers found that, during those two weeks in space, action-muscle strength (the muscles that move us) decreased by 5 percent in the arms and 7 percent in the legs, while bracing muscle stabilization of the spine (the crucial endurance muscles) decreased by up to 70 percent.  

While in space, astronauts continued to exercise their action muscles daily, but they couldn't consistently utilize their bracing muscles because of the absence of gravity. 

Bracing muscle strength is easy to lose but challenging to recover.  As adults, we can't reproduce the conditions and movement patterns of childhood development.

To repair our bracing muscles in the aftermath of injury or atrophy we need to target them with site-specific strengthening exercises, which is the purpose of the STABILITY Series.

Stability Exercise #2: The Hip Hiker

The bracing muscle exercise viewed above is called hip hiker.

In this exercise, keep both legs straight with your knees locked.  It's important to understand the hip being strengthened is the one that stabilizes as the other hip moves. 

Do 25-50 reps on each side. As the STABILITY Series continues, remember that you do not have to do all the exercises at once.  Do a couple of different exercises for your bracing muscles each day and become expert at each exercise.

I will introduce another exercise next week.  

Page 1 of 2
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .