The BRACING Series

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.  

The BRACING Series, No. 1

By Dr. Sean M. Wheeler, M.D.

I have seen some strong patients in my twenty years of practicing medicine: bodybuilders, professional athletes, Pilates instructors, laborers and others who depend on strength for their work.  

"Weak" is not a term we would associate with them, but the longstanding back pain they suffer is the result of a weakness in a particular set of obscure muscles.  The weak muscles in these very strong patients are the bracing muscles, which are unique muscles that require a particular approach to strengthen. 

I introduce the concept of bracing muscles in my book, UPRISE--Back Pain Liberation by Tuning Your Body Guitar, which will have a major impact on the future care of back pain.  In my book I promise to develop a set of exercises targeting these muscles that can improve the stability of everyone, not just people with chronic back pain. 

Over the coming months, that promise will be fulfilled here as we release a series of videos to demonstrate these exercises. 

In a few weeks local gyms will fill with new members on a New Year's resolution bender, trying to get in shape for that spring vacation they've already purchased.  Many will focus on "core" training, which has become an industry in itself.  And yet an extraordinary number of people who are working on their core still experience back pain. 

This is because you have to get the spine stabilized before you can "get in shape."  

Six-pack abs boost your ego but not your stability.  Stability is the role of bracing muscles. 

Trying to exercise heavily when your spine is not yet stable is like trying to build a second story on a home with a cracked foundation.  It is an invitation to injury.

So which muscles are the bracing muscles? 

Truthfully, they can be hard to find.  They aren't muscles you can flex and impress yourself with in the mirror.  Exercising them doesn't build their size, it builds their endurance and circulation. 

There are six bracing muscles that pull your hip into a stable position in the socket, which collectively I call the gluteus stabilizers.  They work in conjunction with the psoas muscle and the pelvic floor muscles to suspend the hip in "mid-air" inside the hip joint, providing stability while allowing movement. 

When these bracing muscles weaken, the psoas spasms, the hip is pulled up into an impinged position and the pelvic floor weakens, leading to pain and dysfunction.  That's the theory, anyway.

Stability Exercise #1:  The Clamshell

The first exercise appearing in the video above is called a clamshell. 

The important points of technique are to keep the body rotation closed, stay leaning forward, and to keep the knee low.  As with any exercise, rushing through it is not helpful. 

Try to do 30-50 reps on each side every day for the next week until I introduce the next exercise. 

Good luck.

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