Essential Pillar Strength For Rehab (Part 3)

An injury can be devastating for any lifter or athlete engaging in the never ending quest to become stronger, faster, more athletic, or simply look like a beast. A herniated lumbar disc will stop a powerlifter from squatting, pec tears will interrupt a bodybuilder’s upper body splits and a hamstring pull will keep a football player from improving his 40 yard dash at the NFL combine.

However these injuries can be avoided and once they have occurred can be prevented from becoming a chronic issue. This is not as exciting as lifting heavy things however is essential to ensure many years of fulfilling those savage instincts! Now take a deep breath and let’s get into it.

As a Performance Physical Therapist at Athletes’ Performance I often initially encounter patients on a strictly rehabilitative level, as an injury is what is bringing this individual to me. The most obvious example of the importance of pillar strength within this population is often in regards to low back pain, however the ability to properly stabilize the spine and maintain its neutral position, proper joint centration and movement kinematics apply to any pathology.

Lower extremity injuries are very commonly related to the influence of the pelvis as it directs what is going on below. Commonly seen, excessive lumbar lordosis with an increased anterior pelvic tilt results in a position of resting hip flexion, increases femoral and tibial internal rotation resulting in increased torsion (twisting) at the tibio-femoral joint (knee),and lateral patellar displacement and pronation (flattened arch) through the foot/ankle complex. These alterations in alignment result in increased joint stresses which can lead to pathologies such as femoral-acetabular impingement, ACL tears, medial tibial stress syndrome (shin splints) and posterior tibial tendonosis.

Similarly a lack of pillar strength often relates to conditions affecting the upper quarter. An anterior pelvic tilt with subsequent excessive lumbar lordosis results in an increased thoracic kyphosis, excessive scapular abduction/anterior tilt and increased lower cervical flexion with compensatory upper cervical extension. These postural deviations limit subacromial space, often resulting in shoulder pain, as well as a host of other conditions affecting the wrist, elbow, shoulder and cervical spine.

The trunk musculature controls the position of pelvis, ideally maintaining it in a neutral position between the extremes of a posterior and anterior pelvic tilt, allowing the spine to assume a neutral position, therefore creating an efficiently positioned foundation for the lower extremity to function off of. Furthermore achieving and maintaining optimal spinal positioning via proper functioning of the pillar musculature allows for a stable base to be established at the scapula on the rib cage for the upper extremity. This is often the initial step in treating chronic foot, knee and hip pain, as well as many other conditions other than just low back pain.

Patients usually present to therapy with poor motor programming in regards to spinal stabilization. This begins with a dysfunction breathing pattern as the accessory respiratory muscles are being used for relaxed breathing, rather than the diaphragm, causing it to be resting in an elevated position. Correcting this breathing pattern is the first step in activating the internal spinal stabilizing system (ISSS). This sagittal stabilization system develops when an infant is 3 months old allowing for her to lift her legs off the ground when lying in a supine position. As this individual matures into an adult, society often integrates faulty stabilization patterns into the “software” that is the central nervous system due to a sedentary lifestyle amongst a host of other contributing factors.

For reversal of this to be possible, proper functioning of the diaphragm must be established as it is able to descend during inspiration allowing for compression of the abdominal contents reflexively activating the pelvic floor and trunk musculature. This creates an increase in intra-abdominal pressure providing ventral (anterior) stability to the lumbar spine, which is important as there is no musculature located directly anterior to the lumbar spine to counteract the commonly dominant lumbar paraspinal musculature directly posterior to the spine.

Proper diaphragmatic function is trained initially with the patient in supine, working on “breathing into his/her groin”, expanding throughout the abdominal region in a cylindrical fashion during inspiration, as if he/she is trying to fill a tire that around the waist (allowing for further lateral abdominal/rib expansion). It often helps to place an object or the patient’s hand on his/her belly so that a cue is provided allowing the patient to focus on letting the object or his/her hand rise with inspiration and fall with expiration. Those patients that rest in an excessive lumbar lordosis and increased thoracic kyphosis will allow their ribs to flare, therefore focusing on maintaining the lower ribs in a dorsal, expiratory position is essential while training appropriate breathing patterns.

Once proper diaphragmatic function is achieved in supine, the same premises are emphasized with the hips and knees in flexion, as we all were as 3 month old infants! Each position is more challenging as the position is progressed further along the developmental spectrum. During development infants are unable to explore a new position or posture until he or she possesses the motor control to do so, forcing appropriate activation patterning and stabilization to be achieved. This approach works tremendously with adults to retrain the central nervous system in the manner in which it initially learned.

Once sagittal plane stabilization is achieved properly, as evidenced by appropriate diaphragmatic function with the lower extremities in flexion when in supine, the patient can then taught to properly stabilize while performing many common “table top” exercises (examples include hip flexion in hooklying, marching, deadbugs, etc.). Next properly transitioning to prone is taught, in other words the patient must be taught to roll properly. Getting into the nuances of proper rolling is beyond the scope of this post however look for further discussion of this subject in future posts!

Progression to quadruped where performance of common exercises, such as quad rocking and bird dogs are often performed before advancing to pillar stability exercises in half and tall kneeling and finally stance positions. As the patient advances into each new position, the base of support is decreasing, as well as elevating further from the ground, enhancing the challenge. Creativity with exercise selection is often the only limitation in these positions assuming that the patient is able to maintain a proper breathing pattern, as well joint centration throughout the spine and all supporting segments.

A patient must first begin at the lowest level in supine as the dysfunctional stabilization stereotype that brought the individual to physical therapy will be his/her preferred method of activation during a higher level task. However as this person advances, the training principles that was discussed in Essential Pillar Strength parts 1 and 2 begin to apply. As a general rule, the further a patient advances in physical therapy, the more similar it becomes to training.

Now take another deep breath. This is in depth stuff and I strongly advise any clinician or coach looks into premises discussed in this posts.

Much of this information on the neurodevelopmental approach to treatment requires further information. For more information regarding this approach to treatment, I strongly advise exploring Dynamic Neuromuscular Stabilization (DNS), developed by Pavel Kolar out of the Prague School in the Czech Republic. They host many courses in the United States and throughout the World in their various levels.

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