by Craig Liebenson 

Mid-Thoracic Dysfunction: A Key Perpetuating Factor of Pain in the Locomotor System 

Dysfunction involving excessive T4-T8 kyphosis is common. Symptoms arising from regions at a distance to the mid-thoracic area are often secondary to T4-T8 dysfunction. This article will discuss why (rationale), when (indications), what (skills), and how (practical integration) T4-8 dysfunction is addressed.

Why

Mid-thoracic dysfunction involves increased kyphosis of the thoracic spine from T4-T8, usually the result of prolonged sitting in a constrained posture. Thoracic, lumbopelvic and cervicocranial posture are interrelated as links in a chain (see Figure 1). When excessive slumping becomes habitual, according to Brügger, it is called the sternosymphyseal syndrome (Lewit 1996, 1999, Liebenson et al., 1998, Liebenson 1999).

Mid-thoracic dysfunction affects the whole body's center of alignment and posture. Head and shoulder forward posture causes orofacial, neck and shoulder disorders; slumping affects breathing by leading to inhibition of the diaphragm and overactivation of the scalenes; and lumbar disc syndromes and nerve impingement have been shown to result from repetitive end-range flexion overload (Callaghan, McGill 2001).

When

Indications for treating the mid-thoracic region arise from postural analysis, passive joint mobility testing, and active joint mobility testing. The postural sign of increased thoracolumbar hypertonus is a classic sign of overactivity of the superficial "global" muscles and indicates poor "deep" muscle function (Janda 1996, Richardson 1999, Jull 2000, Hodges 2002).

Palpation of passive joint mobility and quality of end-feel is best performed in the seated position, as shown by Brügger (Brügger 2000).

The dynamic mobility screen of choice is the standing arm elevation test (Liebenson 2001).

What

Managing T4-8 dysfunction requires a broad skill set incorporating postural advice, manual manipulation, and therapeutic exercise.

Sample Exercises for Improving T4-8 Extension Mobility

• Brügger relief position - beginner

   

  

   

• Back stretch on the ball - intermediate

   

  
• Kolár's wall slide with arm elevation - advanced

   

  

  How

  Knowing why mid-thoracic dysfunction is clinically important, when it should be addressed, and what techniques are therapeutic is only the beginning point for successful management of the patient with a problem in this area. Satisfactory results will result from learning how to incorporate this knowledge and skill into patient care efficiently. A moment or two per session spent explaining the relationship between function and pain is one such step. Each exercise requires a unique "report of findings" to motivate the patient to incorporate it into his or her daily routine.

  The Brügger relief position is an ideal workplace "micro-break." It activates an entire chain of muscles linked to the upright posture. To prevent the tendency to hyperextend the lumbar spine with this exercise, it should be performed with active exhalation.

  The back stretch on the ball is comfortable and relaxing. It promotes improved respiration. It can cause dizziness at first, so the patient should be guided slowly onto it until he or she has learned how to balance on the ball.

  Kolár's wall slide with arm elevation is a functional exercise, since it combines arm elevation, squatting and breathing. Patients typically feel a nice stretch in the lattismus dorsi with this exercise.

  Summary

  T4-8 dysfunction is a common source of muscle imbalance, trigger points, joint dysfunction, and faulty movement patterns. While often asymptomatic, it is nonetheless a key source of biomechanical overload involving the neck, TMJ, shoulder, arm, and even low back regions. Treatments which aim only at the site of symptoms are bound to fail if function is disturbed due to excessive kyphosis in the mid-back.

  Rehabilitation of the upright posture is fundamental to optimization of function in the locomotor system. Neurological programs for maintenance of the upright posture are "hard-wired" into the central nervous system, making rehabilitation of the mid-thoracic area of central importance, both biomechanically and neurophysiologically. The mid-thoracic region is "linked" to a multitude of common musculoskeletal pain syndromes, and the simple assessment and treatments shown here are an excellent complement to chiropractic practice.

  References

   

• Brügger A. Lehrbuch der Funktionellen Storungen des Bewegungssystems. Brugger-Verlag GmbH, Zollikon, Benglen, 2000.
• Callaghan JP, McGill SM. Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force. Clinical Biomechanics 2001;16:28-37.
• Hodges PW, Jull GA. Motor relearning strategies for the rehabilitation of invertebral control of the spine. In Liebenson CS. Rehabilitaiton of the Spine: A Practitioner's Manual (2nd ed). Lippincott/Williams & Wilkins, Baltimore, sched pub 2002.
• Janda V 1996. The evaluation of muscle imbalance in Liebenson CS (ed) Rehabilitation of the Spine: A Practitioner's Manual, Lippincott/Williams and Wilkins, Baltimore, 1996.
• Jull GA. Deep cervical flexor muscle dysfunction in whiplash. Journal of Musculoskeletal Pain 2000. 8:143-154,
• Lewit K 1996. The role of manipulation in spinal rehabilitation in Liebenson CS (ed) Rehabilitation of the Spine: A Practitioner's Manual, Lippincott/Williams and Wilkins, Baltimore.
• Lewit K 1999. Manipulative Therapy in Rehabilitation of the Motor System. 3rd edition. London: Butterworths.
• Liebenson CS, DeFranca C, Lefebvre R 1998. Rehabilitation of the Spine: Functional Evaluation of the Cervical Spine, Williams & Wilkins, Baltimore.
• Liebenson CS, Advice for the clinician and patient: The Brugger relief position. Journal of Bodywork and Movement Therapies 1999. 3:147-149.
• Liebenson CS, Advice for the clinician and patient: Self-treatment of mid-thoracic dysfunction: a key link in the body axis. Journal of Bodywork and Movement Therapies 2001. 5:90-100.
• Richardson C, Jull G, Hides J, Hodges P 1999. Therapeutic Exercise for Spinal Stabilization in Lower Back Pain, Churchill Livingstone. 

See Craig Liebenson speak at the 2012 BSMPG Summer Seminar this May 19-20 in Boston MA.

Co-Presenters at the 2011 BSMPG Summer Seminar, Dr. John DiMuro and Mark Toomey return to Boston in May for the 2012 BSMPG Summer Seminar for a series of lectures that are sure to provide attendees with a number of monumental "ah-ha" moments as they show with fluoroscopy EXACTLY what is happening during exercises in both your rehabilitation and performance training programs.  

The difference between what you thought was happening during simple exercises and what is actually occuring at each joint will have you thinking twice before you prescribe your next exercise program or therapeutic intervention.

Click HERE to listen to a recent interview with Dr. DiMuro and Mark Toomey on SportsRehabExpert.com

Dr John DiMuro DO, MBA

Dr. DiMuro is a Board Certified Anesthesiologist and Pain Medicine expert who specializes in advanced interventional pain treatments for all types of pain conditions. He grew up in central New Jersey prior to attending medical and business school in Philadelphia . He has an M.B.A. in health care management from St. Joseph 's University and completed his internship at the Tampa Bay Heart Institute. He was chief resident during his Anesthesiology residency at Georgetown University in Washington , D.C. prior to completing a pain medicine fellowship at the world-renowned Memorial Sloan-Kettering Cancer Center in New York City . He currently serves on the Carson Tahoe Hospital Cancer Committee. He continues to work in private practice and lectures nationally for the Kimberly Clark Company and Boston Scientific.

Mark Toomey, Sr RKC, CSCS

Mark Toomey is a fitness instructor from Reno , Nevada . He serves as a Subject Matter Expert (SME) in fitness and conditioning for the United States Navy and the United States Marine Corps. He is the Director of Operations for Dragon Door Publications, a producer of cutting edge material on strength and conditioning and acts as a Senior Instructor for the RKC, the first and largest entity specializing in kettlebell and body weight exercise instruction. Mark is an NSCA Certified Strength and Conditioning Specialist and a certified CK-FMS practitioner.

Be sure to register for the 2012 BSMPG Summer Seminar today before they sell out!

Readings from last week.

Enjoy!

Cold-Water Immersion for Preventing and Treating Muscle Soreness After Exercise  

Predictive Factors for Ankle Sprain  

Assessing the SI Joint   

Don't forget to sign up for the 2012 BSMPG Summer Seminar featuring Dr. Craig Liebenson along with 14 other leaders from the worlds of sports medicine, performance and hockey/basketball specific training!

by Art Horne 

I recently travelled to Minnesota to visit a few friends and spend time with the strength coaches from both the Minnesota Timberwolves and the University of Minnesota.  If you’ve ever been to Minnesota you know that packing a winter jacket is a must and this trip this was clearly not the exception!

My first stop was with Cal Dietz from the University of Minnesota.  I’ve mentioned Cal’s new book, Triphasic Training a number of times before, but sitting down with Cal in front of a whiteboard and reviewing his training philosophy gave me a new appreciation and a monumental “ah ha” moment for the three phases of muscle action.

Excerpt from Cal’s book: Preface p. VII

ALL DYNAMIC MUSCLE ACTION IS TRIPHASIC! 

That one simple sentence is what ties every sport together and allows all athletes to be trained using the same method, yielding the same results.  It is what this entire book is about.  Understanding the physiologic nature of muscle action taking place during dynamic movements gives you, the coach, a foundational training method that can be applied to every sport.  Couple this method with a periodization schedule that can be altered to fit with any training time frame and you have the tri-phasic undulating block method.

In a very brief and basic explanation that will be expanded upon at length in later chapters, the triphasic nature of all dynamic movement can be broken down into three phases:

1)   Eccentric phase: This is the deceleration or lowering portion of the movement.  It is associated with muscle lengthening.  During this phase, kinetic energy is absorbed and stored in the tendons of the muscle structure to be used during the stretch reflex.

2)   Isometric phase: This is where the mass, or athlete, comes to a complete stop before being accelerated in a new direction. (This is actually governed by Sir Isaac Newton’s Laws of Motion. More on that and physics later.)

3)   Concentric phase: This is the acceleration of an athlete or mass. It is associated with muscle shortening.

As the adage goes, a chain is only as strong as its weakest link.  If your training program consists solely of methods that train the concentric portion of dynamic muscle action, your athletes are heading into the season with a chain consisting of one strong link and two weak links.  This book is designed to show you how to develop the other two phases of dynamic human movement with a periodization model that will make all three links strong and optimize the performance of your athletes. Remember that:

            ATHLETIC MOVEMENT = DYNAMIC MOVEMENT = TRI-PHASIC MOVEMENT

Now, for the very large majority of us, “triphasic” muscle action is not new. In fact, if you were to look at your college anatomy and physiology books it might be discussed within the very first chapter, but looking at your athlete’s strength programming I’d bet you’ll find it (or at least the isometric and eccentric portions) as scarce as tourists wearing shorts and a t-shirt during a Minnesota winter!  Sure you’ll find some isometric holds or eccentric tempos from time to time but rarely will entire phases be dedicated to developing these qualities.  And even more rare would be finding these qualities developed or emphasized within a sports medicine rehabilitation program!!

With close to 400 pages of information along with sample programs, Cal’s book leaves no preverbal stone unturned.  The addition of video links to each exercise in each sample program and video explanations and other recorded presentations throughout the book makes Triphasic Training one of the most complete training books I have ever read-watched-(and stole from)!

Whether you work in the performance arena and train elite athletes or a sports medicine clinic working with athletes looking to return to activity, Triphasic Training is a must read and will immediately impact each and every athlete you work with!

See Cal Dietz present at the 2012 BSMPG Summer Seminar May 19-20^th in Boston.

Register today before seats are sold out!

Recommended readings from this past week in Sports Medicine and Performance.

Enjoy! Remember to register for the 2012 BSMPG Summer Seminar, May 19-20 in Boston MA.  Seats are limited.

The Brain: How The Brain Rewires Itself 

Vitamin D and Athletic Performance  

Variability in Leg Muscle Power and Hop Performance After Anterior Cruciate Ligament Reconstruction    

by Art Horne

Over the last five years the landmine has become a fixture in almost every strength training center across the country.  Although this piece of equipment surely has its merits when it comes to developing ground based and functional core strength, many performance coaches currently use it for only a handful of exercise selections with the majority of exercise variations coming from handle selections or foot position only, and not a true change in movement pattern or muscle emphasis.  At a cost of around $250, performance coaches need the landmine to become a one stop functional resource – and now they can!

Exercises for the Landmine by SB Coaches College featuring Shawn Windle of the Indiana Pacers, demonstrates exercise variations ranging from kneeling or beginning exercises to more dynamic multi-joint and multi-planar exercises.  Many of the variations and exercises demonstrated within this video I never thought could be used with the landmine including the snatch, deadlift variations and standing rotational press.

With an endless number of exercises and variations demonstrated throughout this video with key points discussed by Shawn Windle, this video is a must for coaches looking to purchase a landmine for their performance center in the near future and for all those that are currently using this piece of equipment on a limited basis only.

See Shawn Windle present at the 2012 BSMPG Summer Seminar May 19-20^th in Boston.

Register today before seats are sold out!

I recently took part in a workshop where both manual and instrument assisted soft tissue therapy were heavily promoted as the gold standard in plantar sided foot pain presentations. While certainly such therapeutic interventions as Active Release Techniques and Graston Technique may act as positive adjuncts in the management of such cases, I often find myself using exercise interventions with relatively more rapid results. As always, patient management should always be context dependent but this is what I’m finding.

Interestingly, when therapists do consider exercise interventions, heel raises/lowers off stairs seem to be the “exercise of choice”. Often such presentations are acute or “hot” and based on Craig Purdam’s work on tendinopathies, such exercises may be too advanced for significant progress to be made.

Now before I introduce some alternative exercises, I’d like to address the “One Toe Syndrome”. Patients with plantar sided foot pain, especially women for some reason, often present with this “syndrome”. They may indeed have five toes, as most of us do, but if you look closely the toes actually function as one unit rather than five individual units.

.

The "One Toe" Syndrome

Continue to read this article by Jeff Cubos by clicking HERE.

Remember to Save the Date for the BSMPG 2012 Summer Seminar - May 19-20th in Boston MA.

Check out three of John Berardi's previous nutrition articles here:

EATING FOR INJURY RECOVERY

WEIGHT GAIN FOR THE BASKETBALL ATHLETE

EATING BEFORE, DURING, AND AFTER COMPETITION

Remember to Save the Date for the BSMPG 2012 Summer Seminar - May 19-20th in Boston MA. Registration is open but seats are limited!

In 2011, BSMPG invited the titans of Sports Medicine and Performance to Boston for the largest conference of its kind, and many attendees left asking the question, "how could you ever top that speaker line-up?"

Well, we did.

BSMPG is proud to announce May 19-20, 2012 as the selected date for Sports Medicine and Strength professionals to desend upon Boston MA for another monster conference! So how could we ever top last year's speaker set? Let's just say that we asked last year's speakers who they wanted to hear and we got em! As we did last year, this seminar will be divided into three distinct educational tracks including a Hockey focus, a Basketball Focus, and a clear Sports Medicine/Rehabilitation Track with Keynote Speakers throughout the weekend bringing each track together for common lectures. Attendees may choose to stay within one track throughout the entire weekend or mix and match to meet their educational needs. Remember to save the date now - you won't want to miss another great summer seminar presented by BSMPG.

Date: May 19-20, 2012

Location: Boston MA. Campus of Northeastern University

Agenda: Click HERE to view

Get to know Keynote Speaker at the 2012 BSMPG Summer Seminar, Craig Liebenson below in an interview by Everything Basketball:

Join Jose Fernandez and other top Sports Medicine and Sports Performance professionals from across the world as they desend on Boston this May 19th-20th for the 2012 BSMPG Summer Seminar.  Choose from a number of specific learning tracks or mix and match to suit your learning needs.  Keynote speakers throughout the weekend include Dr. Craig Liebenson, Chris Powers, Alan Grodin, Irving Schexnayder, and Bill Knowles. 

Register today for this once in a lifetime event! Seats are limited!

Boston Sport Medicine and Performance Conference

Advanced Athlete Monitoring for Injury Reduction

Jose Fernandez

Abstract:

Professional athletes are experts at what they do, regardless how many S&C sessions they perform a week, they either have the quality to average 20 points per night or they don´t. From a physical perspective, coaches need to make sure their athletes are healthy and available to play every night. A healthy professional athlete should be capable to display a good performance just by being healthy. Everything else that can be achieved with training is a plus.

In a league where teams have to play 3-4 games a week and take more than 90 flights per season, time is limited for coaches to carry out physical training sessions with their players. A training program must be precise, specific and adjusted to the individual needs of each athlete. Coaches should focus on maintaining and reducing the loss of training adaptations throughout the season while enhancing the recovery and regeneration strategies.

At this year´s BSMPG Conference, I will be presenting ideas on how to objectively profile athletes attending to their neuromuscular characteristics and type of muscle fiber predominance. Continuing with this neuromuscular approach to athlete monitoring, innovative ways to quantify effects and duration of the training and treatments will be discussed. Being able to control the rate at which each muscle gains and looses activation after a training session or how exactly certain therapy treatment affects the functionality of any muscle group is crucial if we want to schedule training actions at the right moment, with the aim to maximize the physical performance and minimize risk of injury during the competition.

From an injury prevention perspective, new concepts to evaluate athlete´s readiness to train and assessment of change in muscle response induced by training will also be suggested, with a clear focus on practicality and applicability.

Aiming for maximal performance is a complex task. The purpose of my presentation is to offer some insight into the analysis of an athlete´s neuromuscular condition and how this can help coaches optimize training in an objective, reliable and time saving manner.

I look forward to seeing you at the BSMPG Conference in May!